THE LANDSCAPES OF OUR PATIENTS’ JOURNEYS
By Keith A. Rasey, M. Div., LNHA Chaplain
Copyright 2011 Keith A. Rasey
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TABLE OF CONTENTS
Chapter One: Preparing to Join the Journey
Chapter Two: Surveying the Landscapes
Chapter Three: The Landscape of Fear
Chapter Four: The Landscape of Death Avoidance
Chapter Five: The Landscape of Neutral Acceptance
Chapter Six: The Landscape of Approach Acceptance
Chapter Seven: The Landscape of Escape Acceptance
Chapter Eight: The Variegated Landscape: All Over the Place
I owe a great debt to many people. Jeanne Bennett, teacher of the adult development class at Kent, piqued my interest in the ways people face the final wave aka death. Sue McCausland urged me to submit a proposal for the workshop out of which this book grew. Jennifer Cleric was kind enough to review most of the content. Father Ed Luca was very kind to loan me two hymnal/service books from the Roman Catholic tradition. Michelle Vancisin, my daughter, a published author in her own right, helped me with putting it in a format that was useable by ebooks.
Diane Davies Rasey, my wife, was kind enough to read the manuscript and offer suggestions on how to sharpen it.
Of course, any mistakes in the book are completely my own responsibility as, to quote, the Psalmist, “my sins are ever before me.” Please contact me to report errors or formatting issues at krasey1@kent.edu .
Although I wanted to do a more expansive work that included resources from all the major religions, it soon became apparent that would be unworkable. I hope this will be useful to those who accompany patients and their loved ones at the end of their lives here.
Keith A. Rasey, M. Div, LNHA
Medina, Ohio 2011
It has only been a short time that I have had the privilege to work with Keith Rasey in hospice care. We have had the opportunity to work together in building a new hospice program from the ground up. During this time, I have come to know him as deeply thoughtful, highly intelligent, and fiercely passionate about hospice care. He obtained his Master of Divinity degree from Yale University and has led a number of Christian congregations. He has been a pioneer in the hospice movement, having provided pastoral care to the very first hospice patient in the United States in 1977. While he has done various types of work in his lifetime, his calling has always been the care of the dying.
This book itself has been an intense challenge as well as a labor of love. Because of his commitment as a spiritual counselor in hospice care, Keith has found the writing and creative process to also be an evolution in his career as well as a time of growth in his perception of self.
In the time that I have been working alongside Keith, I have been convinced of the power found in relating to each individual’s narrative during end of life care, and the importance of relating to them within that context. As caregivers we are always striving to improve our practice and do better by our patients and families. Herein is a powerful reminder that for all our knowledge and expertise, we have the opportunity to not only provide silent witness or passive presence, but allow the patient to guide us on their journey. We can bear witness on this journey to the grave spiritual concerns they face at end of life, and with insight we may have permission to provide individualized spiritual care.
This book provides a construct in which the patient ‘journeys through a landscape’ as a metaphor for the emotional and spiritual experiences we witness at the end of life. The skilled nature of our care as professionals compels us to search for a way to individualize our response to spiritual distress or pain. This construct allows for just that. Rasey shows us how the use of a data collection tool that helps identify the domain or ‘landscape’ in which the patient finds themselves can help us individualize spiritual care. He shows us how we can come alongside the patient in presence, but also helping them identify landmarks in the landscape. In other words, we can learn how to journey with the patient and help them identify issues or concerns they need to address, instead of imposing a cookie cutter solution of what we think might help.
Most importantly, it is about the patient’s journey. Not our response to it. The patient remains the center of care. And the better we are able to assess and develop insight about the landscape through which they travel, the more focused and effective our care can be.
Jennifer Cleric RN, ND
Aurora, Ohio 2011
The variety of landscapes our patients journey through is breathtaking. Some are mountainous. Some are plains. Some are valleys.
Some are lush and can nurture all kinds of life. Some are arid and it is difficult for any living creature to survive.
Some are stony with monochromatic colors and themes. Some are full of beautiful flowers that make the journey pleasant.
Some landscapes are a combination of many different kinds of terrain and flora and fauna that change with the seasons.
The landscapes can change from day to day, sometimes even hour to hour, minute to minute.
If we listen to our patients and their loved ones, we can discern the contours of the landscapes through which they are traveling. The words, metaphors, symbols and imagery they use will unfold their landscapes for us. The often asked question of end of life caregivers, “What do you say to someone who is dying?” is answered by a deep listening in which we use the language of the patients’/families’ own landscapes to let them know we are listening, we are present.
We do not have to search for our responses because the language, even when it is just silent witness, is given to us through the act of listening while fully present and available to them. They are not alone.
We help validate their journeys by accompanying them. In the end, the ideal and ultimate goal of our companionship with them is to reassure them that it was worth the trip—for both them and for us.
Preparing to Join the Journey
Before we can effectively accompany our patients and their families through the landscapes of their journeys, we have to be sure we have all we need to be helpful and useful. The main instrument of our accompaniment will be our own beings. Who we are and how we are will determine if we can be fully present with our patients to completely hear and employ the words, symbols, metaphors and images they use to describe the landscapes they are traversing.
It was axiomatic, for example, in medieval Christian thought that only one who was fully ready to die was capable of fully living. Momento Mori, “remember you will die,” is one of the mantras intimately connected with contemplative prayer and spiritual formation, especially in monasticism (cf. http://inspirituetveritate.blogspot.com and the comments there about “Momento Mori and Joy”). To be aware of one’s own mortality and humble “creatureliness” (See Note 1) is to realize that now is the time we have. Of the time before we were born there is no personal memory and of the time after death, there is only the hope. Now is the time to embrace life.
This may seem morbid to modern and postmodern sensibilities as we are used to the many ways in which the emphasis on progress has repressed the fact that every creature has a lifespan with a beginning and an end (See Note 2). Those who are accustomed to relating to persons who know they are going to die—and it is more imminent than most are willing to acknowledge— realize the freedom and liberation that comes from this knowledge.
But this liberation from the many cares that keep us from fully living, with the terrible knowledge of our mortality, in the glory of each moment is something that caregivers are to practice with our own attitudes and habits if we are to realize its benefits for our patients. It means we are to be fully capable of overcoming the alienation we have between our bodies and our “souls,” our hearts and our minds (See Note 3).
The ability to fully hear and completely listen—with all our being—to our patients and families is the necessary prerequisite to accompanying them effectively through the landscapes of their journeys. Thus, overcoming the duality between any opposites within our own being becomes crucial. Our effectiveness as listeners, witnesses and companions requires that we become bodysouls, mindhearts, complete and whole human creatures.
As Lao Tzu said it:
Is there a difference between yes and no?
Is there a difference between good and evil?
Must I fear what others fear? What nonsense!
Having and not having arise together
Difficult and easy complement each other
Long and short contrast each other
High and low rest upon each other
Front and back follow one another.
To those of a more philosophical bent, it may be helpful to remember what Alfred North Whitehead wrote about the unitary nature of all that is.
“That is, all the things and events we usually consider…irreconcilable, such as cause and effect, past and future, subject and object, are actually just like the crest and trough of a single wave….For a wave, although itself a single event, only expresses itself through the opposites of crest and trough, high point and low point. For that very reason the reality is not found in the crest nor the trough alone, but in their unity (try to imagine a wave with crests but no troughs). Obviously, there’s no such thing as a crest without a trough, a high point without a low point. Crest and trough—indeed all opposites—are inseparable aspects of one underlying activity.” (See Note 4).
To approach our patients and families with only our hearts or our minds is to not fully use all of the resources we have been given and developed. An approach which is all heart may be so full of sentimentality that it will not be effective. An approach which is all mind may be equally ineffective because it will seem heartless, inauthentic and hollow.
Henri Nouwen has reminded us of the resources of the Desert Fathers and Mothers for spiritual practices that can help us overcome this alienation. In The Way of the Heart he writes of what happens when we think of prayer as something we do with part of our being:
For many of us prayer means nothing more than speaking with God. And since it usually seems to be a quite one-sided affair, prayer simply means talking to God. This idea is enough to create great frustrations. If I present a problem, I expect a solution; if I formulate a question, I expect an answer; if I ask for guidance, I expect a response. And when it seems, increasingly, that I am talking into the dark, it is not so strange that I soon begin to suspect that my dialogue with God is in fact a monologue. Then I may begin to ask myself: To whom am I really speaking, God or myself? (See Note 5).
Please note the duality of how he states this view of prayer: problem/solution, question/answer, guidance/response. Approaching our spiritual preparation—whatever we call it—as if it is separate from our personhood and our work is a formula for failure. It reinforces the alienation that prevents us from being fully present with our patients/families.
Nouwen goes on to say more about just approaching preparation with our minds:
“But there is another viewpoint that can lead to similar frustrations. This is the viewpoint that restricts the meaning of prayer to thinking about God. Whether we call this prayer or meditation makes little difference. The basic conviction is that what is needed is to think thoughts about God and his [sic] mysteries. Prayer therefore requires hard mental work and is quite fatiguing, especially. If reflective thinking is not one of our strengths. Since we already have so many other practical and pressing things on our minds, thinking about God becomes one more demanding burden. This is especially true because thinking about God is not a spontaneous event, while thinking about pressing concerns comes quite naturally.”(See Note 6).
The answer, for the Desert Fathers and Mothers, comes by entering with our minds into the sanctuary of our hearts to present all of ourselves to God. In this practice, alienation becomes swallowed up in wholeness, we are truly skilled and experienced at being body/souls, mind/hearts and can offer this wholeness (note the connection of that word to holiness) to our patients/families.
We find the best formulation of the prayer of the heart in the words of the Russian Theophan the Recluse: “To pray is to descend with the mind into the heart, and there to stand before the face of the Lord, ever-present, all-seeing, within you.” Prayer is standing in the presence of God with the mind in the heart; that is, at that point of our being where there are no divisions or distinctions and where we are totally one. There God’s Spirit dwells and there the great encounter takes place. There heart speaks to heart, because there we stand before the face of the Lord, all-seeing, within us (See Note 7).
It is not even necessary to put this in a religious context. From a psychological perspective, the ideal is to be self-differentiated—a person who is sufficiently self developed to be able to posit “I” when others are putting on the pressure to say the blaming “you” or the co-opting “we.” The difference between self-differentiation and narcissism is that the self-differentiated person is still connected by relationship with others. She is not isolated but rather defines herself by her relationships, especially their quality, with others. The narcissist is too wrapped up in herself to take the time to form quality relationships of depth with others.
The caregiver who is self-differentiated will be able to be connected to the patients and families without being fused with their grief or fear or anger or terror. Without sufficient self-differentiation, one can become so fused with the issues and feelings of the patient/family that the intensity squeezes the life out of all concerned. Fusion overwhelms the caregiver and makes the caregiver ineffective. In the long run, it leads to exhaustion and burn out.
This can be illustrated by the difference between a circuit of light bulbs that is connected in series and a circuit that is connected in parallel. In the circuit that is connected in series, when one light goes out, they all go out. This is fusion—the darkness of one unit magnifies the darkness of all. The dis-ease is catching.
Those who are connected like a parallel circuit, represent precisely the opposite. When one experiences terror or grief or pain, all the others continue to shine offering, by their presence, respite and wholeness.(See Note 8).
Another way to explore fusion can be borrowed from ego psychology. The collapse of ego boundaries leads to role overfunction which may result in harm to the caregiver and the patient/family. It is commonly known, in ethical terms, what it means to violate the boundaries of a patient as far as information or privacy or unhealthy touching and sexualized attention. The goal of healthy boundaries is to prevent fusion by encouraging the caregiver to “stay in their own skin” and not be overwhelmed by the needs or concerns of the patient/family. Here it becomes necessary to know the limits of one’s own boundaries so as not to assume a godlike relationship in meeting the needs of the other. This also prevents burn out by encouraging the self-care of maintaining healthy boundaries. Only a god is available all the time, 24 hours, seven days a week. The rest of us are to savor our limits and keep our boundaries inviolate in order to bring our own healthy selfhood as an instrument of healing and hope to our patients.
To overfunction in our role as caregivers and be fused is to do more for the patient than is in the best interest of the patient’s maximal functioning, integrity and well being. Greater life satisfaction, and better outcomes, result when we only provide the care for the patient that the patient cannot perform for him or herself. To encourage the patient to provide as much self care and self regulation as possible is to truly help them live until they say good bye. Fusion deprives the patient of autonomy and transfers the benefits of the joys of their living more to the caregiver rather than primarily to the patient.
A helpful metaphor, by Henri Nouwen, is to think of two separate hands. If each hand has its fingers tightly intertwined with the fingers of the other, they will form a two handed fist with all the violence that can imply. They are fused—so closely intertwined they are squeezing the life out of each other. In a healthy relationship that is not fused, each hand oscillates, in a kind of relational dance, back and forth with the other. At times, the two separate hands can come together in a prayer or Namaste position which transcends the “aloneness” of each and points to the transpersonal realm of everlasting peace.
Buddhism is particularly helpful in offering a way of imagining this process of spiritual preparation/self-differentiation which is a prerequisite for effectively accompanying our patients/families on their journeys. Joan Halifax, a Zen Priest, in Being with Dying, reaffirms the necessity of preparing for dying in order to fully live. In fact, she notes it is one of the central tenets of Buddhist meditative practice:
After four decades of sitting with dying people and their caregivers, I believe that studying the process of how to die well benefits even those of us who may have many years of life ahead. Yet, the sooner we can embrace death, the more time we have to live completely, and to live in reality. Our acceptance of our death influences not only the experience of dying but also the experience of living; life and death lie along the same continuum. One cannot—as so many of us try to do—lead life fully and struggle to keep the inevitable at bay (See Note 9).
She notes one of the helpful meditative metaphors in Buddhism is “strong back, soft front.” By strong back she means the development of the practice of being rooted and grounded, through the posture of the spine, in one’s own center so that one has the strength to face all that comes one’s way. It would not be too misrepresentative—and I hope it is helpful— to note it helps us to unpack the meaning of this with the psychological concept of self-differentiation.
Please notice that the very way she refers to the meditative practice of “strong back, soft front” locates the strengthening of the whole person in the body. There is no separation of the body from the spirit or the temporal from the eternal. Meditative practice, in Buddhism, can be a way to be connected to the whole of the universe and all that is, was and will be. Duality and alienation are swallowed up in the practice of connecting to the “boundless abode.” In this way, we are fully and timelessly present with our patients/families.
By “soft front” she refers to a comfortable posture of the body of openness to all that is, was and will be. It is a stance of practicing the connection with the boundless abode that, by the very posture of the body, indicates one is open to receiving all that is offered or can potentially be offered. The bodily stance of “soft front” can be sitting upright with your hands at your knees of folded in your lap embodying your openness to those you are with.
“Soft front” is a way of envisioning meditative practice that prepares us to let our patients/families know that we are open to receive all that they have to offer, share and experience, no matter how wonderful, or how terrible. It grounds empathy in our spiritual practice and redeems it from mere sentiment.
When combined, the practice of “strong back, soft front” makes us accessible without overwhelming us with the patients/families’ concerns. It fully establishes we can accompany our patients/families anywhere in the landscape of their journey no matter how rugged or arduous. “”Strong back, soft front” makes us capable of withstanding any patient’s journey and grounds our care giving in a sustainable, long lasting professional posture.
“Strong back, soft front” in its combination of the one with the All and the body with the boundless abode, overcomes alienation and prepares us to be fully and completely present as we accompany our patients and families in the landscapes of their journeys and plumb the depths of their words, metaphors, symbols and images.
No matter how we envision or approach it— entering with our minds into the sanctuaries of our hearts, self-differentiation, “strong back, soft front”— each of these ways of preparing ourselves offers us the capability of effectively accompanying our patients/families as they navigate the landscapes of their journeys. The preparation sharpens our listening skills for we bring all of our beings to the moment. The preparation sharpens our abilities to notice the landscapes we traverse and note their uniqueness as well as their commonalities. This preparation enables us to recognize the challenges and the joys of each landscape so that the trip becomes worthwhile for the patients and the families. The landscape’s words, metaphors, symbols and images themselves, then, offer the nourishment we need to truly enjoy our work and thrive for the long run.
Ultimately, our preparation for being with our patients/families as they find their way through the landscapes of their journeys, not only makes us more effective, it sustains us for the long run by making it possible for us to see the gifts that the patients’/families’ landscapes offer us.
Confucius was presented with a life and death conundrum. Either thread a continuous fiber through nine small holes in a gem or die. What to do? Then he overheard a small girl, near a mulberry bush, say the Chinese word for “secret” which sounds like the Chinese word for “honey.” That provided the solution. He tied a thread from the mulberry bush onto an ant, dipped the gem in honey and let the ant blissfully solve the problem (See Note 10).
In all of our preparation and our companionship with our patients and families through the particular landscapes of their journeys, we can look for, and learn to recognize, the sweetness that makes all of the difficulties worthwhile. Without it, we are going through the motions. With it, we have found the nourishment in our patients’ landscapes that makes their trips worthwhile and helps us look forward to the next journey, and our own, with anticipation.
Surveying the Landscape
The Death Attitudes Profile-Revised
In The Psychology of Death, Robert Kastenbaum notes that the American health care system “prefers not to notice how people think, feel, and communicate at the point of death.”(See Note 1). He does concede that hospice personnel are “often” more sensitive to the needs of the dying and their loved ones but are just as likely as other health care providers to feel the pressure to do the paperwork necessary to fulfill the regulatory requirements and provide the medical care needed.
Kastenbaum’s research, using a kind of “modified psychological autopsy method,” helped better understand the specifics of the context of the “personality and lifestyle, and…the circumstances and events that a person had moved through as the end approached.”(See Note 2) This leads to better care and more sensitively appropriate responses and interventions. “We realized (sometimes too late) that having known the person a little better previously could have helped us offer more sensitive and appropriate care at the time that a…setting was becoming a deathbed scene” (See Note 3).
Efforts to more accurately assess the attitudes and beliefs of the dying and their loved ones are necessary, then, in order to provide the best possible care while there is still time for living, caring, laughing and loving.
There are many instruments available to assess acceptance of death and anxiety about its presence and, perhaps, imminence. The choice of the Death Attitude Profile-Revised (DAP-R) is somewhat arbitrary. It does, however, offer some advantages over other instruments. It is multidimensional, has content validity, internal consistency and is broader than many of the other instruments available.
The DAP-R, displayed at the end of this chapter, consists of 32 statements concerning attitudes toward death. The respondent is asked to rate his/her response either as Strongly Agree, Agree, Mostly Agree, Neutral, Mostly Disagree, Disagree or Strongly Disagree. Each response is evaluated by being given a number from one to seven, with one being Strongly Disagree and seven representing Strongly Agree.
The statements on the DAP-R are grouped into five dimensions, one of which will be explained in each of the succeeding five chapters (along with corresponding hymns, readings, prayer/meditation themes). For each dimension, the mean score can then be calculated by adding up the numerical value of all the responses and dividing by the statements in that dimension.
It is multidimensional in that it does not just measure death anxiety or death acceptance but these five factorially derived dimensions:
Fear of Death conceptualized as confronting death and the feelings of fear it evokes.
Death Avoidance conceptualized as avoiding all thoughts or references to death in order to reduce death anxiety.
Approach/Acceptance in which death is viewed as a gateway to a happy afterlife.
Escape Acceptance which is the view of death as escape from a painful existence.
Neutral Acceptance, the view that death is a reality that is neither feared nor welcomed. (See Note 4).
Other instruments measure death fear and or anxiety but not, always, acceptance and neutrality. For example, the Death Anxiety Scale measures just that, anxiety about death. Its Likert scale is also more limited to just three responses: “not at all,” “somewhat” and “very much.” The Collett-Lester Fear of Death Scale “was devised to provide a measure of death anxiety that distinguished between the fear of death and the fear of dying and between fears for oneself and fears for others” (See Note 5).
In comparison with these other instruments, then, one can see that the DAP-R is broader in its conception and assessment. But is it valid in its construction and its application?
To empirically test this, the researchers who created the DAP-R asked ten young, ten middle-aged and ten elderly persons to place each item (i.e. statement on the DAP-R) in each of the five categories where they think it conceptually fit. There was a large amount of agreement on the categories in which the statements were placed: “All 36 items reached our criterion of 70% agreement in classification. In fact, most of the items exceeded the 90% agreement level” (See Note 6).
So, the DAP-R has a significant content validity. This is also seen in the alpha coefficient of internal consistency, a statistical way of measuring whether each statement is consistently related to each other statement and if the responses to the statements are consistent. For example, suppose a person was to strongly agree with the statement, “I hate ice cream.” If, on the same instrument, the same respondent were to strongly agree with the statement, “I like chocolate ice cream,” the alpha coefficient between the two statements would indicate low internal consistency.
This is not the case with the DAP-R. The alpha coefficients of each of the five dimensions are relatively high and considered reliable. To verify this, the DAP-R was given again to the same 100 young adults, 100 middle aged adults and 100 older adults whose test scores were used to initially determine the content validity and internal consistency of the instrument. The same group, after taking the test again a month after the initial testing, had results that indicated high stability coefficients. This means that, over time, the DAP-R tends to be a helpful way of understanding the lasting views of the respondents.
There tend to be age and gender differences in the attitudes that people bring to their own ideation about death and the reality of their own. “Older adults were significantly more likely to accept death as an escape from life than were both the middle-aged and younger adults. Older adults were also more accepting of life after death, particularly in comparison with middle aged adults” (See Note 7).
It is interesting, and helpful, to note that older adults and younger adults were more likely than the middle aged to strongly agree with the Approach Acceptance dimension. “One plausible interpretation is that young adults may still have residues of beliefs in heaven from childhood. Such beliefs are eroded in middle age but revived in old age” (See Note 8).
Women “were significantly more accepting of life after death and of death as an escape from life than were men. Men, on the other hand, were significantly more prone to avoid all thoughts of death than were women” (See Note 9).
The ways in which these five dimensions can interact are only limited by the variety of human beings that die. A person who has a low fear of death and a high neutral acceptance lives in a much different landscape than one who has a low fear of death and a high escape acceptance. The latter may look forward with relish to the joy of being relieved of burdens while the former may just calmly accept the changes the coming of death brings as one observes the changing of the seasons of the year and watches the flora and fauna become transformed. “Therefore, it is the patterns of different death attitudes rather than the magnitude of a single death attitude that best captures individual differences” (See Note 10).
Neutral Acceptance and Approach Acceptance are, empirically, validated as the most adaptive dimensions in continuing a sense of well being, avoiding depression and living the life that one has left as completely and fully as possible. Approach Acceptance is most akin to what has traditionally been embraced as the “good death” in the Ars moriendi, the fourteenth Latin texts that have traditionally informed western cultural constructs of a “good death,” and in the Victorian Age (See Note 11). The words, symbols, metaphors and images patients/families use to describe this landscape will be easily related by most caregivers to hymns, readings and prayer/meditation themes.
The Escape Acceptance dimension is also amenable to the consoling and comforting resources available in religious traditions and spirituality. The landscape of Escape Acceptance is very familiar to most care givers. The flora and fauna and the typography will not seem alien to those who are accustomed to working with the dying and, to be effective and thrive in their work, have come to terms with their own mortality.
The most difficult landscape to walk through with our patients/families is Death Avoidance. How can one accompany someone who is denying they are on a journey? Comforting someone who is leaving when they do not acknowledge they are going, requires great sensitivity. Practicing the ministry of presence, being fully alive with the person in the landscape they choose to inhabit, may mean chatting about sports, celebrating family milestones, sharing a television show or just showing up with what Buddhists call “the beginner’s mind” to discover, anew, the patients’/families’ psychospiritual “field.” (I use” field” here in the Gestalt sense).
The implications of traversing each landscape and how the landscapes interact will be explored in the last chapter, “Variegated Landscapes: All Over the Place.”
It is not necessary to formally use the DAP-R as an assessment tool. It may seem arbitrary and may invoke hostility if not introduced with humble sensitivity to a situation in which there are so many forms to fill out and professionals making assessments. But keeping these dimensions in mind, if just informally, as caregivers discover the landscapes we share with our patients/families, will help us be more precise and helpful in our interactions. This is why effort was made to establish the content validity and internal consistency of these dimensions. The DAP-R does actually measure, and helps us plumb the depths, of each of its five dimensions.
These five dimensions can be conceptualized as representative of constellations of meaning. If we hear a patient/family say they have an intense fear of death, that alerts us to the fact that they probably also share the other six components or landmarks of that dimension.
In the next five chapters there is an explanation of each of the five dimensions and what religious and spiritual resources are applicable and helpful. I am sure the reader will bring the knowledge of his or her own hymns, readings and prayer/meditation themes to each of the dimensions. The resources are infinite and no one compilation can exhaust their number.
Death Attitude Profile-Revised (DAP-R)
Wong, P.T.P., Reker, G.T., & Gesser, G.
This questionnaire contains a number of statements related to different attitudes toward death. Read each statement carefully, and then decide the extent to which you agree or disagree. For example, an item might read: “Death is a friend.” Indicate how well you agree or disagree by circling one of the following: SA = strongly agree; A= agree; MA= moderately agree; U= undecided; MD= moderately disagree; D=disagree; SD= strongly disagree. Note that the scales run both from strongly agree to strongly disagree and from strongly disagree to strongly agree.
If you strongly agreed with the statement, you would circle SA. If you strongly disagreed you would circle SD. If you are undecided, circle U. However, try to use the undecided category sparingly.
It is important that you work through the statements and answer each one. Many of the statements will seem alike, but all are necessary to show slight differences in attitudes.
1. Death is no doubt a grim experience.
SD D MD U MA A SA
2. The prospects of my own death arouses anxiety in me.
SA A MA U MD D SD
3. I avoid death thoughts at all costs.
SA A MA U MD D SD
4. I believe that I will be in heaven after I die.
SD D MD U MA A SA
5. Death will bring an end to all my troubles.
SD D MD U MA A SA
6. Death should be viewed as a natural, undeniable, avoidable event.
SA A MA U MD D SD.
7. I am disturbed by the finality of death.
SA A MA U MD D SD
8. Death is an entrance to a place of ultimate satisfaction.
SD D MD U MA A SA
9. Death provides an escape from this terrible world.
SA A MA U MD D SD
10. Whenever the thought of death enters my mind, I try to push it away.
SD D MD U MA A SA
11. Death is deliverance from pain and suffering.
SD D MD U MA A SA
12. I always try not to think about death.
SA A MA U MD D SD
13. I believe that heaven will be a much better place than this world.
SA A MA U MD D SD
14. Death is a natural aspect of life.
SA A MA U MD D SD
15. Death is a union with God and eternal bliss.
SD D MD U MA A SA
16. Death brings a promise of a new and glorious life.
SA A MA U MD D SD
17. I would neither fear death nor welcome it.
SA A MA U MD D SD
18. I have an intense fear of death.
SD D MD U MA A SA
19. I avoid thinking about death altogether.
SD D MD U MA A SA
20. The subject of life after death troubles me greatly.
SA A MA U MD D SD
21. The fact that death will mean the end of everything as I know it frightens me.
SA A MA U MD D SD
22. I look forward to a reunion with my loved ones after I die.
SD D MD U MA A SA
23. I view death as a relief from earthly suffering.
SA A MA U MD D SD
24. Death is simply a part of the process of life.
SA A MA U MD D SD
25. I see death as a passage to an eternal and blessed place.
SA A MA U MD D SD
26. I try to have nothing to do with the subject of death.
SD D MD U MA A SA
27. Death offers a wonderful release of the soul.
SD D MD U MA A SA
28. One thing that gives me comfort in facing death is my belief in the afterlife.
SD D MD U MA A SA
29. I see death as a relief from the burden of this life.
SD D MD U MA A SA
30. Death is neither good nor bad.