tag:theconversation.com,2011:/global/topics/coping-with-mortality-27279/articlesCoping with Mortality – The Conversation2016-05-19T19:38:24Ztag:theconversation.com,2011:article/580532016-05-19T19:38:24Z2016-05-19T19:38:24ZHere’s what people in their 90s really think about death<figure><img src="https://images.theconversation.com/files/122252/original/image-20160512-28448-17z82r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People who are over 90 when they die need considerably more support with every aspect of their daily life in their final year.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/pat00139/6064027940/in/photolist-aeRJeS-5L7Y7C-m5E8Ey-6DP7KT-3kDXwq-qzoKz9-54D8Hj-se6NVU-4yCimf-4WSCZV-7VdUam-f3peD4-7nU5XE-7N64zx-kiz6K-5L3JMa-5mvy2-52dAfN-qn87zf-cNxeiS-pSE8bd-5Lvcri-5Lzrn7-3F3Vq3-7ZY2J6-neksHR-zxLC7-7nU8k5-qdaceb-9kK27R-7DMcUa-7nU8v9-aaZNai-oEoxXh-7nU8oQ-7nU8ys-7nQexF-9TpeeF-foKqiG-BPBsj-92SNhn-5L7Yao-bDZoWK-obc3DL-7YCKbn-hYa1V-3gKeR-nwJda5-MLgCH-fNsZm5">Pat Pilon/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is one of two final articles in our Coping with Mortality series. Today’s accompanying piece explains the importance of <a href="https://theconversation.com/palliative-care-should-be-embraced-not-feared-59162">effectively using palliative care</a> services. You can read previous articles in our series <a href="https://theconversation.com/au/topics/coping-with-mortality">here</a>.</em></p>
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<p>Across the developed world more people are living longer, which of course means more get to be extremely old by the time they die. Nearly half of <a href="http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/bulletins/estimatesoftheveryoldincludingcentenarians/2015-09-30">all deaths in the United Kingdom</a> are in people aged 85 or older, up from only one in five just 25 years ago. </p>
<p>Dying in older age can mean a different sort of death, such as becoming gradually frailer in both body and mind and developing numerous health problems over many years. Where years after retirement were previously considered just <em>old age</em>, a longer life span means the later years now include variation <a href="https://en.wikipedia.org/wiki/Old_age">reflected in labels</a> such as <em>younger old</em> and <em>older old</em>.</p>
<p>Our <a href="http://www.ncbi.nlm.nih.gov/pubmed/20122036">previous research showed</a> people who are over 90 when they die need more support with daily life in their last year than even those who die in their late 80s. In the United Kingdom, around 85% of those dying aged 90 or older were so disabled as to need assistance in basic self care activities. Only 59% of those between 85 and 89 at death had this level of disability. </p>
<p>This knowledge has implications for planning support for life and death in different care settings. But what do we know about what the <em>older old</em> (95 plus) people actually want when it comes to decisions about their care as they approach the end of their lives? </p>
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<img alt="" src="https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/123136/original/image-20160519-22307-jpgycr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Very old people in western society are increasingly marginalised.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<h2>How the older old feel about dying</h2>
<p>The oldest and frailest in our society are becoming less visible as many who need the most support, such as those with dementia, are either in care homes or less able to get out and about. But their voices are crucial to shaping end-of-life care services.</p>
<p>In our <a href="http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0150686">latest research</a>, we had conversations about care experiences and preferences with 33 women and men aged at least 95, some over 100, and 39 of their relatives or carers. Of these, 88% were women, 86% were widowed and 42% lived in care homes.</p>
<p>Death was part of life for many of the older people who often said they were taking each day as it comes and not worrying too much about tomorrow. “It is only day-from-day when you get to 97,” said one woman. Most felt ready to die and some even welcomed it: “I just say I’m the lady-in-waiting, waiting to go,” said one.</p>
<p>Others were more desperate in their desire to reach the end. “I wish I could snuff it. I’m only in the way,” was a typical sentiment in those who felt they were a nuisance. Others begged not to be left to live until they were a hundred, saying there was no point to keeping them alive.</p>
<p>Most were concerned about the impact on those left behind: “The only thing I’m worried about is my sister. I hope that she’ll be not sad and be able to come to terms with it.” </p>
<p>The dying process itself was the cause of most worries. A peaceful and painless death, preferably during sleep, was a common ideal. Interviewees mainly preferred to be made comfortable rather than have treatment, wishing to avoid going into hospital. </p>
<p>We found families’ understanding of their relative’s preferences only occasionally incorrect (just twice). For instance, one person said they wanted to have treatment for as long as they could, while their family member believed they would prefer palliative care. This highlights the importance of trying to talk options through with the older person rather than assuming their family knows their views.</p>
<p>We found most discussed end-of-life preferences willingly and many mentioned previous talk about death was uncommon, often only alluded to or couched in humour. A minority weren’t interested in these discussions.</p>
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<img alt="" src="https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/123145/original/image-20160519-22319-1jj66jh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Most of the older old don’t fear death and some even look forward to it.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ambroo/8840916762/in/photolist-etf1xm-pQNgei-pPD4UY-e8SHXJ-7moAP8-pNJYpv-q5Bnm1-7usNuz-8JKKMm-5vVt7z-hJVpMs-7wAebj-dqCnS3-nxEPeF-kLKkBh-3amg3m-99VSXF-mZv8WL-bqZ5KH-aCRSbj-pYvhH3-n9SSU7-pq1BQ6-pqEoSs-pws4Si-p4hDE3-o8D4uA-acuvkc-bY7Xso-dgSXGy-quEQzB-iWmTu8-9t28Te-h7y2MT-ihdEto-6kKhML-fSb7hj-nCSsd7-rLHsvu-6PUA2J-aF62p3-pEkihZ-ny59Fr-eQh22B-rcKPJP-rCLexo-72RYrR-o2aguC-kQfa9-fM7ZaN">Broo_am (Andy B)/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<h2>We need to talk with the older old</h2>
<p>It’s rare to hear from people in their tenth or eleventh decade but there are some studies that have explored the views of the younger old. Most often these have concentrated on care home residents and occasionally on those living at home.</p>
<p>A literature review conducted in Sweden in 2013 found a total of 33 studies across the world that <a href="http://link.springer.com/article/10.1007/BF03324537">explored views of death and dying</a> among older people, although very few of these sought the views of the older old.</p>
<p>A 2002 study found older people in Ghana <a href="http://journals.cambridge.org/action/displayAbstract?aid=110829">looked forward to death</a>, seeing it as a welcome visitor that would bring peace and rest after a strenuous life. And a 2013 study in the Netherlands showed many people <a href="http://www.jpsmjournal.com/article/S0885-3924(13)00146-2/abstract">changed their preferences</a> on how they wanted to die as their care needs changed.</p>
<p>A recent review <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782798/pdf/bjgp-oct2013-63-615-e657.pdf">examined older people’s attitudes</a> towards advance care plans and preferences for when to start such discussions. It identified 24 studies, mainly from the United States and with younger old age ranges. The results showed that while a minority shirked from end-of-life care discussion, most would welcome them but were rarely given the opportunity.</p>
<p>These studies support our findings on older people’s willingness to discuss often taboo topics, their acceptance of impending death, and their concerns around what the dying process would bring: increasing dependence, being a burden and the impact of their own death on those left behind. </p>
<p>To plan services to best support rising numbers of people dying at increasingly older ages in different settings, we need to understand their priorities as they near the end of life.</p><img src="https://counter.theconversation.com/content/58053/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Fleming receives funding from the UK's National Institute for Health Research and The Abbeyfield Society.</span></em></p>It is rare to hear from people in their tenth or eleventh decade but their voices are crucial to shaping end-of-life care services.Jane Fleming, Senior Research Associate, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/591622016-05-19T19:38:19Z2016-05-19T19:38:19ZPalliative care should be embraced, not feared<figure><img src="https://images.theconversation.com/files/121806/original/image-20160510-20575-m974a6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Palliative care aims to comfort rather than cure.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This is one of two final articles in our Coping with Mortality series. Today’s accompanying piece looks at <a href="http://theconversation.com/heres-what-people-in-their-90s-really-think-about-death-58053">how the very old view death</a> and their preferences for care at the end of life. You can read previous articles in our series <a href="https://theconversation.com/au/topics/coping-with-mortality">here</a>.</em></p>
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<p>Palliative care programs are well established in Australia but they aren’t being used effectively. While referral to palliative care should occur early in the course of a likely terminal illness, it is often delayed – sometimes declined – by patients who may feel expected to “fight” the disease or because it seems too soon to go that way.</p>
<p>Doctors can delay referral too. Research has found the name <em>palliative care</em> <a href="http://www.ncbi.nlm.nih.gov/pubmed/19235253">causes distress and reduces hope</a> in patients and their families. Commonly, doctors prefer to encourage their patients with another line of therapy: “Don’t give up. Palliative care? You’re not ready for that yet.”</p>
<p>The decision to move from actively treating a serious disease to focusing on making a patient comfortable can represent abandonment for the patient and failure for the doctor. But without timely access to palliative care, the patient risks exposure to futile treatments and additional discomfort.</p>
<p>Palliative care should be a transitional phase in which care is shared. The doctor can continue treating their patient’s disease while symptom control and preparation for the reality of death track alongside. When attempts to reverse the illness are no longer of use, there will already be an established relationship in place, ready to support the patient through to the end. </p>
<h2>To comfort rather than cure</h2>
<p>Palliative care is terminal care that aims to comfort rather than cure the patient. A <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62416-2/abstract">Canadian study found that initially, patients associated</a> palliative care with hopelessness and dependency that provoked fear and avoidance. But once receiving it, they said it improved their “quality of living”. </p>
<p>In Australia, palliative care replaced the hospice – funded by charitable and community organisations and sitting outside of medicine – in the 1980s. Today, specialist palliative care services are provided in hospitals, residential homes and in outreach care, and funded largely by the government. </p>
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<img alt="" src="https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121476/original/image-20160506-423-1gy1tin.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The precursor to palliative care, the hospice sat outside of medicine and was funded by charitable and community organisations.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/evill1/14892231/in/photolist-2jjWB-gs7P9-fVfhhV-fVf2YA-3KuVg6-6SK9Go-fVeDzh-9txLuS-ePFZLE-gsab2-fVek7C-9tuPyx-fVe61a-aiqgGF-gs5YF-4iiFie-fVesbB-fVf4Xh-yF2zE-fVe8c4-egMmpd-yF2at-9GupU3-gsa4T-9tet1D-gsaeG-8qcd6i-fVesEo-fVeqzF-fVezyw-4iiE3k-fVe5cB-4iiFkz-dJP2D8-fVes4b-yYfDJN-yYgvx3-yiTckj-6jCSvy-o5k47H-9tuP88-gs7CB-fVeGhk-4iiEKP-fVevM4-fVePQt-3KuVX2-9teov4-9thmws-fVeTaf">Aaron Edwards/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>In 2012-13, <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548892">about 11,700 patients received</a> a specialist palliative service in Australia, costing around A$4.7 million. Numbers of both patients and dollars will increase as our population ages so it’s important that palliative care services are used efficiently.</p>
<p>Palliative care, made up of basic medicine and skilled nursing, involves pharmacological and other flexible approaches that consider what matters most to the patient.</p>
<p>Much of palliative care involves managing symptoms; some from the disease, others from its treatments. Pain, nausea, constipation, breathing difficulties and loss of appetite are common. There are also emotional and existential issues that call for sensitive exploration of patient history, expectations, fears and hopes.</p>
<p>There is no one regimen to treat discomfort. To control severe pain, for instance, one patient may need an opioid drug dose ten times higher than another patient.</p>
<p>Palliative care has already moved from a focus on advanced cancer to other causes of dying, such as cardiac, respiratory and neurological illness. The dying phase can be prolonged in the latter cases. When they can’t be supported at home, these patients are too often placed in an aged care facility where palliative care services aren’t adequately resourced.</p>
<p>To make palliative care economically efficient, it should be <a href="https://www.mja.com.au/journal/2013/198/9/palliative-care-everyone-s-business-it-yours-doctor">everyone’s business</a>, not just that of specialist palliative care staff.</p>
<h2>Everyone’s business</h2>
<p>In the United Kingdom, <a href="https://www.researchgate.net/publication/269717474_Non-medical_prescribing_in_palliative_care_A_regional_survey">nurse practitioners</a> have won the right to be trained to prescribe opioids and other medications. We need more nurse practitioners in Australia, better clarification of their roles, more fluid demarcation of their responsibilities and a review of their remuneration.</p>
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<img alt="" src="https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121479/original/image-20160506-420-z3gw06.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Home visits by doctors can help people die at home.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>Nurse practitioners are specially trained nurses that could <a href="http://www.ncbi.nlm.nih.gov/pubmed/24162278">be placed in residential care facilities</a> to <a href="http://www.ncbi.nlm.nih.gov/pubmed/22559906">help assess patient need</a> and record advanced care wishes. Their presence would avoid unnecessary hospitalisation for minor injury and help ensure good palliation on site. </p>
<p>In Australia, the <a href="http://www.ncbi.nlm.nih.gov/pubmed/22892713">majority of people</a> with a terminal illness die in hospital; a <a href="https://theconversation.com/a-good-death-australians-need-support-to-die-at-home-32203">miserable setting</a> for both patient and family. This happens partly because of reluctance to suspend active treatment even when it has become futile as well as too few beds in step-down or aged care institutions, and inadequate support for the home care alternative. </p>
<p>Home care costs less than institutional care. Studies done in Canada show palliative care at home meant fewer days in hospital and a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552298/">cost reduction</a> at CAD$4,400 per patient. In Italy, <a href="http://www.ncbi.nlm.nih.gov/pubmed/24709365">costs reduced</a> to just over one-fifth when home palliative care was instituted and in Romania, a home visit cost only one-third the cost of a day in hospital.</p>
<p>In my 25 years of being a palliative care specialist, I have found home care – with the support of a palliative nurse team and GP visits – improves the chances of dying at home and increases the number of days considered as being good quality. It leaves a family with a sense of a job well done and, I believe, lessens the pain of bereavement. It is often recalled as a time of beauty and bonding in family history.</p><img src="https://counter.theconversation.com/content/59162/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Maddocks does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Palliative care should be a time of shared care; when the doctor continues treating their patient’s disease while symptom control and preparation for death track alongside.Ian Maddocks, Emeritus professor, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/556362016-05-18T19:45:40Z2016-05-18T19:45:40ZSpiritual care at the end of life can add purpose and help maintain identity<figure><img src="https://images.theconversation.com/files/119409/original/image-20160420-25595-128scix.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People nearing the end of their life often express fear of dying alone.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/jCic71ZWQbs">Gerard Moonen/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is the fourth article in our <a href="https://theconversation.com/au/topics/coping-with-mortality">Coping with Mortality</a> series that looks at fear of death across the ages and how to cope with the dying process.</em></p>
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<p>In Australian nursing homes, older people are increasingly frail and being <a href="http://www.pc.gov.au/__data/assets/pdf_file/0004/83380/aged-care-trends.pdf">admitted to care later</a> than they used to be. More than <a href="http://aihw.gov.au/publication-detail/?id=60129544869">half of residents</a> suffer from depression, yet psychiatrists and psychologists aren’t easily accessible, and pastoral or spiritual care is only available in a subset of homes.</p>
<p>Depression at the end of life is often associated with loss of meaning. Research shows people who suffer from such loss <a href="https://www.sciencedaily.com/releases/2015/12/151203112844.htm">die earlier</a> than those who maintain purpose. This can be helped by nurturing the “spirit” – a term that in this setting means more than an ethereal concept of the soul. Rather, spiritual care is an umbrella term for structures and processes that give someone meaning and purpose. </p>
<p>Caring for the spirit has strength in evidence. Spiritual care <a href="http://onlinelibrary.wiley.com/doi/10.1111/appy.12018/abstract">helps people cope</a> in grief, crisis and ill health, and increases their ability to recover and keep living. It also has <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2004.52161.x/abstract">positive impacts</a> on behaviour and emotional well-being, including for those with dementia.</p>
<h2>Feeling hopeless</h2>
<p>Many people have feelings of hopelessness when their physical, mental and social functions are diminished. A 95-year-old man may wonder if it’s worth going on living when his wife is dead, his children don’t visit anymore and he’s unable to do many things without help. </p>
<p>The suffering experienced in such situations can be understood in terms of <a href="http://medhum.med.nyu.edu/view/905">threatening one’s “intactness” </a> and mourning what has been lost, including self-identity.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116160/original/image-20160323-28192-1p0unrm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nursing home residents are increasingly frail and more than half experience depression.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/brian_tomlinson/23167796053/in/photolist-7Z8BS3-7Z8Cam-AXoz64-7Z5ptk-F69CD9-Big1Bx-DfxDqn-yo5YZa-DfdaL3-DDs81c-DKPp3W-E4GbnT-EcWudv-EcWu8a-E2uYpE-z2N68t-xPQuRq-79X52X-hnrHXi-dSBuBH-dSH2y5-94nEGK-dSH7g9-dSH5S1-dSByvg-o36Jct-dSBy7e-dSH319-dSHHZb-dUesbs-dSBxpP-7Z5pGV-dSH7MY-dSHGNE-94qJSG-dSHHJL-dSHHoN-dSH5xj-dSH6Fs-iC2pY-dSH1gQ-7jCCmC-u6TEQ-hUMhZf-5ifhUw-8csF-9TaeiF-An7gYU-bMdq12-sQnNBH">Brian Tomlinson/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Fear is also common among those facing death, but the particular nature of the fear is often unique. Some may be afraid of suffocating; others of ghosts. Some may even <a href="http://onlinelibrary.wiley.com/doi/10.1111/nyas.12474/abstract">fear meeting their dead</a> mother-in-law again.</p>
<p>What <a href="http://onlinelibrary.wiley.com/doi/10.1111/nyas.12474/abstract">plagues people the most</a> though is the thought of dying alone or being abandoned (though a significant minority express a preference to die alone). Anxiety about dying <a href="http://www.ncbi.nlm.nih.gov/pubmed/22530298">usually increases</a> after losing a loved one.</p>
<p><a href="http://pmj.sagepub.com/content/23/5/388.abstract">But such losses</a> can be transcended by encouraging people to pursue their own purpose for as long as they can; in other words, by caring for the spirit.</p>
<h2>What is spiritual care?</h2>
<p>Spiritual care has religious overtones that make it an uncomfortable concept in a secular health system. But <a href="http://pascop.org.au">such care</a> can be useful for all – religious and non-religious – and can be provided by carers, psychologists and pastoral specialists alike. </p>
<p>Spirituality <a href="http://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1429&context=smhs_medicine_facpubs">can be defined as</a> “the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred”. Perhaps the <a href="https://www.psychologytoday.com/blog/the-good-life/200809/ikigai-and-mortality">Japanese term “ikigai”</a> – meaning that which gives life significance or provides a reason to get up in the morning – most closely encompasses spirituality in the context of spiritual care.</p>
<p>Guidelines for spiritual care in government organisations, provided by the <a href="http://www.nes.scot.nhs.uk/education-and-training/by-discipline/spiritual-care/about-spiritual-care/publications/spiritual-care-matters-an-introductory-resource-for-all-nhs-scotland-staff.aspx">National Health Services in Scotland and Wales</a>, note that it starts with encouraging human contact in a compassionate relationship and moves in whatever direction need requires. Spiritual needs are therefore met through tailoring components of care to the person’s background and wishes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116701/original/image-20160330-28468-1gwb0ys.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Spiritual care can involve having your dog nearby or being surrounded by your favourite sports team regalia.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>For instance, one person requested that her favourite football team regalia be placed around her room as she was dying. Another wanted her dog to stay with her in her last hours. Supporting these facets of identity can facilitate meaning and transcend the losses and anxiety associated with dying. </p>
<p>Spiritual care can include a spiritual assessment, for which <a href="https://global.oup.com/academic/product/oxford-textbook-of-spirituality-in-healthcare-9780199571390?cc=au&lang=en&">a number of tools are available</a> that clarify, for instance, a person’s value systems. Such assessments would be reviewed regularly as a person’s condition and spiritual needs can change. </p>
<p>Some people may seek religion as they near the end of their lives, or after a traumatic event, while others who have had lifelong relationships with a church <a href="http://www.bbc.com/future/story/20141219-will-religion-ever-disappear">can abandon their faith</a> at this stage.</p>
<p>Other <a href="http://onlinelibrary.wiley.com/doi/10.1111/jocn.12596/abstract">components of spiritual care</a> can include allowing people to access and recount their life story; getting to know them, being present with them, understanding what is sacred to them and helping them to connect with it; and mindfulness and meditation. For those who seek out religious rituals, spiritual care can include reading scripture and praying.</p>
<h2>Spiritual care in the health system</h2>
<p>Psychologists or pastoral care practitioners may only visit residential homes infrequently because of cost or scarce resources. To receive successful spiritual care, a person living in a residential home needs to develop a trusting relationship with their carer.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120270/original/image-20160427-1352-co6724.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">For those who seek out religious rituals, spiritual care can include reading scripture and praying.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>This can best be done through a buddy system so frail residents can get to know an individual staff member rather than being looked after by the usual revolving door of staff. </p>
<p>Our reductionist health care model <a href="http://www.ncbi.nlm.nih.gov/pubmed/20530402">is not set up to support people</a> in this way. Slowing down to address existential questions does not easily reconcile with frontline staff’s poverty of time. But health care settings around the world, including Scotland and Wales, the <a href="http://www.nationalconsensusproject.org/guideline.pdf">United States</a> and the <a href="http://www.eapcnet.eu/Themes/Clinicalcare/Spiritualcareinpalliativecare.aspx">Netherlands</a>, are starting to acknowledge the importance of spiritual care by issuing guidelines in this area.</p>
<p>In Australia, comprehensive <a href="http://pascop.org.au">spiritual care guidelines</a> for aged care are being piloted in residential and home care organisations in early 2016.</p>
<p>People with chronic mental illness, the elderly, the frail and the disabled have the right to comprehensive health care despite their needs often being complex, time-consuming and expensive. </p>
<p>Finding meaning at all stages of life, including during the process of dying, is a challenging concept. It seems easier to get death over with as quickly as possible. But the development of new spiritual care guidelines brings us one step closer to supporting a meaningful existence right up to death.</p><img src="https://counter.theconversation.com/content/55636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Doyle receives funding from a sub-contract of the National Ageing Research Institute from Meaningful Aging Australia (formerly Pastoral and Spiritual Care for Older People) who were awarded an Australian Department of Health, Aged Care Services Improvement and Healthy Aging Grant. Colleen is Professor of Aged Care, Australian Catholic University.</span></em></p><p class="fine-print"><em><span>David Jackson receives funding from a sub-contract of the National Ageing Research Institute from Meaningful Aging Australia (formerly Pastoral and Spiritual Care for Older People) who were awarded an Australian Department of Health, Aged Care Services Improvement and Healthy Aging Grant.</span></em></p>Research shows people who suffer from loss of meaning die earlier than those who maintain purpose. We can help people find meaning again by nurturing their “spirit”.Colleen Doyle, Principal Research Fellow at NARI, The University of MelbourneDavid Jackson, Research Officer Dementia and Stroke, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/593842016-05-17T19:35:04Z2016-05-17T19:35:04ZEverything dies and it’s best we learn to live with that<figure><img src="https://images.theconversation.com/files/122778/original/image-20160517-15924-8uc7kx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We come into this world, grow and flourish and then decay and die.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/nehle/8176561991/in/photolist-dsx21K-hx9ocv-po7SYz-dyMSBm-iAwZhi-pcVe96-pcQTvn-iAxhmD-5wAvuS-8Gmorf-5z3o82-8Pw5C6-7gdMrW-92NpPm-oSNEFq-qFS5Q5-pHE446-q2Y64h-aVtX2n-8NLeaT-4Nvaxm-drU8Z3-pUefjr-dqXiTf-hTrDH7-8Tt4AU-ptNgLM-91vYKN-pvgzNU-7ZqBVT-gGxpWw-m5bPp-h3X6S5-aQgVZi-gX7oXA-rVqY6-aVtU9x-aCYJM6-582SyQ-8Lxd1C-cuw17Y-rv1NH7-ryUACT-3TTchu-5z8bAY-gPPdXv-mfkmnW-5sGDnu-2uJcv-3p9o7w">Jakob Nilsson-Ehle/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is the third article in our <a href="https://theconversation.com/au/topics/coping-with-mortality">Coping with Mortality</a> series, which looks at fear of death across the ages and how to cope with the dying process. Tomorrow’s piece will argue for spiritual care to be provided in aged care settings.</em></p>
<hr>
<p>Fear of dying – or death anxiety – is <a href="https://www.researchgate.net/publication/233662306_Death_Anxiety_A_Cognitive-Behavioral_Approach">often considered to be one of the most common fears</a>. Interestingly though, neither of the two widely used diagnostic psychiatric manuals, DSM-5 or ICD-10, has a specific listing for death anxiety. </p>
<p>Death is related in the manuals <a href="http://www.sciencedirect.com/science/article/pii/S0272735814001354">to a number of anxiety disorders</a> including specific phobias, social anxiety, panic disorder, agoraphobia, post-traumatic stress disorder and obsessive compulsive disorder. Although many psychologists will argue that <a href="https://theconversation.com/fear-of-death-underlies-most-of-our-phobias-57057">these fears are proxies</a> for the larger fear of death.</p>
<p>Existential therapy directly targets death and the meaning of life. It’s practised by psychiatrist <a href="http://www.yalom.com">Irvin Yalom</a>, a pioneer in understanding fear of death and how to treat it in therapy. He has written a popular book on the subject called <a href="https://mafhom.files.wordpress.com/2012/11/staring-at-the-sun-yalom.pdf">Staring at the Sun: Overcoming the Terror of Death</a>. Existential therapy is one way of treating death anxiety but no matter what psychological approach is used, the underlying theme is generally the same: acceptance. </p>
<h2>What’s so frightening about death?</h2>
<p>All life has death in common, yet it’s striking how little we actually talk about it. In Western cultures at least, the concept can be too much even to consider. But from a <a href="http://www.sciencedirect.com/science/article/pii/S0272735815000914">clinical psychology perspective</a>, the more we avoid a topic, situation, thought or emotion, the greater the fear of it can become and the more we want to avoid it. A vicious cycle. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122786/original/image-20160517-15924-trw6bd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fear of the unknown is one of the specific fears around death.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jacobsurland/15375292758/in/photolist-pqEoSs-fSb7hj-pws4Si-p4hDE3-nCSsd7-hJVpMs-rLHsvu-o8D4uA-acuvkc-6PUA2J-aF62p3-bY7Xso-dgSXGy-pEkihZ-quEQzB-iWmTu8-ny59Fr-9t28Te-h7y2MT-6kKhML-7JUpLo-eQh22B-oqaxCF-rcKPJP-ch6bHL-qUHV8W-rCLexo-72RYrR-o2aguC-fM7ZaN-kQfa9-8gd3K8-5Rk4Nq-p4fPU2-fDE4S4-dYvXHn-gtCSCJ-st7rE7-rTKWvE-nHKdQD-srkHJ1-mT4m8N-oxqQQR-qRaoNU-dwa7Js-byNSsw-8psw14-e8gpUM-9K9Un5-nWQiCc">Jacob Surland/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>If presented with a client who has death anxiety, we would ask them to tell us exactly what they fear about death. Yalom <a href="http://www.yalom.com/intsaloncontent.html">once asked a client</a> what bothered him most. The client replied, “The next five billion years with my absence.”</p>
<p>Yalom then asked, “Were you bothered by your absence during the last five billion years?”</p>
<p>The specific death fear will be different for everyone, but it can often be categorised into one of <a href="https://books.google.com.au/books?id=2mKOAgAAQBAJ&pg=PR10&lpg=PR10&dq=Brad+Hunter+Relinquishment+of+certainty:+A+step+beyond+terror+management.&source=bl&ots=CNC45jlV8n&sig=1bzhxh8D45Dt-BOHwl-UiEGXLdY&hl=en&sa=X&ved=0ahUKEwif_uDKzt3MAhUDqJQKHRtmCJ0Q6AEIGzAA#v=onepage&q=Brad%20Hunter%20Relinquishment%20of%20certainty%3A%20A%20step%20beyond%20terror%20management.&f=false">four areas</a>: loss of self or someone else; loss of control; fear of the unknown – what will happen after death (nothingness, heaven, hell); and pain and suffering of dying. </p>
<p><a href="https://www.psychotherapy.net/article/the-gift-of-therapy">Yalom</a> suggests psychologists speak about death directly and early in therapy. The psychologist should find out when the client first became aware of death, who he discussed it with, how the adults in his life responded to his questions and whether his attitudes about death had changed over time.</p>
<p>Once we understand the client’s relationship to death, there are several approaches to help manage the associated anxiety. These include <a href="http://www.scielo.mec.pt/pdf/aps/v24n3/v24n3a04.pdf">existential therapy</a>, <a href="http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/h0087832">cognitive-behaviour therapy</a>, <a href="https://www.newharbinger.com/get-out-your-mind-and-your-life">acceptance and commitment therapy</a> and <a href="http://onlinelibrary.wiley.com/doi/10.1111/bjc.12043/abstract">compassion-focused therapy</a>.</p>
<h2>How to treat death anxiety</h2>
<p>In <a href="http://onlinelibrary.wiley.com/doi/10.1002/da.20093/abstract">one of the first studies</a> to examine death anxiety directly, cognitive-behaviour therapy (CBT), was found to be successful in treating it in those suffering from hypochondria. The strategies used included exposure (going to a funeral), relaxation strategies (breathing) and creating flexible thoughts around death, such as recognising that fearing death is normal.</p>
<p>Some <a href="http://www.psychevisual.com/Video_by_Ross_Menzies_on_The_Dread_of_Death_and_its_Role_in_Psychopathology.html">researchers argue</a> that CBT should include strategies that explore the probability of life events – such as calculating the chances of your parents’ meeting and having you. Such techniques can shift our perspective from a negative fear of dying to a positive realisation we are lucky to experience life at all.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=537&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=537&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=537&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=675&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=675&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122774/original/image-20160517-15912-1d1gwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=675&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We must learn to accept death. It’s not going away.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Existential therapy has been <a href="http://www.sciencedirect.com/science/article/pii/S0272735814001354">shown very useful</a> in treating death anxiety. It focuses on ultimate existential concerns such as isolation. For instance, we have a deep need to belong and having family and friends means, in some way, we live on after death.</p>
<p>Treatment is directed at finding meaning and purpose in life, increasing psychological and social support, building relationships with friends and family and improving coping skills to manage anxiety in daily life. </p>
<p>In compassion focused therapy (CFT), the client is encouraged to <a href="http://apt.rcpsych.org/content/15/3/199?r=1&l=ri&fst=0">descend into the reality</a> of human experience. That means realising we only have about 25,000 to 30,000 days of life. Suffering is <a href="http://onlinelibrary.wiley.com/doi/10.1111/bjc.12043/abstract;jsessionid=2662BD1A7BE5AC1B907998F122903F49.f01t04?userIsAuthenticated=false&deniedAccessCustomisedMessage=">normalised and the emphasis</a> is on the fact that the trajectory of life is the same for everyone: we come into this world, grow and flourish and then decay and die.</p>
<p>CFT discusses how the human brain has the fantastic ability to imagine and question our very existence – as far as we know a uniquely human quality. We will then say to clients: “Did you design your brain to have that capacity?” Of course the answer is a resounding no. </p>
<p>So we work on the principle that it is not the client’s fault they have death anxiety but that we must work with our brains so they don’t paralyse our ability to live now. </p>
<p>In CFT we will sometimes use the phrase, “Our brains were designed for survival not happiness”. Strategies arising form this include guided discovery (slowing down and giving clients opportunities to make their own insights) and <a href="https://soundcloud.com/dennis-tirch-phd/soothing-rhythm-breathing">soothing rhythm breathing</a>.</p>
<p>Although subtly different in approach these therapies have a similar underlying theme. Death is something we must learn to accept. The key for us in the context of death anxiety is how we get out of our minds and into our life.</p>
<h2>Some tips that could help</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122775/original/image-20160517-15937-1a1bzfl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The human brain has a unique capacity to question its own existence.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>If you struggle with death anxiety, please consider seeing a psychologist. But for now, here are three tips that might be helpful.</p>
<ol>
<li>Normalise the experience: We have tricky brains that allow us to question our existence. This is not your fault but is how the human brain was designed. It is perfectly normal to have a fear of death; you are not alone in this struggle.</li>
<li>Breathe: When you notice anxiety entering your body and mind, try to engage in some soothing breathing to help slow down your mind and physiological response.</li>
<li>Write your own eulogy as if you’re looking back over a long life: Pretend it is your funeral and you have to give the eulogy. What would you write? What would you have wanted your life to be about? This might provide some meaning and purpose for how to live your life now.</li>
</ol>
<hr>
<p><em>James will be on hand for an Author Q&A between 3 and 4pm AEST Wednesday May 18. Leave your questions in the comment field below.</em></p><img src="https://counter.theconversation.com/content/59384/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Kirby is a co-author of the Grandparent Triple P program. The Triple P – Positive Parenting Program is owned by The University of Queensland. The University, through its technology transfer company Uniquest Pty Ltd, has licensed Triple P International Pty Ltd to disseminate the program worldwide. Royalties stemming from this dissemination work are paid to UniQuest, which distributes payments to the University of Queensland Faculty of Social and Behavioural Sciences, School of Psychology, Parenting and Family Support Centre, and contributory authors in accordance with the University's intellectual property policy. No author has any share or ownership in Triple P International.</span></em></p>If presented with a client who has death anxiety, we ask them to tell us what exactly they fear about death. Once we have this information, there are several approaches to treating fear of death.James Kirby, Research Fellow in Clinical Psychology, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/580572016-05-16T19:55:42Z2016-05-16T19:55:42ZAdults can help children cope with death by understanding how they process it<figure><img src="https://images.theconversation.com/files/121107/original/image-20160504-19860-dvwexz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's important to have age-appropriate dialogue with children about death.</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1433209980324-3d2d022adcbc?ixlib=rb-0.3.5&q=80&fm=jpg&crop=entropy&s=277a79d3ce8e40c65b8493e45cd78c22">Micah. H/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This article is the second in our <a href="https://theconversation.com/au/topics/coping-with-mortality">Coping with Mortality</a> series, which looks at fear of death across the ages and how to cope with the dying process. You can read yesterday’s article on how death anxiety underlies most of our phobias <a href="https://theconversation.com/fear-of-death-underlies-most-of-our-phobias-57057">here</a>.</em></p>
<hr>
<p>Our society is death-phobic, a particularly harmful trait when it comes to helping children process the death of someone close to them. Adults often feel uncomfortable discussing death with children. They might consciously or unconsciously inhibit tears or other emotions, assuming they are protecting those too young to understand the weighty concept.</p>
<p>But age-appropriate discussions about death allow children to share thoughts and feelings they inevitably have when someone they know dies. Helping them normalise these can best be done by understanding children’s perceptions of death at varying developmental stages.</p>
<h2>Understanding death</h2>
<p>As children develop, their understanding of death changes and expands. In 1948, <a href="http://www.tandfonline.com/doi/abs/10.1080/08856559.1948.10533458">psychologist Maria Nagy presented</a> a pioneering study that found a relationship between age and a child’s comprehension of death. The study showed three distinct stages. </p>
<p>Children between the ages of three and five, she argued, tended to deny death as a final process but associated it with a journey from which someone would return.</p>
<p>In the second stage, between the ages of five and nine, children understood that death was final but kept the knowledge at a distance. They also thought if they were clever about it, they could trick death and avoid it. </p>
<p>The third and final stage was when children were nine and ten. At this point, they understood death was inevitable and affected everyone, including themselves. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121108/original/image-20160504-1305-j290d2.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children’s understanding of death expands as they grow and develop.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/W9ULJJwG2fA">Michal Parzuchowski/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Nagy’s study relates well to clinical psychologist Jean Piaget’s work, which is drawn on by many child psychologists and educators.</p>
<p>Piaget explained <a href="https://books.google.com.au/books/about/Piaget_s_Theory_of_Cognitive_and_Affecti.html?id=XawkAQAAMAAJ&redir_esc=y">children’s understanding</a> through the following developmental stages:</p>
<ol>
<li><p>Sensorimotor (0-2 years): death is “out of sight, out of mind”.</p></li>
<li><p>Preoperational (2-7 years): Magical thinking and egocentricity are predictable attributes of grief that predominate this stage, meaning children feel responsible for what happens to them and the world around them. When five-year-old Olivia screams at her sister Sophie, “I hate you! I wish you were dead!” and the next day Sophie is killed in a car crash, magical thinking can make Olivia feel she caused this death. She may then need an outlet for her overwhelming guilt.</p></li>
<li><p>Concrete Operations (7-12 years): This is an intermediate stage when children’s thinking matures, becoming more logical. This stage is characterised by curiosity, which could explain why <a href="http://www.theatlantic.com/magazine/archive/2012/03/horror-for-kids/308885/">children this age love reading books</a> and watching films about zombies and skeletons.</p></li>
<li><p>Formal Operations (13 years and up): An adolescent perceives death as distant, at the far end of a long life. But when someone they know dies, they will seek support from peers.</p></li>
</ol>
<h2>Helping children process death</h2>
<p>Research <a href="http://onlinelibrary.wiley.com/doi/10.1037/h0079366/abstract;jsessionid=844AFCAC4A49E6461D18CE9A27B54ED2.d02t02">exploring how bereaved children</a> maintained connection to their parents in the year following their death found that, out of 125 young people in the study, 92 (74%) believed their parents were in a place called heaven. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121105/original/image-20160504-19847-t6qft6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tasks such as drawing a picture of heaven can help comfort children.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The findings underscored the importance of helping children put their relationship with the deceased in a new perspective, rather than encouraging them to separate from it. Supporting a child’s reconstruction of a dead parent includes strategies of connection such as locating the deceased, experiencing the deceased, reaching out to the deceased and using linking objects. </p>
<p>An example of maintaining this connection was a story 11-year-old Michelle wrote and a picture she drew about heaven after her mum died in a car crash. These made her <a href="http://www.amazon.com/Great-Answers-Difficult-Questions-About/dp/1849058059">feel comforted</a> and safe as she was able to hold a positive image of where her mother was. Michelle’s vision was illustrated like this: </p>
<blockquote>
<p>There are lots of castles where only the great live, like my mum … My mum loved to dance. I think she’s dancing in heaven.</p>
</blockquote>
<p>Adults can follow a generic model to support bereaved children. First, they should <a href="http://www.grievingchildren.net/helpful-tips/">tell children the truth about death</a>, considering their developmental stage and understanding.</p>
<p>This could mean <a href="https://books.google.com.au/books?id=wVMlAgAAQBAJ&source=gbs_similarbooks">using phrases</a> such as: </p>
<blockquote>
<p>Usually people die when they are very very old or very very sick, or their bodies are so injured the doctors and hospitals can’t help, and a person’s body stops working.</p>
</blockquote>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121102/original/image-20160504-11494-121jk7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children must be considered as recognised mourners and allowed to attend funerals and memorials.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>When it comes to very young children, it is useful to use concrete language and images while avoiding cliches that can inhibit the grief process. If we tell little Johnny that grandpa went on a long journey, he might imagine grandpa coming back or ask why he didn’t say goodbye.</p>
<p>Second, we must let children be recognised mourners, attending funerals and memorials. Research shows <a href="http://ome.sagepub.com/content/25/4/319.abstract">attending funerals helps children</a> acknowledge the death and honour their deceased parent.</p>
<p>It is helpful to become aware of common signs of grieving children, such as: wanting to appear normal, <a href="http://www.amazon.com/Great-Answers-Difficult-Questions-About/dp/1849058059">telling and retelling their story</a>, speaking of the loved one in the present and worrying about their health or the health of others.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/121113/original/image-20160504-6918-qauc76.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rituals can help children work through grief.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/LkHXBKpwhZ8">Gianandrea Villa/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Adults can encourage kids to use rituals to work through grief. They can say a prayer, send off a balloon, sing a song, plant a flower, write a poem or bury a dog bone. Grieving children can express themselves through memory books, memory boxes, photos and even memory emails. </p>
<p>Girls and boys may have a restricted verbal ability for sharing feelings and a limited emotional capacity to tolerate the pain of loss, but <a href="http://www.guilford.com/books/Helping-Bereaved-Children/Nancy-Boyd-Webb/9781462504510/reviews">they can communicate their feelings</a>, wishes and fears through play. Play therapy can include using imagination and interacting with toy props. A toy telephone can stimulate a child’s dialogue with a loved one. </p>
<p>Childhood grief and loss cover the gamut of life issues but we can empower them by offering age-appropriate language and grief interventions that open safe exploration and communication of feelings.</p><img src="https://counter.theconversation.com/content/58057/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda Goldman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Children’s perceptions of death vary with developmental stages. Understanding these is key to helping them normalise their thoughts and feelings when someone they know dies.Linda Goldman, Professor of Thanatology, King's University CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/570572016-05-15T19:47:50Z2016-05-15T19:47:50ZFear of death underlies most of our phobias<figure><img src="https://images.theconversation.com/files/120926/original/image-20160503-19512-x821j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some people focus their fear of death on smaller and more manageable threats.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/pimthida/5418964298/in/photolist-9fRBhW-5zeB54-6otJia-9eyFvf-63Kkd4-4wgp5g-5JyLGJ-63jHR-49L188-5jhvWc-6EAERh-dVGK3L-cyob43-oPD7kt-pjQTT-pyDRL-6PsDnM-x11QJ6-5pCwdV-8A8Mku-24CpzJ-wGs6a3-5RhNyi-4n81L5-dUpKDY-3PxNn-aRN7fT-5oYpoD-4BZZhD-saYoQz-dudTZ5-9WdKwK-b8ALTR-4pSDhX-edWwLF-opWGzz-2KNNJZ-iMzU6e-mbDwqv-iMzXfk-4vZzNp-4ai2Sq-7pAyAs-qBLqtr-6L3ZrL-nF9nvU-AiLRb-9C55VB-iMzXFF-iMACCE">Pimthida/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>This is the first in our <a href="https://theconversation.com/au/topics/coping-with-mortality">Coping with Mortality</a> series, which looks at fear of death across the ages and how to cope with the dying process. Read the next article on helping children process death <a href="https://theconversation.com/adults-can-help-children-cope-with-death-by-understanding-how-they-process-it-58057">here</a>.</em></p>
<hr>
<p>Awareness of our mortality is part of being human. As author and existential philosopher <a href="https://mafhom.files.wordpress.com/2012/11/staring-at-the-sun-yalom.pdf">Irvin Yalom said</a>, we are “forever shadowed by the knowledge that we will grow, blossom and, inevitably, diminish and die”. </p>
<p>There is growing <a href="http://psycnet.apa.org/books/13748/001">research exploring</a> the overwhelming anxiety that the inevitability of death, and our uncertainty about when it will occur, has the power to create. A social psychological theory, called <a href="http://web.missouri.edu/%7Esegerti/capstone/Arndt.pdf">terror management theory (TMT)</a>, is one way to understand how this anxiety influences our behaviour and sense of self. </p>
<h2>Coping mechanisms</h2>
<p>According to this theory, we manage our fear of death by creating a sense of permanence and meaning in life. We focus on personal achievements and accomplishments of loved ones; we take endless photos to create enduring memories; and we may attend church and believe in an afterlife. </p>
<p>These behaviours bolster our self-esteem and can help us feel empowered against death. For some, however, periods of stress or threats
to their health, or that of loved ones, <a href="https://books.google.com.au/books/about/The_Psychology_of_Death.html?id=dMfC9N2BoDAC">may result in ineffective and pathological</a>
coping mechanisms.</p>
<p>These people might <a href="http://www.tandfonline.com/doi/abs/10.1080/08873267.2012.732155">focus their real fear of death</a> on smaller and more manageable threats, such as spiders or germs. Such phobias may appear safer and more controllable than the ultimate fear of death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120924/original/image-20160503-19538-qdw0yz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We might take endless photographs to create a sense of permanence.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1442507210693-938e0e77fef2?ixlib=rb-0.3.5&q=80&fm=jpg&crop=entropy&s=cfd25c0a66804cec5e2d5b6eee7af581">Annie Spratt/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This makes sense because when we <a href="http://www.sciencedirect.com/science/article/pii/S0272735814001354">look closely at the symptoms</a> of several anxiety-related disorders, death themes feature prominently. </p>
<p>When children experience separation anxiety disorder, it is <a href="http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">often connected to excessive fear</a> of losing major attachment figures – such as parents or other family members – to harm or tragedy from car accidents, disasters or significant illness.</p>
<p>Compulsive checkers repeatedly check power points, stoves and locks in an <a href="https://www.australianacademicpress.com.au/books/details/125/DIRT_Danger_Ideation_Reduction_Therapy_for_Obsessive_Compulsive_Checkers_A_Comprehensive_Guide_to_Treatment">attempt to prevent harm</a> or death. <a href="https://www.researchgate.net/publication/280142510_Menzies_R_G_Menzies_R_E_Iverach_L_2015_The_role_of_death_fears_in_Obsessive_Compulsive_Disorder_Australian_Clinical_Psychologist_1_6-11">Compulsive hand washers often fear</a> contracting chronic and life-threatening diseases.</p>
<p>People with panic disorder frequently visit the doctor <a href="http://www.jpsychores.com/article/S0022-3999(97)00135-9/abstract">because they’re afraid</a> of dying from a heart attack. Meanwhile, those with somatic symptom disorders, including those formerly identified as hypochondriacs, frequently request medical tests and body scans to identify serious illness. </p>
<p>Finally, specific phobias are characterised by excessive fears of heights, spiders, snakes and blood – all of which are associated with death. Phobic responses to seeing a spider, for instance, typically involve jumping, screaming and shaking. Some <a href="http://psp.sagepub.com/content/early/2007/06/01/0146167207303018.short">researchers argue</a> these extreme responses could actually represent rational reactions to more significant threats, such as seeing a person with a weapon.</p>
<h2>Priming death</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120929/original/image-20160503-19521-br2obh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Compulsive hand washers used more paper towels when primed with death.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>More evidence for the TMT hypothesis comes from studies showing that death anxiety is capable of increasing anxious and phobic responding.</p>
<p>These studies use a popular “<a href="http://psr.sagepub.com/content/14/2/155.abstract">mortality salience induction</a>” technique to prime death anxiety in people with other anxiety disorders. The technique involves <a href="http://psr.sagepub.com/content/14/2/155.abstract">participants writing down</a> the emotions that the thought of their own death arouses, as well as detailing what they think will happen as they die and once they are dead. </p>
<p>Spider phobics primed like this had <a href="https://arizona.pure.elsevier.com/en/publications/terror-mismanagement-evidence-that-mortality-salience-exacerbates">increased reactions</a> to spiders, such as avoiding looking at spider-related images, when compared to spider phobics not primed with death. And compulsive hand washers spent more time washing their hands and used more paper towels when primed with death.</p>
<p>Likewise, <a href="http://www.tandfonline.com/doi/full/10.1080/02699931.2015.1065794#.VyFiVEIqv8s">those with social phobias took longer</a> to join social interactions. After they had been reminded of death, they also viewed happy and angry faces as more socially threatening – as <a href="http://www.ncbi.nlm.nih.gov/pubmed/17884328">these faces indicate judgement</a> – than neutral, seemingly innocuous faces. </p>
<h2>Is fear of death normal?</h2>
<p>Given that we are all going to die at some point, death anxiety is a normal part of the human experience. For many of us, thinking about death can evoke fears of separation, loss, pain, suffering and anxiety about leaving those we love behind. </p>
<p>According to terror management theory, this fear has the power to motivate a life well lived. It stimulates us to cherish those we love, create enduring memories, pursue our hopes and dreams and achieve our potential. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/120437/original/image-20160428-30953-vsm8kq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Death anxiety is a normal part of human experience.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/bSYRuzEaT5k">Neil Thomas/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Death anxiety becomes abnormal when it forms the basis of pathological thoughts and behaviours that interfere with normal living. Many obsessive-compulsive hand washers and checkers <a href="http://www.researchonline.mq.edu.au/vital/access/manager/Repository/mq:42972">spend significant amounts of time</a> each day in ritualistic behaviours designed to reduce the threat of dirt, germs, fire, home invasion or threats to themselves and loved ones. </p>
<p>Similarly, those with phobias may go to extreme lengths to avoid what they fear and react with extreme distress when confronted with it. When these thoughts and behaviours lead to impaired functioning, anxiety is no longer considered “normal”.</p>
<p>Treatments, such as cognitive behaviour therapy, for a range of disorders may need to incorporate new strategies that directly address death anxiety. Without such innovation, the spectre of death may tragically haunt the anxious across their lifespan, until it is too late.</p><img src="https://counter.theconversation.com/content/57057/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We manage our fear of death by creating a sense of permanence and meaning in life. But for some people, death anxiety results in pathological coping mechanisms, such as being afraid of spiders.Lisa Iverach, Honorary Associate at Department of Psychology, Macquarie University and Research Fellow, University of SydneyRachel E. Menzies, PhD candidate, Clinical Psychology, University of SydneyRoss Menzies, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.