Rev Relig Res (2011) 53:357–370 DOI 10.1007/s13644-011-0015-4 ORIGINAL PAPER
The Association Between Religious Beliefs and Practices and End-of-Life Fears Among Members of the Presbyterian Church (U.S.A) Nava R. Silton • Kevin J. Flannelly • Christopher G. Ellison • Kathleen Galek • Martha R. Jacobs • John P. Marcum • Faye J. Silton
Received: 2 March 2011 / Accepted: 11 June 2011 / Published online: 28 July 2011 Ó Religious Research Association, Inc. 2011
Abstract This study examines the association between various religious beliefs and practices and fears pertaining to death and dying in a national sample of liberal Protestant U.S. adults. Data were analyzed from a 2002 survey of members and elders of the Presbyterian Church (U.S.A) (N = 935). Four measures of religion were tested together in models predicting four end-of-life fears. Church attendance (p \ .01), other church involvement (p \ .05), and belief in life after death (p \ .001) had negative associations with the fear of what happens after death. Private devotion was inversely related to the fear of dying in pain (p \ .05). Involvement in church activities (p \ .05), aside from religious services, was inversely related to the fear of leaving loved ones behind. Females tended to be more fearful than males of dying alone and dying in pain and older adults tended to be less fearful than younger adults of the unknown and of leaving loved ones behind. N. R. Silton (&) Department of Psychology, Marymount Manhattan College, 221 E. 71st Street, New York, NY 10021, USA e-mail:
[email protected];
[email protected] K. J. Flannelly K. Galek The Spears Research Institute, Healthcare Chaplaincy, New York, NY, USA C. G. Ellison Department of Sociology, University of Texas at San Antonio, San Antonio, TX, USA M. R. Jacobs Department of Continuing and Professional Studies, HealthCare Chaplaincy, New York, NY, USA J. P. Marcum Research Services, Presbyterian Church (U.S.A), Louisville, KY, USA F. J. Silton Department of Program Development, The Massry Residence, Albany, NY, USA
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Keywords
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Death anxiety End-of-life Fear Religion Religious beliefs
Introduction Approximately 80% of American adults belong to some religious denomination and nearly 90% of those who do are Christians (Kosmin and Keysar 2008). Although affiliation in the U.S. has been declining for decades (Kosmin and Keysar 2008; Flannelly et al. 2010; Smith and Kim 2005), professed strength of faith and church attendance have been relatively stable among individuals who are affiliated with a religious denomination (Flannelly et al. 2010). Like other religious faiths, Christianity represents a system of beliefs and practices (Smith 1994). Christian denominations vary in the degree to which they emphasize particular religious practices (e.g., prayer, Bible reading, church attendance), but they share a core set of religious beliefs (Erickson 1998; Mockabee et al. 2001), some of which they share with Judaism and Islam (Smith 1994). The Presbyterian Church (U.S.A) is one of the ‘‘Mainline’’ Protestant denominations, a term which includes American Baptist, Episcopal, Lutheran (ELCA), Methodist, and several other Churches (Kosmin and Keysar 2008; Smidt et al. 2003; Mockabee et al. 2001). Presbyterians (PC U.S.A) have a number of common demographic characteristics with other Mainline denominations, being predominately Caucasian, older (Kosmin et al. 2001), better educated and wealthier than non-Mainline Protestant denominations (Smith and Faris 2005). The Presbyterians (PC U.S.A) and other Mainline denominations also have a common religious orientation (Roof and McKinney 1987; Hoge and Dyble 1981), which tends to be more liberal than that of other Protestant denominations (Roof and McKinney 1987; Donahue 1993; Mockabee et al. 2001). Overall, Mainline Protestants, tend to place less emphasis on reading scripture and other religious practices than do Conservative Protestants (Mockabee et al. 2001), and they are somewhat less likely to believe in life-after-death (Harley and Firebaugh 1993; Hynson 1975). Thus, while members of the Presbyterian Church (U.S.A) represent a select sample of the American religious population, they have much in common with other Mainline Protestant congregants, who constitute roughly 15% of American adults. It has been suggested that the primary psychological function of religion is to address existential distress (Vail et al. 2010)—what Becker called ‘‘The Denial of Death’’ (Becker 1973). Terror Management Theory (TMT) argues that belief in lifeafter-death, which is a basic tenet of Christianity, reduces death anxiety by promising personal immortality (Vail et al. 2010). Others argue that the TMT perspective is too narrow, and that uncertainty about one’s future existence is just one of many uncertainties that one confronts in life, which may or may not be addressed by religion (Hogg 2009; Stapel and Noordewier 2009; van den Bos 2009; Hogg et al. 2010). Uncertainty Management or Uncertainty Reduction Theories deal with uncertainty about many things that are important in people’s lives, including school (McGregor et al. 2009), personal finances (Smith et al. 2007), and belonging (Stillman and Baumeister 2009; De Cremer and Sedikides 2005). However, they
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also may be applied to generic concerns about the world at large (De Cremer and Sedikides 2005; Smith et al. 2007; Hogg et al. 2010). In these theoretical models, uncertainty is not viewed simply as a lack of information, but as a negative emotional state, similar to anxiety. According to Uncertainty Theory, religion should help individuals address personal uncertainty with respect to belongingness, group identification, and lifeafter-death (Hogg et al. 2010). Uncertainties about belongingness and group identification are reduced by the shared rituals, behavioral conventions, and normative values and beliefs that are part of one’s religion. The religious community to which one belongs ‘‘provides consensual validation of one’s religious identity and associated worldview’’ (Hogg et al. 2010, p. 76). A religious worldview imparts meaning and purpose to existence and to everyday life. For many religions, part of that world view includes belief in life-after-death (Smith 1994). This belief reduces existential uncertainty (Hogg et al. 2010), or as TMT researchers call it, existential terror (Vail et al. 2010). Belief in life-after-death varies between and across cultures (Benore and Park 2004). And though belief in an afterlife is part of many religious traditions, the strength and content of the belief varies among religious denominations. A study of Episcopalians found that belief in life-after-death was associated with greater acceptance of and less anxiety about death (Harding et al. 2005). Studies of representative samples of Americans also have found belief in life-after-death to be associated with lower levels of general anxiety and other anxiety disorders (Ellison et al. 2009; Bradshaw and Ellison 2010; Flannelly et al. 2006). While pleasant images of the afterlife are associated with lower levels of anxiety, unpleasant images of the afterlife are associated with higher levels of anxiety (Flannelly et al. 2008). Both TMT and Uncertainty Theory explain how belief in life-after-death can address fears, or address uncertainty about death in terms of what happens after death. However, individuals harbor a number of fears about death. For instance, Hoelter and Epley (1979) identified several types of fears about death, including, the fear of what happens after death, fear of the dying process, and fear for the welfare of significant others after one dies. These fears may not be reduced by belief in lifeafter-death, or by other religious beliefs or practices. Therefore, the present study examined the degree to which specific religious beliefs and practices help one to contend with the fear or anxiety associated with these uncertainties. Present Study The present study uses the data from a national survey of Presbyterian Church (U.S.A) members to examine the relationship between religious beliefs and practices and fears about death and dying. Several hypotheses were tested regarding the association between specific beliefs and practices and specific fears. Since church attendance and involvement provide sources of social support, it is hypothesized that both of them will be inversely related to the fear of dying alone, and the fear of leaving loved ones behind. Although findings on church attendance/ involvement and death anxiety have been mixed (e.g., Harding et al. 2005; Hoelter and Epley 1979; Koenig 1988), since Daaleman and Dobbs (2010) found that social
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support, itself, was associated with reduced fear of death, we hypothesized that attendance and other church involvement would have a salubrious association with the fear of what will transpire after death (i.e., the unknown). Since prayer is generally considered to represent an intimate conversation with God (e.g., Brown 1994; Levy 2002; Ulanov and Ulanov 1982; Foster 1992), we hypothesized that private devotion would be associated with less fear of dying alone or dying in pain. Naturally, it was hypothesized that belief in life-after-death would be inversely related to fear of the unknown.
Methods Data were analyzed from a 2002 survey of members and elders of the Presbyterian Church (U.S.A) (N = 974), who had agreed to serve on a survey panel. The panel consisted of nationally representative samples of each group. Elders are church members who have been elected by their congregation to serve on their church’s governing board. The response rates for members (N = 463, 54%) and elders (N = 511, 56%) were comparable. After a list-wise deletion of cases in which some variables had missing values, the final sample size was 935 individuals. Dependent Variables The survey asked participants to report the extent to which they were fearful about: (a) dying alone; (b) dying in pain; (c) not knowing what will happen to them after they die (hereafter called fear of the unknown); and (d) leaving loved ones behind. The response categories were ‘‘very fearful’’ = 4, ‘‘somewhat fearful’’ = 3 ‘‘not sure’’ = 2, ‘‘not very fearful’’ = 1 and ‘‘not at all fearful’’ = 0. Table 1 shows that survey participants reported moderate levels of fear of dying in pain and leaving loved ones behind, and low levels of fear about what happens after death. Independent Variables Four types of religious measures were recorded. These included: (a) religious service attendance (church attendance); (b) involvement in other church activities (church involvement); (c) private prayer and Bible reading (private devotion); and (d) belief in life-after-death. Church attendance was measured by a single question, which asked ‘‘How often do you generally attend Sunday worship at your congregation?’’ The response options were measured on an 8-point scale ranging from 0 (‘‘never’’) to 7 (‘‘every week’’). Frequency of church attendance was very high, as indicated in Table 1. Church involvement in other activities was measured by participants’ responses to two questions: ‘‘Besides worship and Sunday school, how many hours during the past month have you: (a) attended programs or events at your church; and (b) volunteered your time to teach, serve on a committee, or help with some program or event?’’ Six response choices were provided, from ‘‘0 h’’ (coded 0) to
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Table 1 Descriptive statistics for dependent and independent variables, as measured in the survey (total N = 935) Scored
Mean
SD
Fear of dying alone
0–4
1.53
1.32
Fear of dying in pain
0–4
2.36
1.21
Fear of leaving loved one behind
0–4
2.07
1.45
Fear of not knowing what happens after death
0–4
0.58
1.01
How often do you attend Sunday worship
0–7
6.91
1.10
Hours attended other church events in the past month
0–5
3.14
1.41
Hours volunteered at church in the past month
0–5
2.94
1.49
How often do you read the bible
0–7
4.18
2.12
How often do you pray privately
0–7
6.26
1.39
Believe in life beyond death
1–5
4.55
0.71
Believe you will exist beyond death
1–3
2.75
0.56
Dependent variables
Independent variables
‘‘more than 20 h’’ (coded 5). The Cronbach alpha (a) for the two items was .74, so they were combined into a single score. Private devotion was measured by the following two questions (a = .60): Approximately, how frequently do you: (a) read the Bible privately; and (b) pray privately. The response options were measured on an 8-point scale ranging from 0 (‘‘never’’) to 7 (‘‘daily/almost daily’’). On average, participants prayed almost daily, and they read the Bible more than several times a month (see Table 3). Two items were used to measure belief in life-after-death (a = .71). One item asked participants the degree to which they agreed with the statement ‘‘There is life beyond death.’’ Response choices ranged from ‘‘strongly agree’’ (scored as 5) to ‘‘strongly disagree’’ (scored as 1). The other question asked: ‘‘Do you believe you will exist in some form after your death?’’ The response options were ‘‘yes,’’ ‘‘not sure,’’ and ‘‘no,’’ which were coded as 3, 2 and 1, respectively. Participants strongly believed in life-after-death according to both measures (see Table 3). Control Variables Age, gender, race, marital status and education were used as control variables. Gender was coded as 1 for female and 0 for male, and race was coded as 1 for African American and 0 for all others. Marital status was coded as 1 for currently married and 0 for unmarried. Education was recorded on an 8-point scale, from ‘‘some elementary school’’ = 1, to ‘‘graduate degree’’ = 8. Table 2 summarizes the demographic characteristics of the sample. The vast majority of the participants were Caucasian, and only a few were African American. On average, survey respondents were nearly 60 years of age, and nearly 70% had at least a college degree.
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362 Table 2 Descriptive statistics for demographic variables, as measured in the survey (total N = 935)
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Age (in years)
Mean
SD
59.22
13.70 N
%
Female
496
53.05
Married
600
64.17
21
2.25
Black Education Some high school
9
0.96
96
10.27
Some college
181
19.36
Graduated from college
249
26.63
Some graduate school
126
13.48
Graduate degree
274
29.30
High school diploma
Recoding of Variables Three of the four dependent variables (i.e., fear of dying alone, dying in pain, and leaving loved ones behind) were highly skewed and none of them was normally distributed, so all four of the dependent variables were re-coded into three categories: high = 3; medium = 2; and low = 1. None of the independent variables was normally distributed, and attendance, private prayer and belief in life-after death were highly skewed. So, the variables were re-coded into high, medium and low scores as was done for the dependent variables. Two of the control variables were also recoded into three categories: age and education. Three age groups were formed, and scored 1–3: (1) 21–54, (2) 55–66, and (3) 67 years and older. Since the sample was well educated, education was recoded as: (1) ‘‘some college’’ or less, (2) ‘‘college degree’’ or ‘‘some graduate work,’’ and a (3) ‘‘graduate degree.’’ Statistical Analyses The associations of the control variables and the independent variables with the four dependent variables were analyzed by logistic regression. A series of models were tested for each of the dependent variables. The first series of models analyzed the association between the control variables and the dependent variables (see Table 3). The next series of models analyzed the association between each of the independent variables and each of the dependent variables, controlling for the demographic variables (Table 4). Each independent variable is entered separately in the models without the other independent variables. The net effects of the demographic variables are not shown in Table 4. Finally, a set of four regression analyses were performed in which the net effects of all four independent variables were simultaneously tested with each of the dependent variables, controlling for the demographic variables. Table 5 shows the
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Table 3 Estimated net effects of demographic variables on the odds ratios for fears about death and dying Variables
Dying alone
Dying in pain
Leaving loved ones
Unknown
Age
0.88
0.92
0.70***
0.80**
Female
1.47**
1.50**
1.14
0.96
African American
1.70
1.04
0.95
1.32
Education
1.16
1.09
0.81*
1.12
Married
0.70*
1.01
1.62**
1.16
* p \ .05,** p \ .01, *** p \ .001 Table 4 Estimated net effects of each the religious variables on the odds ratios for fears about death and dying, controlling for demographic characteristics Variables
Dying alone
Dying in pain
Leaving loved ones
Unknown
Church attendance
0.95
0.82*
0.83*
0.57***
Church involvement
0.89
0.95
0.76**
0.65***
Private devotion
0.87
0.72***
0.88
0.67***
Believe in life-after-death
0.97
0.83
1.06
0.59***
* p \ .05, ** p \ .01, *** p \ .001
Table 5 Estimated net effects of all of the religious variables on the odds ratios for fears about death and dying, controlling for demographic characteristics Variables
Dying alone
Dying in pain
Leaving loved ones
Unknown
Church attendance
0.99
0.89
0.93
0.72**
Church involvement
0.92
1.12
0.81*
0.81*
Private devotion
0.88
0.75**
0.92
0.84
Believe in life-after-death
1.00
0.90
1.15
0.65***
* p \ .05, ** p \ .01, *** p \ .001
results of those analyses for the independent and dependent variables; the net effects of the demographic variables are not shown in the table. Other analyzes as described in the text. The variance inflation factor (VIF) was calculated for the independent variables to test for multi-collinearity. The relatively low VIF’s of the four independent variables indicated that multi-collinearity was not a serious problem: church attendance (VIF = 1.23), church involvement (VIF = 1.20), private devotion (VIF = 1.19), belief in life-after-death (VIF = 1.09).
Results and Discussion Table 3 presents the odds ratios for the associations of the demographic variables with fears about death and dying. Older participants in the sample were significantly
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less fearful of leaving loved ones and facing the unknown after death. These findings align with those of various studies that have reported that older adults are less anxious about death (summarized in Harding et al. 2005). Older individuals, who are closer to the end of life, may be less fearful of most aspects of death because they have had time to reflect upon these fears. They may have planned accordingly to ensure that that their loved ones would be taken care, which might be particularly true for Presbyterians, since they tend to have higher incomes than most other Protestant denominations (Smith and Faris 2005). Or they may have come to terms with the notion of dying alone or dying without the knowledge of what occurs thereafter. Hence, older adults may have assuaged their fears and may experience greater comfort in discussing and contending with the end of days. Gender also had a significant association with two of the dependent variables. Female participants were significantly more likely than males to fear dying alone and dying in pain. Although a number of studies have found that females are more anxious about the unknown (summarized in Harding et al. 2005), there was no evidence of this in the present study. Since gender might be expected to interact with religion, we conducted a series of regression analyses that included an interaction of female with each of the independent variables. No significant interaction effects were found. Table 4 provides the odds ratios for the associations between each of the independent variables with fears about death and dying, when each independent variable was tested separately in each model, along with the demographic variables. The inclusion of the individual independent variables in the models did not appreciably alter the observed relationships between the demographic variables and the dependent variables and it did not change the significance of any of the associations in Table 3. Although it was hypothesized that private devotion would be inversely related to the fear of dying alone, neither private devotion nor any of the religious variables were associated with the fear of dying alone. Private devotion was inversely related to the fear of dying in pain, as hypothesized. Since church attendance and other church involvement represent sources of social support, they were expected to be negatively associated with the fear of dying alone, but this was not the case. However, church attendance was significantly and negatively related to fear of dying in pain. As hypothesized, involvement in church activities, apart from religious services, was significantly associated with the fear of leaving loved ones behind, with less fear among those who were most involved. This is generally consistent with Florian and Kravetz’s (1983) finding that more religious individuals are less afraid of the consequences of their death on loved ones, but here the association is specifically a function of volunteering for church activities. Presumably, individuals who are highly involved and committed to the church believe that their church community will help take responsibility or offer care to their loved ones in a time of need. Since church attendance showed the same significant association, the two measures may both be tapping into the social components of living in a faith community. As predicted, those participants who attended church more frequently and were more involved in other church activities were significantly less likely to fear the
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unknown after death. Belief in life-after-death was also inversely related to fear of the unknown, as hypothesized. Table 5 presents the odds ratios for the associations between the independent variables with fears about death and dying, when all of the independent variables were tested together in each model, along with the demographic variables. The inclusion of all of the independent variables in the models did not appreciably alter the observed relationships between the demographic variables and the dependent variables and it did not change the significance of any of the associations in Table 3. None of the independent variables was associated with the fear of dying alone, and the odds ratios reported in Table 5 are very similar to those reported in Table 4, where the independent variables were tested individually in each model. Once again, greater private devotion was significantly related to less fear of dying in pain. The inclusion of private devotion in the same model with church attendance appears to have reduced the net effects of the church attendance on fear of dying alone (see Table 4) to non-significant levels. Thus, it appears that private devotion may provide stronger protection from fear of dying in pain than church attendance does. Similarly, the inclusion of church attendance in the same model with church involvement seems to have reduced the net effects of church attendance on fear of leaving loved ones behind (see Table 4) to non-significant levels. This suggests that the church involvement measure may better capture the social component of living in a faith community than does church attendance. While all four independent variables were significantly related to fear of the unknown when they were tested separately (see Table 4), only church attendance and belief in life-after-death were significantly related to fear of the unknown when all of the independent variables were included in the model. As expected, belief in an afterlife had the strongest salubrious association with fear the unknown. Since religious beliefs and practices may have a differential influence on fears about death among younger and older adults (Neimeyer et al. 2004), we tested another set of regression models that added interaction effects for age with each of the four religious variables. Based on the results of Fortner and Neimeyer (1999), we predicted: (a) that beliefs, but not behavior, would interact with age on the association with fear of the unknown, and (b) that older adults with weaker religious beliefs would be more fearful of the unknown. To the contrary, the interaction of age and beliefs had no association with fear of the unknown in the present study. However, an interaction was found between age and private devotion (OR = 1.26, p \ .05). Participants who engaged in frequent private devotion (the high group) reported the lowest levels of fear of the unknown regardless of age. The negative association between age and fear was evident only among those participants who engaged in less frequent private devotion (the medium and low groups).
General Discussion The current study is unique in that it examines the relationship between religious beliefs and practices and end-of-life fears in a national sample of religious
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American adults. The findings indicate that all four measures of religious beliefs and practices were associated with less fear of the unknown—what will happen after death—to some extent, and that selected measures were associated with other fears. According to Uncertainty Theory, religion should help individuals address personal uncertainty with respect to belongingness, group identification, and lifeafter-death (Hogg et al. 2010). The present results suggest that some religious beliefs and practices may reduce uncertainties about some aspects of dying, but not others. As hypothesized, belief in life after death had a strong negative association with fear of the unknown after death, which is consistent with Uncertainty Theory and TMT. The fact that all of the religious measures were inversely related to fear of the unknown may reflect the close association among all of the religious variables, or the general contention that all aspects of religion provide protection from existential uncertainty. That is, to help individuals cope with the inevitability of death (Dezutter et al. 2009; Radin 1957). By contrast, only selected aspects of religion had salubrious associations with other uncertainties about death and dying in the present sample. For instance, only church involvement had a significant salutary association with the fear of leaving loved ones behind, and only private devotion had a significant salutary association with the fear of dying in pain, when all the independent variables were tested simultaneously. Moreover, none of the religious measures was associated with the fear of dying alone. Both TMT and uncertainty theory can explain how belief in life-after-death relates to fears, or to the uncertainty pertaining to what happens after death. However, the present findings are more consistent with uncertainty theory in that they suggest that other religious practices have salutary associations with fears about additional uncertainties about death, which suggest they may be providing uncertainty reduction. The fear of dying alone may not have been associated with any other religious measure used in the study, since religion itself may not reduce uncertainty about this feature of death. The major demographic findings are consistent with previous research. Females tended to be more fearful of death than males and older adults tended to be less fearful of death than younger adults. Nevertheless, at least two unique aspects emerged from the demographic findings of the present study. First, the findings are similar to those from prior research even though the sample is relatively homogeneous in many respects, especially with respect to their levels of religiosity. Second, the observed associations vary across a number of independent variables, some of which have not been tested in previous research. The main findings for the women in the sample were particularly intriguing. Women were significantly more likely to fear dying alone and dying in pain. Women’s fears about death may reflect women’s greater likelihood to demonstrate anxiety, in general (Seeman 1997). It may also reflect the fact that women tend to have a longer lifespan on average, so they may be concerned that they will not have family members to support them when they are close to death. Other variables, undoubtedly, add to the complexity of the relationships examined here. While co-religionists, such as those in the present sample, espouse a common set of beliefs and practices, a variety of personal differences may account
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for discrepancies in attitudes about end-of-life fears, especially personal experiences with death and loss (Neimeyer et al. 2004). Other variables of interest, which were not tested here, include family background, geographic location and population density. These measures would highlight where people were raised, where they currently reside, and a range of individual life experiences that may shape their belief systems in various ways. Researchers must be cautious to note that individuals of the same faith may express distinct beliefs and forms of intrinsic and extrinsic religious practice. Thus, although this study sought to look at the variability of beliefs and practices within one religious tradition, many other variables may come into play. Future studies could extend these findings by examining the association between formal measures of extrinsic and intrinsic religiosity and beliefs pertaining to fears and concerns of death in a variety of religious faiths. There are several limitations to the present study. The most obvious is that the sample includes members of a single religious denomination, which makes it difficult to generalize the findings beyond members of the Presbyterian Church (U.S.A). Selection bias may also exist, since the response rate is lower than one would want, especially from a group of individuals who had earlier agreed to serve on a survey panel. Finally, since the study is cross-sectional in nature, one cannot make causal inferences about the observed associations between the independent and dependent variables. Further research would benefit from exploring other religious beliefs as well as additional end-of-life fears than those examined in the current study. For instance, Becker (1973) found that one of the greatest fears individuals experience is the fear of being forgotten. An individual supported by a religious community, religious practices, and a personal relationship or close connection with a deity may feel reassured that his/her memory will live on beyond his/her physical death. In this manner, religious affiliation offers a framework to ensure that we will not be forgotten. Various religions have incorporated a schedule of times in which those who have died are remembered into their yearly cycle of services. Whether through the Catholic and Protestant All Saints’ Day, the Catholic All Souls’ Day, or the reciting of the Jewish Yahrzeit Prayer, individuals who are involved in a religious community may believe they will not be forgotten because when they attend these services, they remember those who have died before them. Finally, future studies could examine the level of comfort that the elderly, or individuals approaching the end-of- life, feel with respect to discussing end-of-life issues, death and their mortality. Jacobs (2010) discusses Becker’s (1973) notion that individuals devise strategies to escape cognizance and anxiety over their impending mortality. Becker (1973) suggests that the psychological denial of death is one of the most rudimentary human drives in our individual behavior and is reflected throughout our culture. He believed that we spend our lives trying to create things that are immortal so that we will, through that ‘‘thing’’ become immortal. He explained that one of the most basic functions of culture is to aid us in successfully avoiding awareness of our mortality. Our culture assists in this ‘‘denial’’ by making us feel that we are enduring, invulnerable, and eternal. The notion of immortality motivates us to work to ensure that our lives have meaning, whereas death suggests
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that life adds up to nothing. This perspective aligns with Frankl’s (1959) view that an individual’s primary motivational force is the will to find meaning in his/her life. From an existentialist perspective, he contends that we experience freedom to find meaning in what we do, in what we experience or in what perspective we take when we confront incontrovertible suffering. Helping a patient find or reflect upon meaning in his/her lived life may be integral to best practices for care at the end-oflife. People want desperately for their lives to mean something. Thus, most of us attempt to contextualize our identities in something whose meaning seems permanent or enduring: our country, our nationality, our race, the arts or religion, or bricks and mortar. These cultural icons promise to connect our lives with what endures, what does not perish, or what we perceive does not perish (Jacobs 2010). While some cling to a symbolic immortality through living on through their culture, others seek actual immortality through belief in an afterlife (Cohen et al. 2005). Future research could explore this discomfort with mortality among individuals at the end-of-life and delineate the strategies that individuals may employ in order to assure that their lives endure in a significant way post-mortem. Finally, it would be intriguing to examine how belief in life-after-death and religious affiliation may serve as mediators in the aforementioned relationship. Acknowledgments We gratefully acknowledge the generous support of the John Templeton Foundation. We also wish to thank Research Librarian Helen P. Tannenbaum for her assistance in conducting the literature review.
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