What I find most interesting about this book is that I have already experienced the phenomenon. When I was eleven, I was shielded by my parents and doctors as to the true nature of my uncle’s illness. I also figured out that my uncle also did not know he was dying. I overheard a conversation between my mother and grandmother, explaining the shouting my uncle did on his ambulance ride to the hospital where he later died. He never knew he was in liver failure. At sixteen, my grandfather was dying from kidney disease in the hospital on the hospice floor. This time I knew he was dying. In fact everyone but my grandfather knew he was dying. He was a jovial, positive man, and I now believe that he was pretending he was not really sick so as to enjoy his last few weeks and not spend his time looking at sad, depressed faces. His attitude helped us be around him. I also remember noticing how attentive the nurses were with him. Both of these experiences are given names and explained in Awareness of Dying.
Awareness of Dying was originally published in 1965 by Glaser and Strauss and revised in 2009. This book is a substantive theory book dealing with medical disclosure to terminally ill patients. It is a study of awareness contexts as they pertain to dying in hospitals. Though someone who experiences unexpected loss may not find this to be a good, quick self-help book, it can help explain why people react the way they do to someone’s expected loss. If you wish to answer why people shun or otherwise distance themselves from you in this time of need, the theoretical discourse in this book can provide needed wisdom.
The researchers studied dying patients, the dying patient’s family members, treatment nurses, and doctors in relation in the death process. Glaser and Strauss examined different units of the hospital from geriatrics to hospice, intensive care, the cancer floor, emergency room, and the neonatal ward to obtain their research participants. For both of the researchers, the interest in death and dying in the hospital stems from personal experiences. Strauss experienced the loss of his mother and a good friend. In both cases of loss, Strauss played what he later terms the game of closed awareness in order to prevent the loved one from knowing the true nature of their condition. Glaser dealt with the hopelessness of his father’s dying.
Glaser and Strauss note that medicine is vastly improving. Due to these improvements, it will be more common for an American to die in the hospital versus their bed at home. This phenomenon will create for the dying person, family, nurse, and doctors an “awareness” that “will become more and more central to what happens as people pass from life to death in American hospitals.” The researchers were seeking to understand four situations of dying in the hospital. In the first situation, family, doctors, and nurses know the death will be timely but patients do not individually recognize their own death. In the second situation, patients think they know what is going on and ask their family, nurses, and doctors questions, trying to elicit certain answers. In the third situation, each person knows that the patient is dying but all parties mutually ignore the status. In this situation you usually find a young person (i.e., someone in their thirties or forties) who is not willing to accept this fate. In the fourth situation, everyone knows death is imminent and everyone is comfortable talking about it. The fourth situation is usually an elderly person who has lived their life and accomplished what they had wanted. If you experienced any of the above four situations, you may want to read this book.
Glaser and Strauss were able to develop the overarching theory of “Awareness Contexts.” Out of Awareness Contexts came four types, which each correspond to the situation analyzed. They are closed awareness, suspected awareness, mutual pretense awareness, and open awareness. In order to place a person in each context, Glaser and Strauss interviewed dying patients, family members, doctors, and nurses. They looked at the cues, tones, and body language to determine which situation a person falls into. They realized that once rapport is established, the family and hospital parties will play their parts. It is the patient who is vulnerable and will often cross the awareness boundaries out of fear. However, Glaser and Strauss discovered that in some situations (i.e., the person is not considered socially desirable), the nurses and doctors will not put up any veils or pretend that everything is alright. In these situations, hospital staff members may be found freely discussing the patient’s fate without any concerns of who will overhear. In other situations (i.e., a young child or routine surgery), where there was no expectation of death, death came as a shock and seemed to temporarily paralyze the staff from performing routine tasks. With later publications of this book, the non-expectation of death became the medical malpractice area. Glaser and Strauss also found that nurses had difficulty with young children and/or people their own age because this was not the normal social order of death. However, for these two types of dying people, the doctors seemed to distance themselves so as not to appear affected.
Glaser and Strauss noted, “These formulations should guide others both in research on dying and in developing other theories which must take into account the awareness of people.” The authors’ awareness context theory helps explain why nurses and doctors often act the way they do. The motions are often an unwritten subconscious role that everyone abides by, but no one explains.
- Book Review: Where Medicine Fails: Anselm L. Strauss, Carolyn Weiner: 9780878559510: Amazon.com: Books (chimac.net)
- Rethinking what it means to die (dailycal.org)
- Peace (unitednurses.wordpress.com)
- Viewers Reach Out To Woman Denied Hospice Care Because Of Where She Lives (sacramento.cbslocal.com)