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A Framework for Understanding the End of Life
By Lizza Robb

My grandmother, Ann Robb, wasn’t the sprightly elder who takes wide-eyed grandchildren on magical forest explorations, nor did she garden or attend the ballet or practice yoga. She outlived her contemporaries in a brown recliner while watching television and smoking Virginia Slims 100s. She sipped strong Bloody Marys in the morning and stronger vodka waters in the afternoon. She was a woman of caustic wit who practiced a loose Christianity that included more eye rolls than prayers. Ann passed away in November 2008 after spending a week in hospice care. By her side day and night, my family and I took a journey with her that can well be understood within a framework of symbolic interactionism.

Symbolic interactionism is rooted in three basic assumptions (Blumer, 1994). First, human beings respond to objects—a thing, an idea, an event, or a person—based on the meaning they attribute to those objects. Second, the meaning a person gives to an object emerges from his or her social interactions. Third, these meanings are used, understood, and modified through an interpretative process that is adopted for dealing with objects we encounter.

Symbolic interactionism, simply put, refers to “two-way communication” (Forte, 2007, p. 374), and it points not only to the phenomenon of human dialogue  but to the triumvirate communication dynamic of the self, society, and the processes that construct the self and society. Thus, the individual is an active agent in the creation of society and self. The meaning individuals ascribe to an object is not intrinsic to the object, nor does it arise out of the psyche. Meaning arises through a person’s interactions with other people; it develops out of the way people interact with one another in regard to the object. Symbolic interactionism provides an important foundation for understanding an individual and his or her relationship with society and self. It encourages social workers to delve deeply into understanding a client’s membership languages and empowering him or her in meaningful interpretive processes that encourage problem solving.

My grandmother’s physical health had been poor for as long as I can remember due to biological conditions as well as lifestyle choices. Her activities, as long as I knew her, primarily consisted of watching soap operas, drinking, and smoking cigarettes. Despite a history of lung cancer, skin cancer, colon cancer, multiple fractured vertebrae, and near blindness, with the assistance of family and a few neighbors whom she paid to help out, Ann was able to live alone and somewhat independently until her final hospitalization.

Ann’s cognition and memory stayed incredibly sharp until her final days. As she neared death, however, she began to confuse the past and the present. In particular, she continuously asked why Mary was upset with her. Mary was her sister who had passed away more than 40 years before. At the time, we were quick to remind Ann that her sister was deceased. I wonder now, though, what wealth of information and connection we may have accessed had we been willing to delve into the conversation—to meet my grandmother where she was.

Death reminds us that life is not as linear as we might like it to be. As a person nears death, lines between past and present—reality and imagination—are blurred, which may be frightening for those who care for the dying person. It is upsetting, perhaps, because it is a challenge to our own perception of reality. If Ann could be worried that her deceased sister was upset with her, what does that mean for our own lives?

Ann did not talk much about what she anticipated for the afterlife, but it was interesting to see other family members playing out their beliefs through their interactions with her. I was with Ann for most of her last week, so I was privy to many of the conversations she had with others. For instance, my mother, a fervent believer in the Christian tenets of salvation, read to Ann daily from her Bible; she spoke passionately of the need for Ann to embrace Jesus Christ as her savior so as to ensure eternal life. After a particularly long visit from my mother, I laughed when Ann opened one eye and asked with a mischievous grin, “Is that preacher woman gone?” She had only been pretending to sleep through the Bible passages. My aunt, Georgia, was also vocal in sharing her own beliefs with Ann. Georgia believed very differently from my mother, and her conversations with my grandmother were laden with references to reincarnation and “the Master.”

From a symbolic interactionist perspective, I recognize many missed opportunities to provide an open and accepting forum for discussing issues of death and the afterlife, not from the perspective of loved ones, but of the dying person herself. By imposing our fears, concepts of reality and time, and perceptions of death and the afterlife on conversations with Ann, we missed out on truly connecting with who she was in her final days. After Ann passed, I knew very clearly what my mother believed happens when a soul departs the body; I knew my aunt’s views on death and reincarnation. But I did not know what my grandmother believed.

I arrived in Ann’s hospital room one morning to find her in tears. Concerned by her sadness, my mother projected onto Ann a fear of dying and attempted to soothe her with words of God and faith. My aunt also assumed my grandmother was sad about the realization that she would never be going home. Ann refused to talk to them and kept her eyes closed while they talked, tears running down her cheeks. Alone with Ann later, I sat by her bed and held her hand. “Why are you sad, Nana?” I asked and was silent.

After a time, she spoke in sobs. “I’m ashamed that I had a rancid attitude with my nurses this morning, and now they are all going to look at me and say, ‘There’s that old mean coot.’” She was candid about her remorse and shame. By asking a question, I learned that in her final days of life that my grandmother was more present with her concern about having mistreated her nurses and what they would think of her than she was with her own impending death.

We often forget to ask questions. Full of the certainty of our life views, it is easy to approach others within the context of our own understanding of reality. Challenges of communication are heightened as we bear witness to the end of life for those we love. Symbolic interactionism provides an excellent framework for supporting a dying person in his or her journey. Tenets of symbolic interactionism that focus on empathetic connection and communication open a door to true understanding between individuals.

In her last days, Ann wanted to be reminded of who she had been. We were given many opportunities to validate her old self. Ann had been a model and loved to tell the story of a standing ovation she had received while she paraded around the bases of her hometown baseball field in a bathing suit after winning a pageant. She was a mother of two and the wife of an FBI agent during the cold war and the civil rights movement. In her moments of clarity, she was eager to revisit her experiences. She didn’t delve into the depths of her emotion; she didn’t talk openly about her death. She talked about her life. She wanted us to know that she had worked in a time when most women she knew stayed home. She wanted us to know that she had been beautiful.

Death and dying are challenging issues that provide fodder for a glut of complicated relational and internal processes. Each death is unique just as each individual is unique, and the true empathy of symbolic interactionism requires us to seek access to a person within his or her personal context and culture. Holistic end-of-life care necessitates an amalgam of theoretical models in order to treat a client in the most successful way. Symbolic interactionism is an excellent framework for confronting the challenge of communicating about and understanding a dying person’s perceptions of self and death. In the context of George Herbert Mead’s original assumptions of symbolic interactionism, death is an object that we respond to based on the meaning that we attribute to it. That meaning emerges out of our social interaction and can be used, understood, and mediated through an interpretive process that is adopted for dealing with the objects we encounter.

In the end, my 6-year-old daughter lightened our sadness with her unique understanding of death—a perception built on her own social experiences. Having brought her to say good-bye, I held my child on my lap as she took her great-grandmother’s withered hand. “You know what I think happens when you die, Nana?” she said. “I think you go to heaven and ride a carousel forever and ever. Doesn’t that sound like fun?”

— Lizza Robb is the winner of the Virginia P. Robinson Publication Prize at the University of Pennsylvania School of Public Policy and Practice.

 
References
Blumer, H. (1994). Symbolic Interactionism [1969]. In R. Collins (Ed.), Four sociological traditions: Selected readings (pp. 304–321). New York: Oxford University Press.

Forte, J. (2007). Human behavior and the social environment: Models metaphors, and maps for applying theoretical perspectives to practice. Belmont, CA: Thomson Brooks/Cole.