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A PERSPECTIVEON THE CURRENT STATEOF DEATH EDUCATION

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HANNELOREWASS

Gainesville, Florida, USA

Theauthoroffers some views on the current state ofdeath educationwith focus on the spar-

ing attention given the death education of health professionals and of grief counselors.

There is need for improved integration of the knowledge accumulated in the study of death,

dying, and bereavement into the basic curricula of the parent disciplines and professional

schools. Facilitation of personal engagement with the issue of mortality is an important

component of the educative process.Various assessment problems are outlined and some

suggestions for improvements are offered.The death education needs of various groups,

includingschool age children and olderadults, are noted.Thearticle containsa list of refer-

ences, many not cited in the text, recommended for an extensive review of developments in

death education.

It is satisfying to see this special issue ofDeath Studies devoted to honoringand remembering Herman Feifel, philosopher, psychologist, researchscientist, professor, and the pivotal force in the death awareness move-ment and the development of the study of death. His achievement asprime mover and contributor to thanatology has been recognized byhis colleagues through numerous honors and awards. The latest in hislife was the‘‘GoldMedal Award for LifeAchievement in theApplicationof Psychology.’’1

In paying tribute to Herman Feifel in a discussion of death education,it is fitting to note that he was the first modern death educator. The

Received 25 August 2003; accepted 23 October 2003.Address correspondence to Hannelore Wass, 601X N.W. 54thWay, Gainesville, FL 32653.

E-mail: wass@nersp.nerde.ufl.edu1By theAmerican Psychological Foundation, 2001.

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Death Studies, 28: 2897308, 2004Copyright#Taylor & Francis Inc.ISSN: 0748-1187 print / 1091-7683 onlineDOI: 10.1080/07481180490432315

scientific symposium on ‘‘Death and Behavior’’ he organized and pre-sented to the1956 AnnualMeeting of theAmerican Psychological Asso-ciation, was a powerful and consequential educational act.The fact thatit took more than two years to locate a publisher for the Proceedings2

speaks not only to the prevailing silence on the subject of death in the1950s, but also to Feifel’s strength of conviction and determination tobreak the taboo. He agreed that the ‘‘death awareness movement’’ canbe considered a synonym for ‘‘death education’’ in the broadest sense.3

Beginning with the1960s, considerable efforts have been expended todevelop and refine death education programs. Attention has been paidto important aspects of death education. They include (a) articulationof goals, (b) consideration of content and perspectives, (c) teachingmethods, (d) teacher competencies, and (e) evaluation. Compared tothe pioneering days of thanatology, we have seen advances in death edu-cation offered to a variety of stakeholders including college students,the general public, primary- and secondary-level students, health pro-fessionals, andgrief counselors. In awide range of programs, such as fullsemester courses, teaching units for public school students, and shortworkshops for professionals, it is apparent that attention has been paidto planning, goal setting, execution, and evaluation.

Herman Feifel’s influence, as his emphasis on the multidisciplinarynature of death studies and his insistence that death education benefitsall (including children), (Feifel, 1977) is apparent. Most particularly,the humanistic perspective�the philosophical foundation of the studyof death he articulated�is reflected in the goals of death education,which stress both acquisition of knowledge and development of self-understanding and clarification of values, meanings, and attitudestoward death.The range of experiential activities designed to assist withsuch personal engagement illustrates the commitment to this goal. It isa tribute to his leadership that despite institutional pressures, the over-whelming amount of death literature available, and the temptation tointellectualize death, this humanistic goal is still pursued (e.g., Attig,1992; Gould,1994; Papadatou,1997).

Because of space limitations in this special issue, I have chosen toexamine the current state of death education for health professionals

2The basis for his 1959 path breaking book,TheMeaning of Death.3Personal communication at the Conference on Death and Dying: Education, Counseling,

and Care, December173,1976, Orlando, Florida.

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and for grief counselors. I present some overall conclusions about theplace and state of death education today, based in part, on a review ofaspects of death education not included in this article. However I havelisted references not cited in this text that I recommend for an extensivereview of death education. The conclusions I offer come from the van-tage point of a person who has lived as these developments occurredandwhohas, for better or worse, contributed in some part to this history.

There have been considerable advances in knowledge pertinent to careat the end of life, contributing to the understanding of dying personsand their loved ones. Application of this understanding in education hasimproved the quality of care provided in a variety of health care settings,hospices in particular, but also including hospitals and homes. Promisingdevelopments are underway in education and program developmentfocusing on care in neglected clinical settings (e.g., intensive care units)and for neglected populations (e.g., African Americans in urban andrural communities, and residents in prisons). They are important stepstoward achieving equity in the care of dying persons.

The development and increasing use of counseling and consultingservices to organizations and agencies involved in emergency responseto terror attacks, plane crashes, multiple murders, and natural cata-strophes is a substantial achievement in the area of grief counseling.Likewise, crisis intervention programs in the public schools have beenoffered for public school students, including attempts to introduce long-term suicide prevention (e.g., Leenaars &Wenckstern, 1991; Stevenson,1994).

Nonetheless, death education for health professionals and death edu-cation for grief counselors are of considerable concern. It is important,however, to keep in mind Feifel’s (1982)4 observation that ‘‘we areembedded in our time and culture . . . each generation contends withthe presence of death�raging against it, embracing it, attempting todomesticate it’’, and, at the same time, his further observation thatalthough we are more knowledgeable and realistic about death, there isa persisting avoidance. There are numerous indications of avoidanceand ambivalence in our current death system as well. Breath-takingadvances in medical and biological sciences, such as genetics, genomics,

4Feifel organized a symposium on ‘‘Death in Contemporary America’’ to the AmericanPsychological Association in1981and presented the proceedings in a special issue ofDeath Educa-tionwhich he guest-edited in1982, 6(2).

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proteonics, and in new technologies, such as nanotechnology and regen-eration technology, raise expectations for further extending human livesandunrealistic hopes for physical immortality bolsteredby a flourishinganti-aging industry. Thus, criticism of death education efforts must betempered by consideration of the larger cultural context in which theseefforts are made.

Death Education for Health Professionals

Pioneers in the study of dying patients and their care during the 1960scalled for reform and spent their careers working toward achieving it.Leading educators in the health professions have been mindful of thehumanistic component in death education, attempting to balance train-ing for practical skills with attention to personal understanding andattitudes (e.g., Bertman, 1991; Papadatou, 1997; Quint Benoliel, 1967,1982). During the early years great advances were made in the study ofpain control and symptom management for the terminally ill, even-tually leading to legislation in the United States that entitles patients to‘‘compassionate pain relief ’’ including controlled substances. One mightexpect that those responsible for preparing health professionals wouldhavebeen eager to revise their curriculabased on the data accumulatingsince the 1960s. However, it was primarily nursing schools that devel-opedcourses in death education.Themost visible effect of the new teach-ing was the development of hospice programs as an alternate totraditional ‘‘care.’’

Care for the Dying in Hospice and Hospitals

In professional education, the ultimate test of quality education lies inthe effectiveness of care or counseling. Even though successful, hospiceworkers have been criticized for the paucity of empirical evidence (bytraditional standards of scientific inquiry) documenting efficacy. Thisevidence of hospice success has come largely from qualitative studies,clinical reports, and awealth of personal narratives and testimonials bypatients and their families. Despite nearly 30 years of hospice care inthe United States, the mainstream medical community failed to gener-ally adopt its principles and practices for caregiving in hospitals.Because one of the major findings in early studies (Quint, 1967) showed

292 H. Wass

the lack of communication between physicians and patients with subse-quent adverse effects on patients, it is important to determine whatchanges have occurred since then.

KlenowandYoung (1987) reviewed the literature on physicians’ com-munication with terminally ill cancer patients from the 1960s to the1980s. They reported a dramatic shift from withholding diagnosis andprognosis to telling patients the truth. However, they also pointed toshortcomings in this literature (e.g., sample selection, response rates)that undermine these findings.With the establishment of advance direc-tives, the communication issue has become more complex. Findingsfrom the most extensive study of dying in hospitals (involving over9,000 patients in five major medical centers) indicate that most physi-cians do not know about patients’ end-of life wishes, and of those whoknow, only 15% talk with patients (SUPPORT/Investigators, 1995).Similarly, a key concern of hospice pioneers was to achieve optimalpain/symptom control in order to allow patients to live their last daysand to die with dignity. Many more pain centers have been establishedin the United States and abroad since the early days of hospice care,enabling sophisticated pharmaceutical and other means to control pain.Yet in the study cited above nearly half of the dying patients in hospitalsenduredmoderate to severe pain, and nearly half spent their last10 daysin intensive care units.

Medical and Nursing Education

Not surprisingly, there hasbeen inadequate attention to death anddyingin medical curricula at all levels. Dickinson is a long-time observer ofdeath education in medical, nursing, and other health-related profes-sional schools. In a 1975 survey of U.S. medical schools he found thatonly half of them offered something more than ‘‘a lecture or two’’on thesubject of death. Moreover, most course offerings listed were electives,and fewer than10% offered a full course (Dickinson,1976).More recentsurveys indicated improvement. By the 1990s nearly all medical, nur-sing, pharmaceutical, and social work schools offered some educationabout death and dying, most of it integrated into the basic curricula. Inmost schools, that consisted of only a few lectures. Full course offeringswere improved over the past but still inadequate (13% in schools ofmed-icine, 15% in nursing). Full-course electives were taken by a fourth ofthe students.When queried about future plans, half of the medical and

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nursing schools had no plans to offer or expand death education. Timeconstraints, no need, and limited faculty resources were themain expla-nations given (Dickinson, Sumner, & Frederick, 1992; Dickinson &Mermann, 1996). Serious inadequacies in palliative care education inthe United Kingdom have been reported as well. Surveys showed theaverage medical student received approximately 6 hours of death-related instruction, andatbest, 20 hours in a 5-yearmedical curriculum(Doyle,1991). Surveying nursingandmedical school faculties inCanadaand the United Kingdom, Downe-Wambow& Tamlyn (1997) reportedresults similar to those by Dickinson for the United States. Death educa-tionwas included in most programs, mostly integrated into regular cur-ricular offerings or offered as an elective, and only a small minorityrequired a full course. Nursing programs in both countries provided abroader range of topics and allocated a greater number of hours to classand clinical sessions than did programs in medicine which focused pri-marily on pain control/hospice care and ethical/legal issues. In bothcountries, the theorist most often discussed in death education wasElizabeth Kˇbler-Ross. Death education content was taught primarilyby faculty members of the respective disciplines, except for the UnitedStates medical programs in which half the teaching was provided byother disciplines, such as psychiatrists, social workers, and nurses(Dickinson et al., 1992).

Content analysis of professional textbooks further indicated the ser-ious neglect of care for dying patients. An examination of 50 best-sellingmedical textbooks in multiple specialties in terms of content in 13 end-of-life domains, found that with few exceptions (e.g., family medicine,geriatrics), content in end-of-life care is minimal or absent (Rabowet al., 2000). Nursing textbooks have been found similarly deficient.Examination of 50 major textbooks used in nursing schools on 9 essen-tial content areas in end-of-life care showed, overall, less than 2% ofthe content was devoted to end-of-life care (Ferrel, Virani, & Grant,1999).

Paramedics are among other professionals that routinely work indeath-related situations and are often first-line respondents to familiesin distress and grief. The literature is scant on death education for thisgroup. In a national survey of paramedic programs, Smith andWalz(1995) reported that nearly all programs offered some death educationthat is integrated into their curricula and only a small fraction offered aseparate course.The didactic method of instructionwas most frequently

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used. Most textbooks practically ignore death and only a minority ofrespondents use supplemental material so that paramedic graduatesmay have read less than one page of death-related text.What death edu-cation is available is inadequate. It offers little opportunity for partici-pants to become knowledgeable about death and grief, to deal withtheir own feelings, or to develop empathy.

NewDevelopments in End-of-Life Care Education

Since 1995, medical and nursing associations have made recommen-dations for and developed end-of-life education programs. Theseprograms have been designed to assist physician and nurse educators inself-directed study, to conduct continuing education programs, and tointegrate end-of-life information into their basic curricula. For example,the American Academy of Hospice and Palliative Medicine in 1996developed Unipacs, a training program in hospice and palliative carefor physicians, consisting of eight modules, with content includingassessment and treatment of pain and other symptoms, alleviating psy-chological and spiritual pain, ethical and legal decision making, com-munication skills, hospice/palliative approach to caring for patientswith HIV/AIDS and for pediatric patients (www.aahpm.org/).

In 1998 the American Medical Association developed the program‘‘Education for Physicians on End-of-Life Care’’ (EPEC) (www.epec.net/), consisting of 20 modules. In addition, programs were developedto fit into particular programs. For example, the American Academy ofFamily Physicians prepared guidelines for a curriculum for family prac-tice residents on end-of-life care. This organization added physicians’personal attitudes towarddeath as a component of the program. Similarprograms have been developed for nurses. The American Associationof Colleges of Nursing recommended competencies and curricularguidelines for end-of-life nursing and in 2000, based on these guidelines,designed the ‘‘End of Life Nursing Education Curriculum’’ (ELNEC)(www.aacn.nche.edu/elnec/curriculum.htm).

Death Education for Grief Counselors

Most counseling models for bereaved people were derived from tradi-tional psychotherapeutic interventions and focused almost exclusively

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on traumatic bereavement and complicated grief reactions.Therapy fortrauma and pathological grief traditionally have been the domain ofpsychiatrists or clinical psychologists, often affiliated with psychiatrichospitals, outpatient services, or in private practice (Raphael,Middletoa, Martinek, & Misso, 1993). Early studies in adult bereave-ment led to the establishment of mutual and self-help services and orga-nizations. As more data were generated, grief counseling evolved into aprofessional specialty. Leading experts have questioned the need forsuch a specialty, suggesting that well-trained and experienced mentalhealth professionals, such as clergy, funeral directors, and physicians,can learnwith short-term training what is needed to counsel‘‘normally’’bereaved people, whereas the issues in grief therapy require more in-depth preparation (Worden, 1991). However, others observed that thisdistinction is not being made in practice (e.g., Raphael et al., 1993).

The preparation of grief counselors has consisted primarily of conti-nuing education programs such as workshops, seminars, summer insti-tutes, and the like and has been widely dispersed. The need for suchfurther education is shown in studies. Less than 50% of graduate pro-grams in clinical psychology and related professions cover death-relatedproblems, such as suicide (Bongar & Harmatz, 1991). And there is evi-dence to suggest that beginning counselors feel intensely uncomfortablewhen faced with client issues concerning grief or impending death(Kirchberg & Neimeyer, 1991). A follow-up study showed that highlevels of discomfort were predictors of personal fear of death, suggestingthat death and grief counselors with high death anxiety are vulnerable.In addition, an overall low level of empathy was found (Kirchberg,Neimeyer, & James1998). Participants in death education programs forgrief counselors may include graduates with beginning or advanceddegrees in psychology, the health professions, or other areas.They maybe offered by educational institutions, professional associations, andthey may be hospital-, community-, or agency-based and provided byprivate organizations. Because of their large numbers,5 they are difficultto track or to study to ascertain quality and consistency.The inadequacyof preparation of counseling practitioners revealed in the Kirchberg/Neimeyer studies were also found in surveys. In a national survey ofcounselors and counselor educators, Rosenthal (1981) found more than80% of the respondents recognized the need for grief education and

5Internet search engines provide thousands of links to training programs.

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only slightly over half had any. In a national survey of the formalmentalhealth training of paid hospice staff, more than half reported the needfor further training (Garfield, Larson, & Schuldberg, 1982). About halfof the respondents were trained by social workers or physicians, a thirdby nurses, and a fourth by counselors.The training format was didactic,90% lecture, and 84% readings.

To further complicate the picture regarding the preparation of griefcounselors, many of the agents that provide training have made certifi-cates available, of special importance in the United States and Canadawhere no state or provincial grief counseling or therapy certification isrequired (Wolfe, 2003). Reports of dubious and bogus credentials inmental health counseling (Woody, 1997) make this issue urgent. A fewstudies have begun to examine credentials of grief counselors (Zinner,1993).

In recent years attempts have been made to avoid some of the frag-mentation and truncation in preparing grief counselors. Several univer-sities and colleges have begun to offer an alternative to continuingeducation for preparing professionals. For example, Brooklyn Collegeof NewYork City offers a 33 credit hour concentration in conjunctionwith an M.A. degree program in Community Health. Hood Collegein Frederick, Maryland offers a Masters Degree, and King’s College inLondon, Ontario offers undergraduate and graduate certificates indeath-related counseling.

Some Conclusions

Need for Integration

Less than a fifth of students in the health professions are offered a fullcourse on death; the rest typically are provided death-related contentin a few lectures. This lack of depth dissatisfies teaching faculties andleaves graduates entering their professions inadequately prepared tocare for dying people and their families or to counsel bereaved or suici-dal people.6 Thus although the contemporary study of death, dying,and bereavement is remarkable in scope and range, the knowledgeaccumulated has not substantially affected the curricula of the health,

6And only aminority of primary and secondary school students are provided death educationor suicide intervention/prevention, depriving too many of the potential benefit of these interven-tions.

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counseling, or teaching professions or related disciplines of psychologyand sociology.

What happens to this knowledge?Much of it will reside in the journalliterature to be shared with other professionals in thanatology withoutbenefit to the mainstream fields and parent disciplines and ultimatelythe general public whom it is intended to serve. Data suggest a patternof resistance at the institutional level.The barriers essentially consist ofthe failure to acknowledge the need for death education and, closelyrelated, a lack of commitment, primarily of resources. The pursuit ofbetter integration should be the shared responsibility of thanatologistsand professionals in the related fields. Fortunately, some of the barriersare starting to come down. Recent programs in education for end-of-lifecare for nurse/physician educators and practitioners are promisingbeginnings toward correcting existing deficiencies.

Attending to the Personal Dimension

Short exposure to death education invariably means that the knowl-edge transmitted is inadequate and that little or no attention is paid tothe personal dimension, that is, encouraging students to confront, clar-ify, and share personal understandings and attitudes about death. Thepersonal dimension is the component intended to help students to dealwith their anxieties, to become comfortable interacting with people incrisis, and to develop empathy�attributes that make caregiving ahumane and compassionate task for professionals and non-professionalsalike. It is also a reasonwhy educators should be familiar with the basicsof group dynamics and able to create psychologically ‘‘safe’’ environ-ments for small group discussions, role-playing, and other experientialactivities.

Packaging and bundling death education into portable modules orpacks may be efficient but discourages spontaneity in interactionsbetween teachers and participants. Self-directed study may be econom-ical but it deprives the learner of the opportunity for face-to-face inter-actions with a live teacher and others in a group of participants�essential aspects of the learning experience. In self-directed study it ismore difficult to become comfortable with the subject of death, to easeanxiety and worry, and to develop empathy. Self-directed and distanceeducation are valuable and appropriate if the goal of death education istransmission of knowledge. It is far less appropriate for attending to the

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personal dimension in learning about death, dying, and bereavement.In the face of ever-increasing reliance on technology, personal interac-tions become critical.

Need forAssessments

Missing DataIt would be desirable to obtain data on death educators, for instance,

their preparation, competencies, parent disciplines or fields, length oftime in the position, continuing education programs they completed,and to whom they are accountable. An urgent need concerns the pre-paration of professional grief counselors.The wide dispersion and frag-mentation of death education for grief counselors and the lack ofadequate data leave unanswered questions about the adequacy of pre-paration. This state of affairs threatens the quality of the interventionsbereavedpeople receive andthe integrity and image of the grief counsel-ing profession. A step toward a solution would be the establishment ofagreed upon principles and guidelines. Grief experts, counselors, andeducators might collaborate (and even reach consensus) to address fun-damental questions, such as, What interventions are appropriate forwhat situations? What knowledge, skills, and personal understandingsare necessary, and what kind of certification is appropriate? Whatresearch and evaluation exists, and what areas need to be examined?Leaders in grief research can facilitate these efforts by working towardsettling some fundamental disagreements among them, such as the defi-nition of grief and distinctions between ‘‘normal’’ and ‘‘abnormal’’ grief.Recent efforts to integrate grief theories andmodels, as done by Stroebeand Schut (2000), should be continued. Such work may make the studyof grief more manageable and assist in the integration of grief-relatedknowledge into the curricula.7

Effectiveness StudiesIn keeping with the humanistic philosophy underlying death educa-

tion, emphasis has been placed on personal understandings, attitudes,and meanings. However, these aspects are not adequately reflected in

7The considerable amount of ‘‘missing data’’ in several areas related to death education shouldbe priorities for future research. Reliable estimates of death education occurring at the collegelevel and at primary and secondary school levels would be useful for developing strategies foractive promotion.

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the formal evaluation of the effects of death education on attitudes. Forone, most studies have used death anxiety scales that inadequatelyrepresent the complexity of death-related attitudes of which death anxi-ety is only one dimension. Standardized instruments measuring therange of attitudes from anxiety to acceptance and other more positiveand cognitive aspects of death attitudes are available and are recom-mended for use (Robbins, 1994; Wong, Reker, & Gessel, 1994). Anyexpectation that personal confrontationwith death in a death educationprogram automatically reduces the participants’death anxiety is unrea-listic. The data show that individuals in a given group differ in theirresponses to confronting their own death. Indeed, as Feifel (1990)observed, both death acceptance and death anxiety may be present inthe same person.To assess effects of person-focused death education weneed to use approaches andmethods that yield information on the indi-vidual participants. This assessment goal cannot be accomplished byquantitative research alone. Even though such research yields usefultrends, it systematically ignores individual differences.Thus, the unim-pressive findings on effects of death education on death attitudes maynot so much point to mediocre death education, than to the inadequacyof our means and methods of assessment.There is a need for qualitativeassessment. New approaches to assessing qualitative data, such as jour-nal entries and other personal narratives are already available andmaylead to more appropriate assessment of these goals (Neimeyer,199771998).

Formal evaluation of the effectiveness of death education can benefitfrom a broadened conceptualization.Teaching method (primarily usedin effectiveness studies) certainly is an important variable to consider,but there are others as well. Teaching and learning are complex pro-cesses in which psychological, social, and situational variables interactin dynamicways. For example, personality characteristics of the instruc-tor, teaching experience, expectations of participants, group dynamics,and physical environment may all be contributing factors.

Attending to Neglected Groups

Other ProfessionalsWorking in Death-Related SituationsMedical emergency technicians routinely work in situations that

involve death or the threat of death and receiveminimumor no prepara-tion, even though theyare often first-line respondents to patients/victims

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and their families (Smith & Walz, 1995). Police officers are frequentlyexposed to life-threatening danger and regularly have to handle lethalweapons.They are as vulnerable to post-traumatic stress disorder as sol-diers in combat (Sugimoto & Oltjenbruns, 2001). Firefighters are sucha group, as are emergency rescue workers, and certainly members ofthe military such as mortuary officers.These and similar groups shouldbe adequately prepared to carry out their difficult assignments.

School-Age ChildrenEven though death education and crisis intervention programs exist,

they are available to only aminority of the 48million students attendingpublic school in the United States. Death education should be three-pronged:

1. Cultural education. Death is a reality and part of our culture andtherefore should be part of children’s cultural education, as HermanFeifel (1977) admonished. Provided in a low-keyed manner andembedded in larger curricular contexts, it would be unlikely to causepsychotic episodes as some alarmists have feared.

2. Suicide/violence prevention. In view of the increasing rates of sui-cides and suicide attempts in young people, both suicide crisis inter-vention and long-term prevention programs need to be offered in allschools.Youth violence is a new focus in crisis intervention and pre-vention. Recommendations for violence prevention and interventionprograms are available (Surgeon General’s Report, 2000;Wenckstern & Leenaars, 1993), as are various online educationalmaterials (e.g., The National Center for Children Exposed to Vio-lence, Yale Child Study Center). Pro-social skills, anger manage-ment, and conflict resolution skills can be discussed and offered asalternatives to violent behavior.

3. Death education as antidote. Death education can help children andadolescents cope with the overwhelming presence of violent death inthe entertainment media and its potentially negative effects (King& Hayslip, 2001;Wass, 2003). Media literacy, actual crime statistics,and discussion of ‘‘natural dying’’may correct distorted images thatglorify or trivialize death.

In communities where parents object to death education in school,parent education programs, community sponsored death education, or

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death education offered by churches and synagogues may be alterna-tives.

Old PeopleAdults of all ages, including old adults, have fears of dying and fears of

the unknown (Ciricelli, 2001). Death education can help to reduce thesefears. Discussion of the dying process, management of pain and symp-toms, various care alternatives, and so on, may remove some worriesand uncertainties regarding dying. Information regarding advancedirectives is needed for all adults andespecially thosewith greater proxi-mity to dying, in light of the legal complexities of the directives (Lens& Pollack, 2000), the gap between patients who wish to die and healthprofessionals who keep them alive (Teno et al., 1997), or who may notbe aware that patients have given advance directives (SUPPORT/Inves-tigators, 1995). Spiritual issues and conflicts might be addressed by dis-cussing various beliefs about existence after death and by invitingrepresentatives of churches, synagogues, and other faiths to clarify theirvarious theologies.

Nursing home residents are disenfranchisedpeople. First, theyare oldand ill or frail�serious handicaps in our youth-oriented society. Sec-ond, many suffer from illnesses and conditions with unpredictable dyingtrajectories that do not qualify as ‘‘terminal’’ and do not fit within thetime period projected for dying people to die.They are dying too slowlyand often without the benefit of the care and compassion that morequickly dying people receive. Sensitivity training seminars are recom-mended for families of residents, nursing home administrators, and allstaffs.With empathy may come better understanding, communication,and care. For residents with full capacities, death educators/counselorsmay be asked to periodically release residents from an hour of televisionwatching, or finger painting and invite them to group discussions inwhich they can feel free to voice their concerns about dying and deathand free to talk about and share the losses of other residents that is anall to frequent experience.

Final Comment

In the years the study of death evolved into a field, we have seen a num-ber of death-related euphemisms disappear. However, new euphemisms

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have been creeping into our language.They are even in the language ofdeath and dying experts.We are taking the ‘‘D’’ words out of new deatheducation programs, calling them education for ‘‘end-of-life care’’, ortime-efficiently, ‘‘EOL,’’ ‘‘EPEC.’’ ‘‘Hospice’’ care is becoming ‘‘pallia-tive,’’ ‘‘palliative’’ is taking the place of ‘‘terminal,’’ and dying patientsare merely ‘‘life-threatened.’’ This avoidance of death words is reminis-cent of George Orwell’s world in which certain words are eliminatedfrom the language, so that people will no longer think and talk withthem and eventually forget what they represented!

Death education canbenefit all people from childhood to old age. It iscritical for helping professionals. Future death education for all popula-tions�but especially these groups�needs to be expanded in scope anddepth and provide opportunities for personal engagement.We need toremind ourselves that the field of death, dying, and bereavement inHerman Feifel’s vision, is both science and humanity. Death educationneeds to attend to both its scientific and humanistic goals.

References Recommended for a Review of Developmentsin Death Education

Attig,T. (1992). Person-centered death education.Death Studies, 16, 3577370.Balk D. E. (1989). Arousing empathy and promoting prosocial behavior toward

bereaved peers: Using guided fantasy with elementary school children. DeathStudies, 13, 4257442.

Barton, D., Flexner, J. M., van Eyes, J., & Scott, C. E. (1972). Death and dying: Acourse for medical students. Journal ofMedical Education, 47, 9457951.

Barton, D. & Crowder, M. K. (1975).The use of role-playing techniques as an instruc-tional aid in teaching about dying, death, and bereavement.Omega, 3, 2437250.

Block, S. (1975). A clinical course on death and dying for medical students. Journal ofMedical Education, 50, 6307632.

Bertman, S. L. (1991). Facing death: Images, insights, and interventions.Washington, DC:Hemisphere.

Bertman, S. L. &Marks, S. C., Jr. (1985). Humanities in medical education: Rationaleand resources for the dissection laboratory.Medical Education, 19, 3747381.

Bongar, B. & Harmatz, M. (1991). Clinical psychology graduate education and thestudy of suicide: Availability, resources, and importance. Suicide and Life-Threatening

Behavior, 21, 2317245.Cicirelli,V. G. (2001). Personal meanings of death in older adults and young adults in

relation to their fears of death.Death Studies, 25, 6637683.Combs, D. C. (1981). The effects of selected death education curriculum models on

death anxiety and death acceptance.Death Education, 5, 75781.

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Corr, C. A. (1978). A model syllabus for death and dying courses. Death Education, 1,4337457.

Corr, C. A. (1984). Helping with death education. In H.Wass & C. A. Corr (Eds.),Helping children cope with death: Guidelines and resources, second edition (pp. 49773).Washington, DC: Hemisphere.

Corr, C. A. (1992).Teaching a college course on children and death: A13-year report.Death Studies, 16, 3437356.

Crase, D. R. & Crase, D. (1984). Death education for older children. In H.Wass &C. A. Corr (Eds.), Childhood and Death (pp. 3457363). NewYork: Hemisphere.

Cullinan, A. L. (1990). Teachers’ death anxiety, ability to cope with death, and per-ceived ability to aid bereaved students.Death Studies, 14, 1477160.

Dickinson, G. E. (1976). Death education in U.S. medical schools. Journal of Medical

Education, 51, 1347136.Dickinson, G. E. &Mermann, A. C. (1996). Death education in U.S. medical schools,

197571995. AcademicMedicine, 71, 1348�1349.Dickinson, G. E., Sumner, E. D., & Frederick, L. M. (1992). Death education in

selected health professions.Death Studies, 16, 2817298.Doyle, D. (1991). Palliative care education and training in the United Kingdom: A

review.Death Studies, 15, 957103.Downe-Wamboldt & Tamlyn, D. (1997). An international survey of death education

trends in faculties of nursing andmedicine.Death Studies, 21, 1777188.Durlak, J. A. & Reisenberg, L. A. (1991).The impact of death education.Death Studies,

15, 39758.Durlak, J. A. (1994). Changing death attitudes through death education. In R. A.

Neimeyer (Ed.), Death anxiety handbook: Research, instrumentation, and application

(pp. 2437260). NewYork:Taylor & Francis.Engel, G. L. (1980). A group dynamic approach to teaching and learning about grief.

Omega, 11, 45759.Epting, F. R. & Neimeyer, R. A. (1982). Personal meanings of death: Applications of personal

construct theory to clinical practice.Washington, DC: Hemisphere.Ferrel, B., Virani R., & Grant, M. (1999). Analysis of end-of-life content in nursing

texts. Oncology Nursing Forum, 26(5), 8697876.Feifel, H. (1959).The meaning of death.NewYork: McGraw-Hill.Feifel, H. (1977). Death and dying in modern America.Death Education, 1, 5714.Feifel, H. (1982). Death in contemporaryAmerica.Death Education, 6, 697174.Feifel, H. (1990). Psychology and death: Meaningful rediscovery. American Psychologist,

45, 5377543.Fulton, R., Markusen, E., Owen, G., & Scheiber, J.L. (Eds.) (1978). Death and dying:

Challenge and change.Reading, MA: Addison-Wesley.Garfield, C. A., Larson, D. A., & Schuldberg, D. (1982).Death Education, 8, 1897204.Giles, K. (1993). Educating Air Force mortuary officers.Death Studies, 17, 85791.Glass, J. C. (1990). Changing death anxiety through death education in the public

schools.Death Studies, 14, 31752.Gould, J. B. (1994).‘‘A picture is worth a thousand words:’’A strategy for grief educa-

tion.Death Studies, 18, 65774.Grollman, E. A. (1970).Talking about death. Boston: Beacon.

304 H. Wass

Hayslip, B. & Walling, M. L. (1985). Impact of hospice volunteer training on deathanxiety and locus of control.Omega, 16, 2437254.

Hutchinson,T. D. & Scherman, A. (1992). Didactic and experiential death and dyingtraining: Impact upon death anxiety.Death Studies, 16, 3177330.

InternationalWork Group on Death, Dying, and Bereavement. (1992). Assumptionsand principles concerning education about death, dying, and bereavement. DeathStudies, 16, 59765.

InternationalWork Group on Death, Dying, and Bereavement. (199171992). A state-ment of assumptions and principles concerning education about death, dying, andbereavement for professionals in health care and human service. Omega, 23,2357239.

Jackson, E. N. (1984). The pastoral counselor and the child encountering death. InH.Wass & C. A. Corr (Eds.), Helping children cope with death: Guidelines and resources(2nd ed., pp. 33747).Washington, DC: Hemisphere.

Jones, C., Hodges, M., & Slate, J. (1995). Parental support for death education in theSchools.The School Counselor, 42, 3717376.

Kastenbaum, R. (1977).We covered death today.Death Education, 1, 85792.Kastenbaum, R. J. (1998). Death, society, & human experience. Boston, MA: Allyn &

Bacon.Kastenbaum, R. & Aisenberg, R. (1972).The psychology of death. NewYork: Springer

Publishing.King, J. &Hayslip, B. (200172002).Themedia’s influence on college students’views of

death.Omega, 44, 37756.Kirchberg,T.M.&Neimeyer, R. A. (1991). Reactions of beginning counselors to situa-

tions involving death and dying.Death Studies, 15, 6037610.Kirchberg, T. M., Neimeyer, R. A., & James, R. K. (1998). Beginning counselors’

death concerns and empathic responses to client situations involving death andgrief.Death Studies, 22, 997120.

Klingman, A. (1987).Teachers’workshop in death education:The effects of simulationgames and bibliotherapy-oriented methods.Death Studies, 11, 25733.

Klenow, D. J. & Young, A., Jr. (1987). Changes in doctor/patient communication of aterminal prognosis: A selective review and critique.Death Studies, 11, 2637277.

Knight, K. H. & Elfenbein,M. H. (1993). Relationship of death education to the anxi-ety, fear, and meaning associated with death.Death Studies, 17, 4117425.

Knott, J. E. (1979). Death education for all. In H.Wass (Ed.), Dying: Facing the facts(pp. 3857403).Washington, DC: Hemisphere.

Leenaars, A. A. (1995). Suicide. In H.Wass & R. A. Neimeyer (Eds.),Dying: Facing the

facts (2nd ed., pp. 3477383).Washington, DC:Taylor & Francis.Leenaars, A. A. &Wenckstern, S. (Eds.) (1991). Suicide prevention in schools.Washington,

DC: Hemisphere.Lens,V. & Pollack, D. (2000). Advance directives: Legal remedies and psychosocial

interventions.Death Studies, 24, 3777399.Leviton, D. (1969).The need for education on death and suicide prevention. Journal of

School Health, 39, 2707274.Leviton, D. (1977).The scope of death education.Death Education, 1, 41756.

305Perspective on Death Education

Lockard, B. E. (1989). Immediate, residual, and long-term effects of a death instruc-tional unit on the death anxiety level of nursing students.Death Studies, 13, 1377159.

Maglio, C. J.&Robinson, S. E. (1994).The effects of death educationondeath anxiety:A meta analysis. Omega, 29, 3197335.

Mahon, M. M., Goldberg, R., & Washington, S. K. (1999). Discussing death in theclassroom: Beliefs and experiences of educators and education students. Omega, 39,997121.

McGovern, M. & Barry, M. M. (2000). Death education: Knowledge, attitudes, andperspectives of Irish parents and teachers.Death Studies, 24, 3257333.

McNeil, J. N. (1984). Parents talk with their children. In H.Wass & C. A. Corr (Eds.),Childhood and death (pp. 2937313).Washington, DC: Hemisphere.

Moore, C. M. (1993).Teaching about loss and death to junior high school students. InG. E. Dickinson, M. R. Leming, & A. C. Mermann (Eds.),Dying, death, and bereave-ment (pp.13716). Guilford, CT: Dushkin.

Neimeyer, R. A. (199771998). Death anxiety research:The state of the art.Omega, 36,977120

Neimeyer, R. A. (Ed.) (1994).Death anxietyhandbook:Research, instrumentation and applica-tion.Washington, DC:Taylor & Francis.

Neimeyer, R. A. (2000). Suicide and hastened death: Toward a training agenda forcounseling psychology.The Counseling Psychologist, 28, 5517560.

Neimeyer, R. A. (199771998). Death anxiety research.The state of the art.Omega, 36,977120.

Papadatou, D. (1997). Training health professionals in caring for dying children andgrieving families.Death Studies, 21, 5757600.

Perlin,T.M. (1982). Deathvisualizations: Ateachingand learning device.Education, 6,2947298.

Pickett, M., Barg, F. K., & Lynch, M. P. (2001). Development of a home-based familycaregiver cancer education program.The HospiceJournal, 15, 19740.

Pine, V. R. (1977). A socio-historical portrait of death education. Death Education, 1,75784.

Pine,V. R. (1986).The age of maturity for death education: A socio-historical portraitof The era197671986.Death Studies, 10, 2097231.

Quint, J. C. (1967).The nurse and the dying patient.NewYork: Macmillan.Quint Benoliel, J. (Ed.) (1982)Death education for the health professional.Washington, DC:

Hemisphere.Rabow,M.W., Hardie, G. E., Fair, J.M,&McPhee, S. J. (2000). End-of-life care con-

tent in 50 textbooks frommultiple specialties. JAMA, 283, 7717778.Raphael, B.,Middleton,W.,Martinek, N., &Misso,V. (1993). Counselingand therapy

of the bereaved. In M. S. Stroebe,W. Stroebe, & R. O. Hansson (Eds.), Handbookof bereavement:Theory, research, and intervention (pp. 4277453). NewYork: CambridgeUniversity Press.

Robbins, R. A. (1994). Bugen’s Coping with Death Scale and Death self-efficacy. InR. A. Neimeyer (Ed.),Death anxiety handbook: Research, instrumentation, and application(pp.1497165).Washington, DC:Taylor & Francis.

Rogers, C. R. (1961). On becoming a person. Boston: HoughtonMifflin.

306 H. Wass

Rosenbaum, S. D. & Ballard, J. A. (1990). Educating Air Force mortuary officers.Death Studies, 14, 1357145.

Rosenthal, N. R. (1980). Adolescent death anxiety:The effect of death education. Edu-cation, 101, 957101.

Rosenthal, N. R. (1981). Attitudes towarddeath education andgrief counseling. Counse-lor Education and Supervision, 20, 2037210.

Rosenthal, N. R. (1986). Death education: Developing a course of study for adoles-cents. In C. A. Corr & J. N. McNeil (Eds.), Adolescence and death (pp. 2027214).NewYork: Springer.

Ryerson, D. (1990). Suicide awareness education in schools:The development of a coreprogramand subsequentmodifications for special populations or institutions.DeathStudies, 14, 3717390.

Sattem, L. (1990). Suicide prevention in elementary schools.DeathStudies, 14, 3297346.Servati-Seib, H. L., Peterson, J., & Spang, D. (2003). Notifying individual students of

a death loss: Practical recommendations for schools and school counselors. DeathStudies, 27, 1677186.

Stevenson, R. G.(Ed.) (1994).What will we do? Preparing a school community to cope with

crises. Amityville, NY: Baywood.Smith,T. L. & Walz, B. J. (1995). Death education is paramedic programs: A nation-

wide assessment.Death Studies, 19, 2577267.Stroebe M. & Schut, H. (1990).The dual process model of coping with bereavement:

Rationale and description.Death Studies, 23, 1977224.Sugimoto, J. D. & Oltjenbruns, K. A. (2001).The environment of death and its influ-

ence on police officers in the United States. Omega, 43, 1457155.SUPPORT/Investigators. (1995). The study to understand prognosis and preferences

for outcomes and risks of treatment: A controlled trial to improve care for seriouslyill hospitalized patients. JAMA, 22/29, 159171598.

Surgeon General’s Report on Youth Violence. (2000). www.surgeongeneral.gov/library/youthviolence/report.html

Swain, H. L. & Cowles, K.V. (1982). Interdisciplinary death education in a nursingschool.Death Education, 5, 1719.

Teno, J. et al. (1997). Advance directives for seriously ill hospitalized patients: Effec-tiveness with the Patient Self Determination Act and support intervention. Journalof theAmerican Geriatrics Society, 45, 5007507.

Ulin, R. O. (1977). Death and dying education. Washington, DC: National EducationAssociation.

Warren,W. G. (1981). Personal constructions of death and death education.Death Edu-cation, 5, 2917310.

Warren,W. G. (1989). Death education and research�Critical perspectives. NewYork: TheHaworth Press.

Wass, H. (1979).Dying: Facing the facts.Washington, DC: Hemisphere.Wass, H. (1984). Parents, teachers, and health professionals as helpers. In H.Wass &

C. A. Corr (Eds.), Helping children cope with death: Guidelines and resources (2nd edn.,pp.757130).Washington, DC: Hemisphere.

Wass, H. (1985). Visions in death education. An adaptation in L. A. DeSpelder &A.L. Strickland, (Eds.),The path ahead: Readings in death and dying (pp. 3277334).

307Perspective on Death Education

MountainView, CA:Mayfield. Presented at theAnnualMeeting of theAssociationfor Death Education and Counseling in Philadelphia.

Wass, H. (2003). Children and media violence. In R. Kastenbaum (Ed.), MacMillan

encyclopedia of death and dying (vol.1, pp.1337138). NewYork: Macmillan.Wass, H., Miller, M. D., & Thorton, G. (1990). Death education and grief/suicide

intervention in the public schools.Death Studies, 14, 2537268.Wass, H. & Neimeyer, R. A. (1995). Dying: Facing the facts(3rd ed.) Washington, DC:

Taylor & Francis.Wenckstern, S. & Leenaars, A. A. (1993).Trauma and suicide in our schools.Death Stu-

dies, 17, 1517171.Wolfe, B. (2003). Grief counseling and therapy. In R. Kastenbaum (Ed.), MacMillan

encyclopedia of death and dying (vol.1, pp. 3897393). NewYork: Macmillan.Woody, R. H. (1997). Dubious and bogus credentials in mental health practice. Ethics

& Behavior, 7, 3377345.Wong, T. P., Reker, G. T., & Gesser, G. (1994). Death Attitude Profile�Revised: A

multidimensional measure of attitudes toward death. In R. A. Neimeyer (Ed.),Death anxiety handbook: Research, instrumentation and application (pp. 1217148).Washington, DC:Taylor & Francis.

Worden, J.W. (1991). Grief counseling and grief therapy: A handbook for the mentalhealth practitioner. NewYork: Springer.

Zinner, E. S. (1992). Setting standards: Certification efforts and considerations in thefield of death and dying.Death Studies, 16, 67777.

308 H. Wass