Human beings begin life on earth as infants through the natural cycle of birth, and gradually progress through the stages of childhood, adolescence and adulthood, attaining accomplishments, experiences and meaning along the stages. Nevertheless, the cycle of life is finite and humans are mortal, and thus, death is a universal and unavoidable phenomenon that cannot be escaped in the human experience. Biologically, death is the cessation of functioning organs, which is determined by the cessation of brain activity, heart rate, blood pressure and endocrine hormone levels. However, some experts suggest that simply defining death in terms of brain activity is too restrictive, and argue that losing the ability to think, feel, reason and experience the world may also be defined as death. Ressner (2001) believes his view considers the psychological ramifications as well, and that a person who has suffered irreversible brain damage, is in a coma, or will never experience anything approaching a human life can be considered as dead, even though some sort of primitive brain activity persists. Even with all the knowledge about death, coming to terms with personal mortality is overwhelming and still a huge challenge for every individual.
Death is a natural part of life and an unavoidable consequence of ageing, but that doesn’t make its acceptance any easier or its fear any less. The society avoids discussing death as it requires people to accept their vulnerability of being mortal, to realize that one day they will no longer exist on earth with their family members. Much of the anxiety associated with death stems from the fear of the unknown. Death is viewed as a painful experience, and there is great uncertainty in what happens after death. The realization of the inevitability of death and the uncertainty of when or how it will occur can cause overwhelming anxiety and depression in individuals, especially for those in the autumn of their lives.
As individuals progress towards the autumn of their lives, the old age, they experience numerous changes in their being in terms of physical, emotional and sometimes social aspects. Physical changes include changes in appearance owing to the appearance of wrinkles, loss of teeth, greying of hairs, difficulty in movement and so on. Losing friends and family to old age, difficulty coming to terms with personal mortality and fear of separation from loved ones contribute to the emotional changes. Social changes might include neglect or abandonment from family or loved ones, and the fear of being alone in their final moments. Psychology understands death through various concepts related to mental state, one of which is the Terror Management Theory (Becker, 1973; Greenberg et al., 1997; Solomon et al., 1991 a; Solomon et al., 1991b). The Terror Management Theory (TMT) is based on the assumption that humans are instinctively driven towards survival and continued existence, while at the same time have the cognitive capacity to realize their own mortality, which allows for the realization of their inevitable death. This realization of the inevitable death has the potential to create anxiety. TMT theorizes that at the core of the death anxiety is the fear of annihilation and that the fear of death is the root of all other fears. According to this theory, the experience of such anxiety would be paralyzing without some means of suppressing it from awareness, and the theory aims to identify the factors that help maintain this suppression. TMT theorists assert that over the course of time, cultural views were developed by individuals in various societies that characterized the universe or society as having rationality, predictability and permanence, and socialization in any of these cultural views provides a sense of protection against the fear of annihilation. It allows people to set standards of value for a meaningful life, and thus, rise above death. When individuals engage in socialization and meet the standards set by their culture, they attain greater self-esteem and a promise of immortality.
The primary psychological mechanism that helps in the suppression of an individual’s death anxiety is self-esteem, and it is facilitated by culture which acts as a buffer (Greenberg et al., 1994; Greenberg et al., 1997; Solomon et al., 1991a; Solomon et al., 1991b). Self-esteem develops in the early stage of life, as children observe, interact with and meet the expectations and standards of their parents, and is then carried forward to adulthood when an individual’s self-esteem is maintained and enhanced by learning the teachings of their culture, attaining goals and fulfilling roles valued by their culture and experiencing social validation in personal relationships. These cultural norms, values and beliefs help in creating an illusion of being protected from death, or eventually rising above it. Beliefs in these cultural systems lead individuals to attain both literal and symbolic immortality. Literal immortality refers to the belief that an intangible or non-material aspect of the individual will live on indefinitely in some way. Symbolic immortality is the belief that individuals are represented by someone or something that will continue to exist even after they are dead. Individuals may continue to live literally through various pieces of art or propounded ideas, or symbolically by viewing children and grandchildren as extensions of themselves that continue to live even after they themselves are dead, carrying forward their legacy and making a permanent mark in the world through things that they produce or achieve. Thus, individuals in their old-age often yearn for children and grandchildren, expecting them to carry forward the legacy of their family. This somehow creates an illusion of them being alive through their progeny and helps them cope with the anxiety associated with death.
The first professional to systemically study, and in turn, influence our understanding of the way people approach and confront their own deaths was Elisabeth Kübler-Ross. Kübler-Ross developed a theory on death and dying based on her interviews with dying people and those caring for them (Kübler-Ross, 1969, 1982). The interviewees were patients who were diagnosed with a terminal illness and thus were well aware of their impending death due to their medical condition. The five basic stages, suggested by Kübler-Ross, through which individuals pass as they approach their deaths, the stages being- Denial, Anger, Bargaining, Depression and Acceptance.
- The first stage, denial, is one in which individuals search for every reason to resist the idea of death and explain that they are not dying. They may refuse to believe the news or reject the diagnosis, stating that the test results were incorrectly executed or the diagnosis was not accurate.
- After denial, an individual enters the second stage which is anger, which can stem from loneliness, guilt, meaninglessness or fear. The anger may be directed towards those caring for them, doctors or even God, often reasoning that they had been good people and did not deserve to die.
- This idea leads into the third stage, bargaining. “If you are good, you will be rewarded”– many people try to apply this idea that was introduced to the individual as a child, to reason with their impending death. In this stage, people often have private moments with God, promising to be better people and overcome their flaws if God saves them. Sometimes, people try to negotiate their way out of death by asking God to prevent death until their children are married or they are blessed with grandchildren. But death is inevitable and no negotiation with God is enough to prevent it.
- When the realization that death is inescapable hits the individual, they enter the fourth stage, depression. When they realize that death cannot be bargained away, they are engulfed by a deep sense of loss- the realization that they would be losing their loved ones and reaching the end of their lives. The depression may be reactive or preparatory. Reactive depression is when the sadness is based on the events that have already occurred, like the end of a job or the feeling that they might not have contributed enough to the society or that their work has not got the necessary recognition. Preparatory depression is when people feel sadness over future losses, like the end of relationships or the disappointment of not being able to see their future generations.
- The fifth stage of the theory is acceptance. According to Kübler-Ross, people who have developed acceptance have neither positive nor negative feelings about the present nor future. They become unemotional and uncommunicative, as they become fully aware and accepting of the fact that death will come to them eventually.
It can take a long time to reach the stage of acceptance, and having a support network of family and friends can provide guidance and comfort during this difficult journey. Grief counselling and support groups, along with familial support can go a long way in helping an individual cope with the fear and anxiety associated with death.
Very often, the individuals might also turn to spirituality at the old age. Spirituality may be defined as “the way individuals seek and express meaning and purpose in life; way they experience their connectedness to the moment, with self and others, to nature and to the sacred”. Providing spiritual care might also aid in the acceptance of the inevitable. Spiritual care begins with encouraging human contact in a compassionate relationship and then progresses in whatever direction is needed and required by the individual. Components of spiritual care can include allowing the elderly to reminisce their life story, showing an interest in getting to know them, being present with them, understanding what is important and precious to them and helping them connect with it, encouraging mindfulness and meditation, praying and reading books or religious scriptures to them. Sometimes, some individuals express a final desire of either wishing to see their favourite personality or being surrounded by their family and loved ones in their final hours. Acknowledging and supporting these aspects of identity can facilitate meaning and bring a sense of peace within them, helping to accept the anxiety and losses associated with dying.
In an attempt to facilitate acceptance, the elderly may resort to socio-emotional selectivity and cut down contacts with those threatening their sense of being or might engage in cognitive reframing of events with optimistic re-interpretation. Additionally, the elderly are also able to maintain their self-esteem through generativity- in which they seek to contribute to the world and as a result, derive a sense of purpose. A sense of purpose or generativity would lead to a sense of integrity in the elderly- a sense of satisfaction upon reflecting back on their lives. Perhaps the Japanese concept of ‘Ikigai’, which means a reason for being and that which makes the life worthwhile, would closely describe this sense of integrity that the elderly seek.
Upon reminiscence, when the life lived brings a sense of satisfaction and contentment, rather than regrets or longings, and when the final moments are spent with the ones close to the heart, acceptance of the inevitable death becomes somewhat easier, and the phrase ‘rest in peace’ somehow becomes felicitous.
