Answered>Order 27594

The construction of the good death: A dramaturgy approach

Abstract:

The study examines interview transcripts of 26 elderly Israelis who are describing their own death, using the dramaturgy analysis approach. The study identifies eight meaning-making strategies used to construct the “good death”: using story in the form of drama; describing multiple scenarios; assuming the director and playwright roles in varying degrees; explaining what a good death is not; comparing previous experiences with death; using questions, similes, and metaphors; commenting with sarcastic remarks and black humor; and describing dreams. A composite drama, resulting from the stories of all participants, is presented in three acts, including the time prior to death, the imminent death, and the funeral. Each dramatic episode is constructed by descriptions of the script, purpose, action area, actors, and performances. The ultimate intent of a drama is to establish new meanings of dying and its aftermath for actors and audience, which is to maintain and promote continuity of one’s identity, heritage, and legacy. D 2001 Elsevier Science Inc. All rights reserved.

1. Introduction “Old Goriot,” a classic portrait of Parisian society, portrays Goriot dying, while holding on in hopes that his two daughters would appear to comfort his last hours. They did not appear before Goriot died (Balzac, 1951). A comparison could be created between the book and actual life concerning the wishful and actual final scenes of life. Balzac’s (1951) book portrays in fiction the ways in which individuals build an image of their “good death,” their ideal script for the final act. These images often go beyond the deathbed scene as the dying person envisions the completion of an entire life and its legacies (Kastenbaum, 1994; Leichtentritt & Rettig, 2000). This study is the second phase of a research project aimed at reaching an inductive understanding of “the good death.” The current phase of the study emphasizes the strategies elderly individuals use while describing the good death. The emphasis on strategies of description is important since reaching a comprehensive understanding of a phenomenon requires paying attention not only to what appears, but also to the ways in which things appear, including the strategies individuals use while constructing their viewpoint of the good death (Spiegelberg, 1960). The process of constructing an experience or event is referred to in the literature as “meaning-making” activity. The goal of the current research is to recognize the meaning-making strategies individuals use while constructing the good death experience. Meaning making is “a social act whereby an actor interprets stimuli in a setting and represents the situation to him or herself in symbolic terms” (Nadeau, 1998, p. 15). Individuals engage in meaning-making activities in order to resolve issues and understand life events and their implications (Davis, Nolen-Hoeksema, & Larson, 1998; Frankl, 1984; Janoff-Bulman, 1992), since meaning “exists only when implicit knowledge is conveyed explicitly to another” (Hinds, Chaves, & Cypess, 1992, p. 62). Individuals further engage in meaningmaking activities in order to clarify purposes and values (Samarel, 1995), and arrange activities surrounding threatening life events, such as death and dying, so that a coherent and reasonable account is constructed (Moos & Schaefer, 1986; Parkes & Weiss, 1983). The good death has been recognized as a multidimensional phenomenon based on physiological, personal, interpersonal, social, and cultural domains of life that incorporate past, present, and future time periods (Leichtentritt & Rettig, 2000). The multidimensional perspective describes the good death as a process that is influenced by both individual wishes and social norms and laws (Emanuel & Emanuel, 1998; Leichtentritt & Rettig, 2000). The theoretical and scholarly justifications for the current study lie in the lack of knowledge concerning the good death phenomenon (Byock, 1997; Kastenbaum, 1994). Emanuel and Emanuel (1998) described a paradoxical situation in which scholars are increasingly concerned about death and dying, there are tremendous technical capacities available to relieve symptoms and improve care, but yet we persistently observe the suffering of dying patients and continue to deny death. In order to resolve this paradoxical situation, scholars (Emanuel & Emanuel, 1998; Mayo, 1998) have recently urged researchers to put biases aside and closely examine what terminally ill and elderly people have to say about the “good death.” How do elderly people perceive the good death? How is the best scenario constructed? What does this scenario contain? What are some of the modifications that need to be made in order to provide the options for elderly people to experience a good death? The research goal of identifying the meaning-making strategies individuals use while imagining the good death cannot be achieved if ignoring the social contexts in which the phenomenon is constructed. Mishler (1979) emphasized that all human experience is contextdependent and can only be understood within those contexts. Social histories, rituals, norms, 86 R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 and laws assist individuals in constructing the good death by specifying the: appropriate place in which death should occur, procedures involved in the dying process, roles of the dying person and his/her family members, as well as the professionals who are involved in the process. Social norms further specify the structure and forms of rituals following the death of a close family member. The environmental context of the current study is the Israeli society where death is very much a part of the daily societal fabric due to the many wars and terrorist activities the country has faced and the constant legacy of the Holocaust (Silverman, Weiner, & El-Ad, 1995). Nevertheless, death within this context is an unexpected, sudden tragedy. Natural dying experiences are a neglected area of study (Malikinson, Rubin, & Witzman, 1993; Shamgar-Handleman, 1986) and an unlikely topic of discussion within Israeli families (Gilbar & Steiner, 1996; Leichtentritt & Rettig, 1999). The prescribed norms and rituals regarding death and dying in Israel are strongly influenced by the Orthodox Jewish traditions (Abramovich, 1991; Sobel & Beit-Hallachmi, 1991). The Jewish tradition emphasizes the precedence of human life over all biblical injunctions (Rosner, 1991). Therefore, the individual’s rights for end-of-life decisions have only recently emerged in Israel (May 1996) and include the right for withholding and withdrawing treatment (passive euthanasia). These rights, however, are currently being implemented with many difficulties (Glick, 1997; Resnik, 1998) because hospitals tend to use technology to the fullest extent following the social and religious norms of fighting death at nearly all costs (Glick, 1997; Shuval, 1992). The dying and mourning processes are further influenced by the Orthodox Jewish perspective and follow strict interpretations of the Jewish law. The funeral in Israel takes place within 12 to 24 hours after the death, is arranged by the burial society, and is paid for by the state (Abramovich, 1991). There is no public viewing of the body and the body is not buried in a coffin. These strong norms highlight the need to examine the ways in which elderly Israelis construct the good death in a culture that prescribes one way to die, one way to be buried, one way to mourn over the loss of a close family member; and further tends to block open communication about natural death and dying. The results of this research will contribute to our universal knowledge about death and dying while highlighting the unique characteristics of the issue within the Israeli society. The current study follows DeSpelder and Strickland’s (1994) observation that understanding how people in various cultures approach death assists us in shedding light on our own perspectives. 2. Method 2.1. Informants Twenty-six older adults participated in this study which identified meaning-making strategies that were used while constructing the good death phenomenon. To participate in the study, the adult had to be at least 60 years of age, independent in everyday activities, and reside in the community. These criteria were selected in order to involve people who were less constrained by current life situations in their thinking of the good death. Participants R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 87 were located by the use of advertisements, personal connections, and the chain sampling technique (Patton, 1990). The initial contact with them was by telephone to explain the study and all but one of these persons expressed an interest and agreed to prticipate. Fifteen of the participants were women, six of whom were widows. Among the 11 men, one was a widower and one was never married. Four participants labeled themselves as religious Jews and the others as secular. Israel is a small country with a diverse population due to the fact that it is an immigrant society. It is important to mention that Jewish rituals and customs of dying and bereavement have been modified by the immigrants’ countries of origin (Silverman et al., 1995). Only two of the participants in the current study were born in Israel. Most of them arrived in their late adolescent years from areas that included Central and Eastern Europe, South America, North Africa, and the Middle East. 2.2. Personal interviews Individual interviews were conducted with the informants during the summer of 1997. The median interview duration was approximately 2 hours, with a range from 1 to 4 hours. All interviews took place at the participants’ homes and were conducted in Hebrew. The interviews covered: (a) family characteristics, personal health status, and religiosity; (b) the participants’ experiences with death and dying; (c) descriptions of the ideal death; (d) concerns about death, dying; and (e) attitudes and behaviors related to the anticipated losses. Examples of questions included: If you could choose, then how would you like death to occur? Can you describe the process? Do you know anyone whose death was a good one? Can you describe this experience? Follow-up interviews were completed with 4 of the 26 informants in order to clarify their perspectives. 2.3. Ethical considerations Several ethical challenges were potentially problematic in the described research. First, the interviews brought forward painful memories and high levels of anxiety. Sharing personal thoughts about potential dependence, death, and dying elicited strong feelings of discomfort and ambiguity that people typically try to avoid (Vandecreek & Frankowski, 1996). Second, the fact that death and dying in the natural ways have rarely been discussed in the family or at the social/public level, resulted in informants who admitted they had never before spoken to anyone about these issues. Third, the research questions, by referring to the good death, allowed the participants to construct and direct an ideal performance. This process had the potential of generating frustration and anger, as in Israel one’s choices are limited. “What does it matter what I want? You and I, we both know things are not going to be different … Israel in 1997 is not ready for that!” (06) “There is no point in talking … We are just treading water here … There is no way things are going to be any different” (19). Efforts were made to minimize these risks as research ethics was an integral component of each phase in the research process, including the dissemination phase (Lincoln, 1995). Several days after an interview was completed, phone calls were made to inquire about the participants’ overall feelings and well-being. Continuing phone calls were maintained for the 88 R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 next few weeks for several of the cases. Ethical procedures were developed for each interviewee ±interviewer relationship using case-by-case agreements. These agreements included providing the transcripts to several informants, and avoiding the use of a tape recorder in other cases. Knowing and being part of the Israeli culture further resulted in giving attention in all phases of the research to oppression of the social norms (Thompson, 1992) in Israel (Abramovich, 1991). The research served as an opportunity for empowerment of the participants which entails: (a) viewing participants as subjects rather than objects; (b) providing them with complete information on research goals, processes, and results; (c) treating them respectfully throughout the research; (d) helping them find meaning in their research participation; and (e) allowing their voices to be heard during the research process and through the results (Massat & Lundy, 1997). 2.4. Analysis approaches The analysis began by following the phenomenological analysis approach that requires examining the text as a whole (Giorgi, 1997). The original choice of the phenomenological perspective followed the understanding that this approach explores, not only the essence of what appears, but also the way in which things appear, and considers meaning and meaning making as connected to each other (Carlsen, 1988; Kvals, 1996). The understanding that was reached after the first step of the phenomenological analysis resulted in the decision to then use the dramaturgy approach for data analysis. The dramaturgy method (Hare, 1985; Turner & Edgley, 1976) was appropriate first and foremost because death is a dramatic occurrence for an individual, as what ever else death might be, it is definitely dramatic. A drama is the largest unit of dramaturgiacal analysis that includes the “five phases of (a) developing an actable idea, (b) providing a stage, (c) selecting the actors and training them in their roles, and (d) enacting the idea, with the result of (e) new meanings for actors and audience” (Hare & Blumberg, 1988, p. 154). The selection of the dramaturgy approach was appropriate since the language of drama closely represented the ways in which the informants described their perspectives: In my mind, [describing the good death] it is a creation of a whole show with a grand opening … in case you miss the premiere, there is no `second chance.’ It is a one-time performance, with no dress rehearsals (09). The transcripts further followed several principles of the dramaturgy approach, which strengthened the rationale for the selection of this data analysis method. The dramaturgy method is appropriate when examining a phenomenon for which “society is expected to have some knowledge, accurate or inaccurate, about … and appropriate norms which govern the role performance of an individual concerning this act” (Berg, 1995, p. 44). The recognition of the existence of one socially appropriate way for death and dying was strongly evident in the data. In correspondence with the dramaturgical method, the informants cast the roles of actors, including self and family members, in relation to one another in their narratives. Friends, family members, professionals, and semiprofessional persons were also placed in important supporting roles (Hare & Blumberg, 1988). The last principle of the dramaturgy R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 89 approach that was found in the transcripts was that drama provides a basis for defining situations. The informants used the narratives as a strategy to create meanings out of an anticipated life-threatening event: one’s own death and dying (Cochran, 1986). 2.5. Analysis procedures The analysis procedures involved three essential steps. First, the phenomenological approach called for addressing the text as a whole in order to reveal different meaningmaking strategies that were used by the informants while describing the good death (Giorgi, 1997). This process required reading and rereading the transcripts several times, allowing for immersion in the informants’ words while searching for different meaning-making strategies. This process was a prerequisite for allowing the researchers to select the data analysis approach which would fit best and capture most accurately the ways in which the informants constructed the good death phenomenon. The second step appears in both phenomenological and dramaturgy approaches and requires examining the transcripts in order to identify the dramatic units that are also called acts or episodes. A drama is a story with a beginning, middle, and end Ð a complete action or experience (Cochran, 1986). An episode is the natural unit of social activity during which the informant constructed a plan or carried out a sequence of actions necessary for reaching a purpose or a goal (Harre & Secord, 1972). Third, each episode was carefully analyzed to identify the dramaturgy elements of scene, purpose, agent, and agency (Burke, 1990). Several essential questions were answered in the current phase including: what was done in thought or in deed (a script which might be divided into several scenes); when was it done (individual, social, and natural time); where was it done (action area); why was it done (purpose); who did it (actor or agent); and how was it done (performance or agency) (Burke, 1990)? 3. Findings A clarification is needed before presenting the results of the study since the informants did not perceive death as a “good phenomenon.” Death, in and for itself, was mostly addressed as an inevitable reality of the life circle, a process that one has to accept because it cannot be avoided or overcome. Recognizing this distinction allowed for presenting the ways in which participants constructed their perceptions of a good (or in other cases, the least dreadful) death: “The good death performance.” 3.1. Addressing the texts as a whole The interviews were first addressed as a whole in order to identify overall meaningmaking strategies. Eight meaning-making strategies were identified. The first strategy was recognizing that the informants’ narratives and stories were constructed in the form of drama with a beginning, middle, and end. The second strategy involved the use of multiple scenarios in which informants had more than one ideal script for the good death performance. The third strategy depended upon acceptance or rejection of the socially prescribed norms 90 R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 and rituals of dying, death, and bereavement. Participants who accepted these rituals described how they would direct the performance, while others who preferred alternative scenarios, created unique and original patterns as if they were playwrights. The fourth meaning-making strategy involved explaining what a good death is not. This strategy was often accompanied by a fifth strategy that compared the ideal death with previous experiences with dying and bereavement. The informants further used rhetorical questions, metaphors, and similes as a sixth strategy. Sarcastic remarks and black jokes were used by one-third of the participants as a way in which the ideal script of the good death emerged. The last meaning-making strategy involved the use of dreams as a strategy for constructing the good death performance. 3.1.1. Constructing a drama of the ideal death Participants constructed meanings of the good death with the use of stories and narratives in the form of drama. The dramas were constructed with a beginning, middle, and end. They were described vividly and were embellished with extensive detail concerning the settings, actions, and outcomes. The stories were provided with the intention that if the person had the freedom to decide and to control these uncontrollable processes of death and dying, then some things would change. The changes would have the potential for creating outcomes that would be more desirable and would provide new meanings of the person’s life. 3.1.2. Describing multiple scenarios The description of multiple scenarios as a meaning-making strategy was used in varying degrees. Two informants had two very different scenarios of the good death. The first scenario referred to a sudden, unplanned, unexpected death: Going out to buy milk and never coming back … Quick snap that you do not think about. You do not agonize over such a dying process. One moment you are fully alive. The next moment you are fully dead [laugh] Ð nothing in between, a clear and easy cut (23). The second scenario described an expected and more prolonged process: Since you cannot reach my age [73 years] without thinking about death … without burying some of your best friends and family members, that [unexpected] `good death’ cannot occur in old age. A sudden death is NOT a good death at young age (08). The existence of multiple scenarios suggested that informants did not enter the interview with a well-established script of the good death. On the contrary, the drama was built throughout the conversation as participants made various kinds of revisions, and therefore, further demonstrated that it was a meaning-making process. 3.1.3. Assuming “director” vs. “playwright” roles A director is a person who provides an interpretation for a well-known script (the social norms), rehearses the actors, and provides cues at the time of the performance. A playwright is the person who provides the original idea, image, theme, or plot for the performance (Hare & Blumberg, 1988). A continuum was identified in the transcripts based on the participants’ roles as describers/constructors of the good death. Several informants (n = 3) limited their role R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 91 to the director by providing interpretations for the socially accepted norms (scripts) of death and dying. Other informants took the role of playwright by changing the social script, adding original ideas, and taking out established norms from the performance. Participants also took different roles in each part of the script. One informant clearly moved from the role of a playwriter to the role of director as the script changed and the interview proceeded. Her original script corresponded minimally with Jewish norms and rituals, but as the interview proceeded, she moved closer towards the social norms and ended with a drama demonstrating conformity. This change was discussed after the interview was completed. If I could only make up my mind, I am sure you wouldn’t have to sit here for so many hours. If only I was consistent in my viewpoint … I have not talked about these issues with anyone before. I think about it, but saying it out loud, this was the first time for me [silence]. I started with a radical [giggle] perspective [pause], but hearing myself say that, It was scary … I thought it is too much. This is partly why I think my thoughts were not so organized and I kept on changing my mind … I will still have to think about what I have said here today. This is why I wanted a copy of the tape. I am not sure whether I will change my mind once again in a few days … (17). 3.1.4. Explaining: what a good death is not The fourth meaning-making strategy was used by all informants who made statements about what a good death does not mean: It is definitely not lying in bed waiting for the process to come to an end. That is NOT what I will call a good death. Allowing people to get to the point in which they can no longer function, they do not look or think like human beings, this is not what I or anyone else can wish to experience … (18). Bury me in a coffin, and allow me to control my own dying process … and one more thing, please do NOT say prayers at my funeral! (19). 3.1.5. Comparing previous experiences with death The meaning-making strategy of comparison included references to deaths that were perceived as enviable as well as those that were to be avoided (what a good death is and is not). Participants often referred to a dying process of close family members or friends as a way of constructing meanings towards their own death. I wish my death to be like my uncle’s death [pause]. It was almost like … Um … [pause] you can call it a `holy thing’ (16). References were further made to customs of other religions such as Muslim and Christian, and different social contexts such as in India, Tibet, or Eskimo: “Leaving me in my home, letting nature takes its course … this is similar to what the Eskimos used to do with their elderly” (05). 3.1.6. Using questions, similes, and metaphors Questions, similes, and metaphors were used in the process of constructing the good death. Informants consistently checked with the interviewer to determine whether others would perceive their scripts as “desirable”: “Would you not say this is a good scenario?” (03). “Do you not agree that is peaceful?” (12). The similes and metaphors were often taken from 92 R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 nature, comparing the dying process to the sun sinking: “dying is like a [pause] like a sun sinking … you cannot fight it. In the end it will disappear into the sea” (11). “Like the tree that used to bloom next to my kitchen window. One morning it just did not happen any more … [gets up to show the tree she is referring to] … This huge tree, all of the sudden from being part of my regular view, one morning it was gone” (13). One informant further used his army career as a source for describing the good death, comparing the dying process to a battlefield, and the dying person to the commander of the performance (06). 3.1.7. Commenting with sarcastic remarks and black humor Sarcasm is defined as “taunting, sneering, cutting, or caustic remarks, gibe or jeer, generally ironical” (Webster’s New World Dictionary of the American Language, 1970, p. 1263). A few of the participants frequently used sarcasm as a meaning-making strategy throughout the interview. “My ideal relation with death is that I do not bump into his territory, hoping he will not bump into mine” (04). “You know what a beautiful view you have from the cemetery? It is the place with the best and cleanest air in the whole city” (07). The use of sarcasm established distance from the emotionally difficult topic, reduced anxiety levels, and changed the focus of attention. 3.1.8. Describing dreams Few participants discussed their dreams as a meaning-making strategy. Dreams were used mostly while constructing one’s funeral, a dramatic unit that was addressed only towards the last quarter of the interview. Discussing one’s dreams about his/her own death was an emotionally difficult experience. “Twice in my life I dreamed about my own funeral. It is kind of strange as I usually do not remember my dreams, but I do remember parts from these two [pause] it is strange” (17). “It was not scary … I am not even sure it was really mine. I assume so … I do not remember the whole dream, I have some sights of it Ð but that’s all” (04). 3.2. Identifying dramatic units The second step in the analysis process required dividing the data into manageable units, since one cannot analyze the whole drama simultaneously. Meaning making regarding one’s owns death is an activity that involves past, present, and future time orientations. Therefore, the drama of the good death was divided into three dramatic units (episodes), including prior to death, the imminent death, and after death Ð the funeral. These episodes referred to different times, action areas, scripts, purposes, actors, and performances. The descriptions of different episodes did not strictly follow the time sequences, however, because participants tended to go back and comment about previously discussed ideas. They also might begin the description at death and go backward to the beginning of the dying, as in the technique of “flashback.” These varying description techniques made it difficult at times to identify the boundaries of the episodes. Other writers have also faced these issues of ambiguous boundaries: “the problem with a dramatic structure is that one never comes to an end” (Cochran & Claspell, 1987, p. 18). The fact that the dramatic units were not exclusively R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 93 separated from one another strengthens the idea that all of the identified episodes formed the overall performance of the good death. 3.3. Analyzing dramatic episodes The last phase of the analysis involved analyzing the dramatic episodes. This process required answering six essential questions including: what was done (a script which might be divided into several scenes); when was it done (individual, social, and natural time); why was it done (purpose); where was it done (action area); who did it (actors); and how was it done (performance); (Burke, 1990)? Meaning making is a process-oriented phenomenon. Therefore, in order to stay as close as possible to the data and to the informants’ viewpoints (to remain valid and ethical), the following paragraphs present detailed descriptions of the results, accompanied by parts of the narrative from Informant 15 3.3.1. First dramatic episode: constructing the preparations for death and dying The first episode was the only one that was divided into two scenes. The two scenes had the same purpose of maintaining life quality, and were therefore perceived as one episode. The scenes were different in the constructing process, by means of the timing, action area, actors, and performance. The differences in these essential drama components justified the separation into two scenes. The first scene described several weeks or months prior to death and was perceived as a “warm-up” scene because it was the first period of enacting the dying role (Hare & Blumberg, 1988). The second scene addressed the last few days or weeks of life. 3.3.1.1. Episode 1, Scene 1. The first scene (warm-up) referred to participants’ descriptions of the last few weeks or months before death and was initiated by the understanding that one is now entering the dying role. A person was considered to be dying when death was no longer the inevitable abstraction but had become, in the informants’ perceptions, a real timebound condition. How I wish to die, this is what you are asking Ð right? Well, I have thought about that, but there is reality which frightens me, and there is my fantasy, what I wish will happen … In reality what are my options? You know there is a long line to get there [referring to the one of the very few hospices in the interviewee’s hometown]. So I am not sure what is better, dying before getting there … or actually getting there. Actually, I prefer the first to the second … Seriously, one should prepare. I, for example, need to take care of all my affairs before I am no longer around, to make sure that everything is organized, that all is taken care of, that things are written down so that my family members do not have to go through all that … (15). The script for the warm-up scene described making preparations for death and dying. The purpose of the scene was to maintain quality of life. Participants expressed their general wishes to continue living a normal life until the very last moment: “to be independent, to be able to do what I wish for … not to pray for death to arrive” (06). Participants also referred to undesirable scripts (reference plots) including: “being in any kind of an institution” (08); and living with one of the children “violating everyone’s privacy” (06). 94 R.D. Leichtentritt, K.D. Rettig / Journal of Aging Studies 15 (2001) 85±103 Two main actors were identified in Episode 1, Scene 1: the self and family members. The performances of the participants were active ones, including social roles of “parent,” “spouse,” “grandparent,” and “provider.” This active-living performance was often introduced through criticism towards the current social expectations for an elderly or a dying person. Family members were assigned to more passive or secondary roles, such as “helper,” or “companion.” The warm-up scene was distinguished from the continuation of the good death performance because informants used present tense while re

 

"Not answered?"