A Model Death Education Program

                                         A Model Death Education Program

                                                   by Marco M. Pardi

Note: All comments are appreciated, read, and responded to accordingly.  The comments sections for all previous articles have been opened for use.  I will certainly look forward to your comments. 

In recent years several people, including college administrators, have expressed interest in how I devised a comprehensive Death Education program for colleges. The following, though lengthy, was published subsequent to an address I gave to the Florida Academy of Sciences at the Florida International University venue in 1980.  I was a Member of the Academy. The article was published in the Proceedings of the Florida Academy of Sciences cited below. I retain copyright.

FLORIDA SCIENTIST [Vol. 43 Nov. 1980

ROLE OF COMMUNITY COLLEGES IN DEATH EDUCATION— Marco M. Pardi, Polk Community College*, 999 Avenue “H”, Northeast, Winter Haven, Florida 33880.  *Since restructured as Polk State College.

Abstract: In this article I discuss the evolution and development of a death education program at Polk Community College, Polk County, Florida. Included is an overview of the community role involvement typical of such colleges and a working model for enhancing that involvement in any college/community setting. The social and institutional resources usually available in the environment of most colleges are listed and discussed as areas of need and as justification for the development of death education programs at community colleges.

From its inception the community college concept has been one of mediating between the university and the real world of the laboring public. The needs of the community have traditionally crystallized into 3 basic areas: 1) the more personalized college transfer programs which provide the core for university degrees, 2) A.S. degrees which are vocational in nature and are now becoming transferable, and 3) self-enrichment on a non-threatening level for people of all ages, backgrounds and interests.

Most science courses today, including anthropology, are life oriented even in fine detail, and have little to say about death. Death and even the process of dying are not included in most curricula as topics of study or interest. Even with the progress being made today, actual coursework in death studies is all too often restricted to medical schools, seminaries and some universities.

Granted, it is the social scientist and the professional who initially address the issues of human life phenomena which necessarily imply death phenomena. But death is an appropriate concern for all people, including the lay person.

Obviously the total life-needs of the community include ordered, considered and humanistic approaches to the multi-faceted issues of death. Such factors as probate court, insurance benefits, funeral costs and social security ramifications are most often reconciled on a learn-by-doing basis. Countless actualities involved in the dying process are, by default, left not dealt with in our life-oriented society.

A purpose herein is to open and share an area of concern. The ultimate issue of life happiness must be realized in total. It must be realized in the ultimate perspective that life should come to a meaningful close.

Within the framework of this concept the community college has a unique opportunity. While not all its graduates will become university scholars, lab technicians or better policepersons, all will die. Indeed, the community college must reach the people who support it with the very best it can offer.

Most community colleges are relegated to a county area as the domain of influence and supportive justification. Within these county domains various structures such as hospitals, nursing homes, funeral parlors and cemeteries are daily involved in the realities of death. Additionally, several less obvious structures such as ambulance services, florists, laboratories, beauticians, newspapers, police and fire departments confront death as a meaningful part of the daily routine which must sustain life.

Clearly the community college must not classify the study of death and dying as a level of inquiry beyond the scope of the everyday living student. But once having recognized the relevance of this study, how is the community college to institute the process in a way which best serves the needs of its students?

In an attempt to address my own question which I feel certain is a question asked by many in recent months, let me initially state that no one college department is by its nature or subject matter any better qualified to present itself as the exponent of the ways of understanding death. At Polk Community College the implementation of this new concept most comfortably fell into the hands of the resident anthropologist for no reasons other than my interest and willingness to get involved.

In 1973, I drafted a proposal for a general survey course entitled “Introduction to Death”. The course was designed to utilize the archaeological and ethnographic data available from anthropology, the clinical skills available from nursing and psychology, and the interpersonal enrichment afforded by humanistic psychology, philosophy and comparative religion.

Not without difficulty, the course was accepted into the curriculum by a tie-breaking vote. Polk Community College opened 1 trial section of “Introduction to Death” with 35 seats available. Over 90 students were turned away for lack of room. Thereafter, 2 sections of similar capacity were offered and there has been no difficulty filling the available seats during the 3-yr life-span of the course. In fact, the community response to the course has been extremely positive in the form of demands for speaking engagements, radio and television appearances and community workshops.

The course is an open elective and therefore draws a wide variety of age groups, interests and backgrounds into the classroom setting. As indicated by questionnaires administered to the first 300 students who took the course, most felt strong personal need to be able to deal more effectively with the self and/or significant others regarding death. Additionally, most were able to accurately project their own expectations of death: males anticipated death at a younger age than females and they expected more traumatic circumstances than did females.

To further my own awareness and acquire new information for the “Introduction to Death” course, I accepted a personal invitation from Dr. Elizabeth Kubler-Ross to assist her in presenting the First International Seminar of Palliative Care held in Montreal, Canada (Royal Victoria Teaching Hospital in association with McGill University), November 1976. A major portion of the seminar, attended by such notables as Drs. Elizabeth Kubler-Ross, Cecily Saunders, and care providers from five nations was devoted to the careful explanation and development of the hospice concept.

Very basically, a hospice is a residential/ medical setting within which the patients are aware of the terminal nature of their respective illnesses. More than a nursing home, the hospice provides the attentions of a physician, nursing staff, volunteer help and a chaplain. More importantly, the family of the patient is involved in the total process of helping the patient live until he/she dies. Usually this means a simple freedom of visiting hours, but it may go as far as allowing the spouse to share the room or suite with the patient. The understanding here is that the presence of the relative is both supportive of the patient in a familial sense and supportive for other patients in a community sense.

As the “Introduction to Death” course evolved, many students expressed interest in further work with the subject. In particular, several expressed the feeling there should be some way for more people in the community to benefit from their newly acquired understanding. They had learned to cope with the ultimate issues regarding death and felt the need to share. Naturally the hospice concept was appealing to these students.

But, founding a hospice locally was out of the question. The hospice concept generally takes years of careful planning and tremendous funding to materialize. The students were anxious to put their skills to work during their community college careers.

It was within, and in response to such a need that the following working model was proposed, implemented and studied as a means of involving existing community facilities and interactions in the development of a “community hospice without walls”.

ANY 299, Death Lab/ Seminar, is a 3 credit-hr course which provides opportunities for applied follow-up for the “Introduction to Death” students and collegiate activity for medical professionals currently employed but also interested in acquiring additional college credit.

The process of designing the course began with an analysis of the college faculty and administration. Nine people were chosen to cooperate as ‘participating faculty’. The purpose here is to maximize the usage of college resources both in terms of interdisciplinary input and, more importantly, in terms of humanistic support. All 9 instructors, coming from biology, philosophy, administration and other fields, are caring people. Their role as participating faculty is also geared in the direction of assisting the flexibility of the course itself in terms of departmental transfer to universities. Enrolled students, of which there are never more than 21 per section, are divided into 3 major seminar groups and matched with faculty from their common areas of study and interest. The faculty members coordinate the seminar activities of their groups once each week in a 1-hr session on campus. As director of the program, I attend each session.

Aside from the on-campus seminar meetings, each student is required to spend at least 3 hr per week on-site in a community nursing home, hospital or private home engaged in direct inter-personal contact with a patient who has been medically classified as terminally ill.

The seminars include experience and idea exchange among all participants. Additionally, the faculty presents information regarding how to facilitate interaction with the patients, interaction between the patient and his/her family, how to offer information effectively regarding funeral laws and arrangements, and techniques for helping the patient and family cope with death. The participating faculty members have been trained by myself and have access to a variety of resource materials including the textbook, Death: An Anthropological Perspective.

Students are selected according to the following criteria and procedures. They must have completed the ANY 208, “Introduction to Death” course, with a B or better, or they must be currently employed as a medical professional. Having satisfied either of these, they are interviewed by myself, the Director of Nursing and by 1 psychiatric nurse. Any student apparently more interested in academic credit than in people is weeded out, as are those who feel duty bound to impose their religious beliefs on the patients.

The cooperating institutions are responsible for selecting the patients they feel would best benefit from the interactions with the student. The institutions also maintain all authority over the actions of the students and understand that, unless recommended by the attending physician, the students are to play no role whatever in the administration of medical services. This stipulation is clearly made to preclude any unauthorized behaviors on the part of the student and any conflicts of authority within the institution.

In the event that a patient/student match does not work well, adjustments are made. Also, if a patient dies during the course of the lab, the student is assigned another patient. Should a student complete the lab and his/her patient is still alive and in need of interaction, a student enrolled in the next semester’s lab will be assigned. The interactions are planned for a minimum of 14 wk.

The interplay of expectations is a significant area of concern. Dealing first with the student, the guidelines are as follows: 1) the student is expected to interact with the patient and, if necessary, his family at the pace set by the patient and/or family, 2) the student is expected to help the patient and family develop appropriate means for solving problems associated with the dying process, 3) the student is expected to help the patient and family vent their needs and concerns, and 4) the student is expected to master academic knowledge of the techniques of easing the dying process.

A very obvious concern would be the area of legal liability. In the event that a student might slip and fall on a wet floor, or have a traffic accident en route, or if a family claims that the student relationship caused the patient to move into depression and die prematurely, certain safeguards must already be in place. An authority and release clause as well as a participant contract are 2 very simple instruments which may be used to avoid these potential problems. Such forms are easily drawn-up by an institutional attorney.

Because the students are in fact taking a 3 credit hour course there must be some means of evaluation. This is based on the following paradigm: 1) construction and presentation of an anonymous case study, 2) a central test unit given to all groups, and 3) individual test units constructed by the participating faculty closest to the student’s major area. Parts (1) and (2) constitute 80 % of the grade and part (3) constitutes the remaining 20 % of the student’s final grade.

In conclusion, several interrelated personal variables should be noted. Among these are the potential benefits to the participants in the program:

Colleges — Starting with the community college, it must appear obvious that a death studies program of this scope represents very definite involvement with many hitherto isolated community groups. By taking an active role the college is serving as a coordinator for more meaningful and serviceable relationships. The increased visibility of the college as an involved and innovative institution brings positive returns that are pertinent to more areas than just the death studies program.

Participating faculty — Individually the participating faculty have abundant opportunities to experience the kinds of interactions which not only meet the issue of in-house isolation, but also provide rich source material for their own curriculum development. And, their participation as concerned persons facilitates their ability to express and examine their own feelings in an atmosphere of sharing.

Students — The potential benefits for the student are of monumental proportions. In a very real sense, those who do need academic credit for such things as renewing a nursing license can participate in an activity which is perhaps more relevant than sitting exclusively in a classroom. There is also the occasion for them to achieve new understandings of themselves and others. Furthermore, there is the high probability that the student will some day need to take an active role in the easing of the dying process for a loved one or even himself. Whereas experience may be the best teacher, an organized academic framework for the experience can be conceptually very helpful.

Cooperating Institutions — The nursing homes and hospitals participating in the program benefit in 2 related ways. Most patient-care staffs find themselves responding to their typically large caseloads by simply putting physical priorities first. And even those physical needs must be ranked in order of importance. This places a patient’s possible need for reassurance, empathy or even a sounding board for anger at the very bottom of this institutional priority list. It is not uncommon to find the staff members harried and feeling guilty when the priority shuffle allows a needy patient to slip into quiet resentment. The presence of a trained and empathetic student goes a long way toward assuaging these professional guilts as well as lightening the load for these busy people.

Family — Unfortunately, the seemingly petty day-to-day problems of communication present in many families only magnify as a member is identified as terminal. Hitherto unresolved issues such as wills, funeral arrangements and long-suppressed needs become even further taboo, for fear (on the part of the family) of seeming too anxious to get on with the death. Conversely, the patient often feels guilt at having made a burden of him/ herself both economically and emotionally. The students are well informed in the requirements of state laws covering all aspects of the dying and disposition process. While they certainly will not function as an attorney, they will be able to help the family select and obtain whatever professional supports it may require. And of course, the student represents an often needed outside and neutral listener as the family attempts to sort out and understand its changing milieu.

Patient — The most critical valence of this now recognizably dynamic relationship is the one between student and patient. It is understood that grades cannot be applied to human relationships. Credit hours cannot be applied to such involvements. Before introduction to the student the patient is made aware that he/she is not being classified as an object of study. In fact, the direct aspects of his/her relationship with the student have no bearing on the student’s grade. The patient is being afforded a companion with whom he/she may ventilate feelings without fear or guilt. Within the limits of obligations generated in broad relationships, the patient may come to expect certain kinds of aid pertinent to his/her situation. Thus, a simple request for a glass of water may be accomplished without feelings of being a burden to medical staff or family.

Much publicity has been given to Dr. Elizabeth Kubler-Ross’, “Stages of Dying”. One of these stages is called depression. We know that, in our high autonomy-oriented culture, even non-terminally ill persons experience varying degrees of depression when they perceive themselves as unduly dependent on other people. In the Death Lab/ Seminar course it has been found that as the condition of the patient gradually deteriorates, an increasing fear of irreversible dependence manifests itself. The presence of the student offers a subtle, and hitherto untapped, means of helping the patient avoid deep depression. By encouraging the patient to vent feelings, the student, who is generally younger than the patient, is actually maneuvering the patient into the role of teacher. Thus, the patient is able to achieve and maintain a feeling of self -worth; a feeling of being useful and productive in the lives of other people.

As a final note, the participating faculty are aware that even the most stable students may find themselves very acutely in need of contact at the death of a patient. For this reason all faculty members participating are immediately available to their respective students on a 24-hr a day basis. While dedicated to the furthering of necessary academic skills, we applaud the courage and concern with which the students face their roles.

Florida Sci. 43(3): 174-179. 1980.