Figure 13.13 A young man sits at the grave of his great-grandmother. (Credit: Sara Goldsmith/flickr) For most of human history, the standard of living was significantly lower than it is now. Humans struggled to survive with few amenities and very limited medical technology. The risk of death due to disease or accident was high in any life stage, and life expectancy was low. As people began to live longer, death became associated with old age. For many teenagers and young adults, losing a grandparent or another older relative can be the first loss of a loved one they experience. It may be their first encounter with grief, a psychological, emotional, and social response to the feelings of loss that accompanies death or a similar event. People tend to perceive death, their own and that of others, based on the values of their culture. While some may look upon death as the natural conclusion to a long, fruitful life, others may find the prospect of dying frightening to contemplate. People tend to have strong resistance to the idea of their own death, and strong emotional reactions of loss to the death of loved ones. Viewing death as a loss, as opposed to a natural or tranquil transition, is often considered normal in the United States. What may be surprising is how few studies were conducted on death and dying prior to the 1960s. Death and dying were fields that had received little attention until a psychologist named Elisabeth Kübler-Ross began observing people who were in the process of dying. As Kübler-Ross witnessed people’s transition toward death, she found some common threads in their experiences. She observed that the process had five distinct stages: denial, anger, bargaining, depression, and acceptance. She published her findings in a 1969 book called On Death and Dying. The book remains a classic on the topic today. Kübler-Ross found that a person’s first reaction to the prospect of dying is denial: this is characterized by the person's not wanting to believe he or she is dying, with common thoughts such as “I feel fine” or “This is not really happening to me.” The second stage is anger, when loss of life is seen as unfair and unjust. A person then resorts to the third stage, bargaining: trying to negotiate with a higher power to postpone the inevitable by reforming or changing the way he or she lives. The fourth stage, psychological depression, allows for resignation as the situation begins to seem hopeless. In the final stage, a person adjusts to the idea of death and reaches acceptance. At this point, the person can face death honestly, by regarding it as a natural and inevitable part of life and can make the most of their remaining time. The work of Kübler-Ross was eye-opening when it was introduced. It broke new ground and opened the doors for sociologists, social workers, health practitioners, and therapists to study death and help those who were facing death. Kübler-Ross’s work is generally considered a major contribution to thanatology: the systematic study of death and dying. Of special interests to thanatologists is the concept of “dying with dignity.” Modern medicine includes advanced medical technology that may prolong life without a parallel improvement to the quality of life one may have. In some cases, people may not want to continue living when they are in constant pain and no longer enjoying life. Should patients have the right to choose to die with dignity? Dr. Jack Kevorkian was a staunch advocate for physician-assisted suicide: the voluntary or physician-assisted use of lethal medication provided by a medical doctor to end one’s life. This right to have a doctor help a patient die with dignity is controversial. In the United States, Oregon was the first state to pass a law allowing physician-assisted suicides. In 1997, Oregon instituted the Death with Dignity Act, which required the presence of two physicians for a legal assisted suicide. This law was successfully challenged by U.S. Attorney General John Ashcroft in 2001, but the appeals process ultimately upheld the Oregon law. As of 2019, seven states and the District of Columbia have passed similar laws allowing physician assisted suicide. The controversy surrounding death with dignity laws is emblematic of the way our society tries to separate itself from death. Health institutions have built facilities to comfortably house those who are terminally ill. This is seen as a compassionate act, helping relieve the surviving family members of the burden of caring for the dying relative. But studies almost universally show that people prefer to die in their own homes (Lloyd, White, and Sutton 2011). Is it our social responsibility to care for elderly relatives up until their death? How do we balance the responsibility for caring for an elderly relative with our other responsibilities and obligations? As our society grows older, and as new medical technology can prolong life even further, the answers to these questions will develop and change. The changing concept of hospice is an indicator of our society’s changing view of death. Hospice is a type of healthcare that treats terminally ill people when “cure-oriented treatments” are no longer an option (Hospice Foundation of America 2012b). Hospice doctors, nurses, and therapists receive special training in the care of the dying. The focus is not on getting better or curing the illness, but on passing out of this life in comfort and peace. Hospice centers exist as a place where people can go to die in comfort, and increasingly, hospice services encourage at-home care so that someone has the comfort of dying in a familiar environment, surrounded by family (Hospice Foundation of America 2012a). While many of us would probably prefer to avoid thinking of the end of our lives, it may be possible to take comfort in the idea that when we do approach death in a hospice setting, it is in a familiar, relatively controlled place.