A C T A U N I V E R S I T A T I S L О О 2 I f N S I S FÜLIA SOCIÛLO GICA 22, 1991
Anssi Peräkylä
AN OUTLINE OF THE STUDY OF THE SOCIAL MEA N I N G S OF DEATH IN MOD ERN H O S P I T A L 1
1. The research task
The aim of the research is to find out the social mea n i n g s of death in hospital, seen from the point of view of the staff. This is to say, an effort i3 made to des crib e how the hos pita l staff sees and e x p erie nces death and dying, and to ana lyze where this specific way of e x p e r ie ncing stems from.
The approach to the social mea ning s of death in this study is e t h n o m e t h o d o l o g i c a l - p h e n o m e n o l o g i c a l . The phe n o m e n o l o g i c a l t r a d i -tion leads us to describe the interpr etati ve schemes, through which death and dying get their mea ning in hospital. Acc or d i n g to the p h e nome nolog ical analysis, no e x p erie nces are m e a ning ful in t h e m -selves. Our e x p erie nces get their mea ning only whe n we "return" to our e x p erie nces and exp licate them with the hel p of our f o r m -er exp-eriences, stored as i nt erpr etati ve schemes [s e e S c h u t z , L u c k m a n n , 1973, p. 16; L u с k m a n n, 1983, pp. 73-76]. The interpr etati ve schemes related to death and use d by the h o s -pital staff could be called, fol lowi ng the ideas pre se n t e d by S c h u t z and L u c k m a n n [1983 ], the sta ff's social
The aim of this paper ie to out line the a pp roac h applied, and the central results received this far, in a sociolo gical study of social mea ning s of death in mo d e r n hospital. The study is car ried out by me at the Uni vers ity of Tampere, and it is tutored by Professor Seppo Randell. The study has been going on since August 1986.
stocks of knowledge related to death. Thus the research task, seen from the point of view of the phenomenolog ical sociology, is to describe them.
The ethnome thodo logic al tradition points to the ever ongoing process of pro duction of meanings. The starting point in e t h n o -methodological ethnography is, as Robert D i n g w a l l [1981, p. 134 ] puts it, "the question of how the p ar tici pants in some event find its character and sustain it, or fail to, as a joint activity". The character of the events is not pre -giv en to the people par tici patin g in them. The character is defined by people themselves, as a joint activity. This activity takes place w i t h -in the flow of events, or more precisely, it is part of the events themselves. Anthony G i d d e n s [1986, pp. 238-241] has adopted this per spective in his theory about . the constit ution of meaning: "The sense of words and the sense of actions do not derive solely from the dif ferences created by the 3ign codes [...]. They derive in a more basic way from the methods which speakers and agents use in the course of practical action to reach "interpretations" of what they and others do" [ G i d -d e n s , 1986, p. 538]. Fol lowing the policies of e t h n o m e t h o d o -logical ethnography, I will try to describe those activities, through which the members of hospital staff find and sustain the meaning of death.
The res earc h is based on an ethnographic field work. Active field work lasted six months. I spent almost the whole working days and weeks at three wards of a Finnish uni versity hospital. My role as a researcher was evident to eve rybody at the wards; the staff was informed about my topic being death and dying, but the patients were told only that I was doing research on the interaction between the staff and the patients. I recorded e v e r y -day occasions and talks in my field notes. Besides ,that I also made and tape-recorded 25 u n s t r uc tured interviews with the staff m e m b e r s .
2. Some p r e limi nary results
2.1. The social stocks of kno wledge rel ated to death
During the fieldwork, and while rea d i n g t h r ough my field notes and the interviews, twn dif ferent layers of kno wl e d g e r e -lated to death took shape. The layers are 1) moral and c o g n i -tive principles, 2) symbols.
Both layers take part in the c o n s t i t u t i o n of the mea n i n g s of death in hospital. They refer to c o n cept s used by the p a r t i c i p -ants, i.e. the hospital staff. In other words, they are not c o n -str ucti ons made by the researcher (cf. Hammers ley, Atk i n s o n 19B3, 178). But their gro upin g as separate layers and their exp lici t formula tion is naturally done by the researcher.
2.2. The moral and cog ni t i v e p r i n c i p l e s
The fun damental layer of kno wled ge related to death is c o m p o s ed of a number of moral and c o g n iti ve p r i ncip les. These p r i n -c iples from an u n d erly ing pattern, ref le c t e d in the eve ryda y talk and other act ivities at the ward. A no v i c e in hos pita l - w hether a new staff member or an e t h n o g r a p h e r learns this u n derlyin g pat tern step by step while p a r t i c i p a t i n g in c o n v e r s a -tions and action [cf. G a r f i n k e l ’ s ana l y s i s of the d o -cum enta ry m e t h o d of interpretation, in Gar finkel, 1967, pp. 76-193]. The events rel ated to death are then int erp r e t e d In the light of these principles.
My f o r mula tion of the pri n c i p l e s con s i s t s of twenty items. It is evident that if somebody else were doing this research, he would exp li c a t e the p r i ncip les in a sli ghtl y d i f f e r e n t way. This is due to the fact that the e xp lici t f o r m u l a t i o n is dons by the res earcherj in the msel ves the p r i n c i p l e s are for great deal som et h i n g tacit and taken for g r a n t e d [cf. G i d d e n s , 1984, pp. 21-23]. My formula tion of the p r i n c i p l e s is the f o l -lowing.
1. P o s t p o n i n g death. This p r i n c i p l e is an a s s u m p t i o n about the role of the hospital and hospital staff in r e l a t i o n to death
and dying. It is used in making decisions. The core of the p r i n -ciple is that dying is something to be avoided. It is the h o s p i -t a l ’s -task -to keep people alive.
2. D e a th as a result of underlying, ide ntif iable physical processes. It is taken for granted that processes taking place in the p a t i e n t ’s body before death are con tinously defined with the help of medical knowledge and facilities. The most important definition, the diagnosis, is followed by a con ti n u u m of minor d e -finition and assesments based on daily examina tions and tests. The "cause of death" is always identified. The final conclus ions are usually drawn after reviewing the results of the autopsy. The phy sici ans have the active role in pro duci ng the definitions, but eve rybo dy wor king at the ward uses them in int erpretation of the p a t i e n t s ’ situation.
3. Time of death as an object of p r o f e ss ional knowledge. Both in discuss ions related to the decisions about the treatment, and in everyday talk, the staff is supposed to be aware of the coming death of the patient. The p a t i e n t ’s and the f a m i l y ’s
o
awa reness of the death is regularly assessed . There is a vague norm o b l igat ing the staff to inform the patient and the family about the coming death.
4* D y i n g pat ient as an object of active intervention. It is taken for gra n t e d that the hospital staff, using various f a c i l i -ties at hand, intervenes the body and also the mind of the patients. Forms of physical int ervention aim at p o s tpon ing death, gai ning kno wled ge about the physical pro cess es in the patient's body, and at the all eviation of pain. The interve ntion into the mind of the dying patient takes place through the use of c o n -sultative techniques, the purpose of which is to help the patient and his family to come to terms with the approac hing death. The use of these techniques is quite incidental, in com parision
G l a s e r and S t r a u s s [1965, pp. 29- 1 0 6 3 have used the not ion of "awareness contexts" - different c om bina tions of p a t i e n t ’s and s t a f f ’s awa reness about the coming death - as a gui ding idea of their work. My observa tions show that the idea of awa rene ss contexts is not primarily a pro fess ional s o -cio logical construction, but a part of the s t a f f ’s stock of k n o w l e d g e .
with the systematic and definite cha ract er of the phy sica l i n -tervention .
5. M i n i miz ing the suffering. When talking about and giving reasons for what they do, the staff mem bers use as a mea s u r e the idea about min imiz ing the suffering of the dying patient s and their families. E.g. when a nurse is rep or t i n g me her ways of acting with a dying patient, she is p o i ntin g to how her doings alleviate the mental suffering (the neg ativ e feelings, see p r i n -ciple 9) of the dying. And when ass essi ng the d e c i s i o n s about wit hold ing active treatment, a relevant argument is whether the treatment cause a lot of suffering.
6. Close contact with the dying. When d i s c u s s i n g with me about the dying patients, the staff mem bers reg ularly made r e -ferences to the p a t i e n t s ’ need of close and intiir.ate pre senc e of other people. It is seen as a task of the staff mem bers to be close to the dying. Speaking with the dying patients about their feelings and thoughs is defined as an important aspect of the care.
7. D is tanc e fro* the dying. This p r i n cip le is in a close contact, and in opposition, to the pre cedi ng one. It was often said by the staff that one could not stand this work if one were involved with the feelings of the dying patient s and their f a -milies. You have to keep dis tanc e bet ween you rsel f and the patients, between your private life and your work. I was told several times how those working in the hospital forget the patients immediately when leaving the ward; only e x c e p t i o n a l dea ths are rem embered at home.
8. Pri aarity of the e ve ryda y pra ctic al affairs. The e v e r y -day practical affairs - nursing care and medical examinations, giving the medicine, was h i n g the patients, h e l ping them to empty their bowels, and so on - are g iv en pri marily in the c ou rse of the everyday activity at the ward. A c c o m p l i s h i n g these tasks compose s the rhythm of the wor king day. The e ve ryda y practical affairs det ermine for a great deal which of the pat i e n t s get a special att ention in the s t a f f ’s talk; it is those who require most treatment and other measures. When tal king wit h the p a -tients the staff mem bers usually con ce n t r a t e on cur r e n t p r a c -tical issues.
9. D ea th as a source of n eg ativ e feelings. The staff takes it for granted that the dying pat ient s and their families have strong feelings of grief, anxiety and sorrow. A vague d e v e l o p -mental scheme was used very often when talking about p a t i e n t ’s or family m a m b e r s ’ feelings: the stages of denial, depression, anger and the like are aeen to follow one a n o t h e r 3 . The staff members the mselves are also supposed to have feelings about the death of their patients; but on the other hand I was told several times, with regret, that actually one does not feel too much when somebody has died. When patient s or their families behave in a strange way, e.g. a patient wit hdraws from interaction w it h the s ^ a f f , or the family members a decease d patient are aggressive towards the staff, this is often int erpreted in the discuss ions among the staff as an indication of' hidden feelings about the death. This model of interpr etati on is sometimes used also about staff members: the reason for their troubles may be the rep ressed bad feelings caused by the death of the p a -tients .
10. Avo i d i n g d ra *ati c scenes. The staff han dles the s i t u a -tions of death and dying in a detached manner, avoiding e x p r e s -sions of feeling. The families and the patient s are also supposed to Control m a n i f e s t a t i o n s of affection; scenes like sho utin g and crying are reg arde d as exceptional. Tranquil patient s and family «•i.mbers are som etim es even adm ired in the informal talk among tne staff members. Adm ini s t e r i n g sedatives, tranquillizers, sleepin g medicine, and ana lges ics is a practical and videly app licated means of keeping the p a t i e n t s calm; tranqui llize rs and s le epin g m ed icin e are often off ered to the family members of d ec ease d pat i e n t s as well.
11. Adj u s t e e n t to death. When telling about the dying öf patients, the staff members regularly made references to the p a t i e n t ’s adj ustm ent tu her/his death. Underlying these references there is an idea that people can and should accept their dying.
E. К u b 1 e r-R о s s [ 1 9 6 93 pre s ent ed twenty years ago a theory about five stages of dying. K u b l e r - R o s s ’s theory has since then rece ive d a very wide audience. It is evident that this theory has given rise and l eg iti m ati on to a "folk model" in the
The stages of var ious em o tion ? b ef ore d eath can end in acceptance. To die without h av ing a c c ept e d it is mcr o tragical than dying when one is well adjusted to death. The staff m em b e r s are also seen to go through a p s y cho l o gic a l d e v e lop m enta l process, thus lea rning to accept the fact that some p at i ent s die.
12. Hope and struggle ae responses to severe illness. When talking about the patients, ref ere n ces are of ten made to whe the r they are s t r ug gl in g against their illness and death, or have gi ven up. In the leu kaemia w ar d the way of tal k i n g of the p h y -sicians and n ur ses is c on sc i o u s l y d e s i g n a t e d to k e e p up the spirits of the patients. In general, hope and s t r u ggl e are va lued as positiv e respons es to illness. But a p a t ien t still s t r ugg l ing and h op in g at the imm ediate face of death b e h a v e s in an i n -appr opr ia te way.
13. Fear of death. The idea of fear of d ea th is at the staff's disposal when d e s cr ib in g the p a t i e n t ’s, family's, other staff m e m b e r ’s or ev e n one 's dwn r e l a t i o nshi p to death. Peo ple tend to fear de ath and the dead; but one can also get rid o f that f e a r .
14. I a p o r tance of pain. W he n de a l i n g with and talking about dying patients, pain is a matter of hi g h relevancy. Tfte pains of the patient are m o n i t o r e d through ask i ng q u e s t i o n s and ma k i n g inferences. They are co n t r o l l e d with the he l p of analgesics. When telling about the dying of a p at i e n t to her family, a d e s c r i p t i o n is usu ally given about the p ai ns of the patient.
15. D y i ng pat ien t as a me mber of the faaily. W he n the p a -tient app roa c hes death, the family b e c o mes hig h ly rel evant in the dis cu s s i o n s and gossip among the statf, and in the s t a f f ’s actions. The family members* rea ctions, f e e l i n g s a nd aw a ren e s s are m o n i t o r e d and assessed. The family m e m b e r s are usu a l l y i n -formed about the ap p ro a c h i n g death, and imm edi a tely af ter the de ath they are con tacted. In the cas e that a p a t i e n t has s u d d -enly come to the hospi ta l in bad condition, and is likely to form of a p r o p o s i t i o n - s c h é m a f Q u i n n, H o l l a n d , 1 9 8 7 , pp. 2 4 - 2 6 J, or ą "lay social t h e o r y ” [ D i n g w a l l et al., 1983, pp. 5 5 - 5 6 j of the p a t i e n t s e m o t i o n s b e f o r e ' d e a t h , us e d by the staff.
die soon, every effort is made to find his family. When the patient is in bad con dition or unconscious, the family is su p p o s -ed to represent his will when dis cussing the line of the tr eat-ment. In summary, the issue of dying is bound to the family of the patient in various ways. A dying pat ient is seen as a member of his fa m i l y 4 . The con nec t ion in this extent does not exist in the case of those pat ients who are not sup posed to die.
16. Right to a full life-cycle. The death of an old person is ex p erienced and defined entirely unlike that of a young person. Young p e r s o n s ’s death arouses more affecti on and it Is remembered longer. In discuss ions the staff members told me that it is much easier to accept the death of old people than that of young, because young persons die untimely. Und erlying . these c o n s i d e r a tions there is an idea of a full life cycle as a norm, as s o m e -thing bel o nging to everybody.
17. D eath as a nat ural fact. When d is cussing with me or among themselves, the staff members often de s crib ed death as a natural part of life. As a natural fact, it has to be accepted when it comes.
18. Har aony In death. The view of a p re ferable death, p r e -sented and referred to in various occasions, is c ha racterize d Dy harmony. Death is harmonius when the patient has accepted his death, when he has no pain, and he dies while sleeping, without noticin g the final moments. He has no unsolved pro blems with his family; and those close to him are acc ompa nying him during the last moments. A met aphor used very often as a s ub stitute for dying is "to sleep away" (nukkua pois); an attribu te reflecting harmony is often added: "to sleep away in peace" or "to sleep neatly away".
19. H orror of death. When des cr ib in g and di s c uss ing the deaths of the patients, a d im ension of horror is present. Certain kinds of deaths are defined as horrible: to choke to death, or
4
Applying the concepts of H. S a с k s [1974], one could say that the mem ber s hip c at eg or iz ati on "dying patient" implies c at eg or iz ati on as a member of ones family, too.
to die because of m assive bleeding, and to be aware of what is happening, is horrible. Being left alone when dying is also r e -garded horrible.
2Ü. Religion as a help for the dying. When tal king about death, religion is sometimes referred to. Rel i gio u s p a t ien t s and staff mem bers are s up pose d to come to terms wit h de ath more easily than the others. In some actions related to the death - like cov erin g the body with a sheet and d e c idin g about the autopsy - the c hurch aff ili a t ion of the p at ient has to be taken into account. In an a t h e i s t ’s sheet a cross should not be f o l d -ed, and a Jew would never permit an autopsy. All the ways in which religion is regarded reflect an idea of individual religiosity! religion is a quality of individuals. The hospital as a c o l l e c -tive has no religious dimension, in the view of those who work t h e r e .
2.3. The symbolic layer
The other layer of kno wled ge related to death refers to the symbolic level of mea ning and signification. In this paper I shall describ e it only briefly.
Traditional s o c i e t y ’s ways of dea ling with death have been one of the main areas of interest of social ant hrop ologi sts.
Ro-bert H e r z f 19 6 0J adopted a symbolist account on mortuary
rituals. He tried to u n d erst and the symbolic m ea ning s of the ways
of dealing with the corpse. H u n t i n g t o n and M e t -c a l f [1979, pp. 1 8 4 - 2 1 1 ] have adopted H e r z ’s per spe c t i v e in their analysis of Ame rica n funerals; they state those r e -present the idea of life as fulfilment, and death as a state of
p e a c e .
The mea ning s and act ivities related to death in mod ern h o s -pital can also be analysed from a sym bolist perspec tive. I find here the de f ini t i on of symbol given by Paul R i с o e u r [1974, p. 1 2 ] very applicable: “I define » s y m b o l « as any s t r u c -ture of si g nif i c a t i o n in which a direct, primary, literal m e a n ing des ignates, in addition, another m e a nin g which is indirect, s e -condary, and figurative and w hi ch can be ap p re h e n d e d only through the first". Alfred S с h u t z ’ s [1971, p. 337, 3 4 3 ]
défini-tion of symbol follows the same lines. By stu dying careful ly the literal and direct meaning s of care of the dying, su m marized in the 20 moral and cognitive principles, we can find behind them some indirect, secondary and figurative meanings.
The symbolic mea nings found behind the pri nc ip le s are the notion of control and the n ot io n of c o M u n i o n . Thus, in spite of the fragmentary cha racther of the principles, a thematic l i k e -ness can be found in them. But the two sym bolic themes are in conflict with each other.
Several pr i ncip les imply the idea of control and management (see princip les 1, 2, 3, 4, 5, 8, 12, 15). The hospital staff manages and controls dying through kno wledge and activities. Death cannot be avoided, but it can be pos t poned and anticipated. The p a t i e n t ’s situation is defined in biologi cal and psychia tric terms. His body and soul are interve ned with the help of adequate pr o fessional techniques.
The notion of communi on is also implied in several pri nciples (see pri ncip les 5, 6, 7, 9, 14, 15, 16, 20). Death seems to be in a very close co n nect ion to the idea of s ol idarity and strong ties between people. Com munion is sup posed to exist bet w een the dying per son and her family, and also between her and the hospital s t a f f .
When interpr eted from a symbolic per spec tive, taking care of the dying people is to warrant them control and communion. S o m e -times problems and tensions arise because of the inc ompatibil ity of these two things. It is felt to be di f ficu lt to control and manage the events, and to love the patie nt s at the same t i m e .
2.4. The princip les and the social reality
The pri n cip le s overvie wed above are quite d is similar in many respects. Some of them are pri marily normative, and the others interpretative; although in most of them the nor ma ti ve and the i nterpretati ve aspects are mingled. Thus the pri nciples, or imply, both normati ve and i nt erp retative rules. Some pri nciples are tacit, so that they can be "read" only from p e o p l e ’s ways
of acting and doing things, and the others discu rs iv e, e.e. they have been ver ba li zed by the staff members t h e m s e l v e s 5 .
It is evident that several pri ncip l es are in c o n f lic t with each other. One pri nciple (6) gives a nor m and a d e s c r i p t i o n of the s t a f f ’s clo seness to the dying patients, and a no ther (7) of its distance from them. One pr i ncip l e (9) p r e s u p p o s e s an a f f e c -tive reaction to death, and another (10) r e c o mme nd s r es trained beh aviour. Besides the overt con f licts whi ch might be i n t e r pre ted as expr ess io ns of the opp osi t e poles of the same i n t e r -pr e tati ve dim en si on s - there are deeply rooted implicit co n flic ts among the principles. E.g. p ri nc i p l e num ber 3 (Time of death as an object of profess io nal kno w ledge) implies a n or m about the d i s t rib uti on of the kn o wled ge from pr o f e s s i o n a l s to the family and the patient; but pr i n cip le 5 (Min imi z ing the s uf feri ng) may be used as a le g itimation for not sharing d i s t r e s s i n g infor ma tio n with them.
Bec ause there are overt and implicit c o n f l i c t s bet we en the pr i ncip les of the care of the dying pat ients, they can not be regarde d as simply d e t er mi nin g the m e a nin g s of dea th in hospital. The c on s t i t u t i o n of the me a n ing of death in h os pita l is a much more c om pl i c a t e d issue than a der i v a t i o n from these general features of the stocks of kno wl ed ge related to death.
Fo rmulations , which make it p o s si bl e to u n d e r s t a n d bet ter the dy n amic s of the mea nin g s of death in hospital, have been p r e -sen ted in the e t h n o m e t h odo lo gic a l tra dition, and rec entl y also in the "cultural models" researc h de v elo p e d from the cog nitive anthropology. The basic idea p ro pose d by these two tra di ti on s is the following.
Cul tural and social knowledge, like the p ri n c i p l e s pr e se n t e d
G i d d e n s [ 1904, pp. 2 2- 23 3 bas said that social rules can be cha ra ct e r i z e d by the fo l lowi ng d im ensions; int ensive vs. shallow; tacit vs. discursive; informal vs. formal; w ea kly s a n c -tioned vs. str ongly sanc-tioned. The p r i n c i p l e s p r e s e n t e d above could be for mulated as rules, most of the pri n c i p l e s con t ain in g several rules. Different rules would have d i f f er e nt c h a r a c -ter istics p r o po se d by Giddens. But this kind of p r e s e n t a t i o n would become very com plicated; t h a t ’s why I ’ll con ten t my self with principles, h aving the two cha rac t eri st ics , nam e ly i n t e r p r et ati ve vs. normative, and tacit vs. discursive.
above, giving rise to the mea nings ex p erienced in concrete s i -tuations, has an indefinite and partial character. Because of the partial cha racter of the cultural knowledge, there is in-evitably room for negotiations, alternative con str u c tio n s and dif fering views [ s e e K e e s i n g, 1987J. No rules or p r i n ciples, or sets of them, are com plete enough to cover all the c o n -tingencies and sur roun ding facts in their application. They never can det e rmine how people define their si t uati on and act in it [se e H e r i t a g e , 1984, pp. 103-134; D i n g w a l l , 1981, p. 126]. This is an app ropriate way or seeing also the pri nc ip les of the care of the dying people. They all have and i n -d e f i n i t e an-d partial character.
Because of the open and fragmentary character of the moral and cog nitive principles, a def inite fo r mulation of them is im-possible. All closed formulations - such as the one done by me - hide som ething while pre s enting so m e thi ng else [cf. S h a r- r o c k , A n d e r s o n , 1906, p. 52; G i d d e n s , 1984, pp. 21-23].
Q u i n n and H o l l a n d [1987, p. 10] say somethi ng about cultural models that could very well be applied also to the pri nci p les pr e s ent e d above: They "are better thought of [...] as res ources or tools, to be used when suitable and set aside when not" Robert D i n g w a l l [l98l] points to the same, when he says that the actors are to be seen as cultural p r o ducers rather than cultural products. The p ri n c i p l e s are a r e -sou rce at the s t a f f m e m b e r s ’ disposal, when they pro duc e and or g aniz e their ever yda y life and s et ting through their action^.
In summary, It has been said until now that the social m e a n -ings of death in hospital are a result of the s t a f f ’s selective use of numer ou s cog nitive and moral principles, in their e v e r y day work at the hospital. This c o n c lu s i on is any thing but s a t i s -factory. C a n ’t we find any dee per logic in the use of the moral
Cf. the m a x im presented by G a r f i n k e l [1967, p. 33]: "A pol icy is re c ommended that any social setting be viewed as sel f -or g aniz i ng with respect to the int e l l i g i b l e character of its own ap p earances [...]". In the process of organizing their own setting, the m em bers of the ward use the p r i n -ciples.
and co g niti ve prin cip le s? C a n ’t we say s o m e t hi ng more than that the principles are -used "when sui table and put aside when not"? In other words, we must now make an effort tow ard s a more deta ile d desc rip t ion of the m e m b e r ’s methods in accomplishing
social order in the cir cu ms ta nce s that are full of amb igu i tie s and seem to provide no pr e - giv e n order [cf. A t k i n s o n , 1978, p. 180].
I think that one step further tow ards u n d e r s t a n d i n g the logic of the use of the moral and cog n iti v e p r i n c i p l e s can be taken with the help of G o f f m a n ’s c o n cep t i on of frame.
2.5. Four frames
In a na lyzing the various p e r s p e c t ive s on death o pe ne d by the twenty moral and cog nitive principles, the c on c e p t of frame, de v elop ed by Erving Goffman, is very u s e f u l 7 . G o f f m a n n [1 974, p. 1 0 1 1 j says that the way we have framed a cer t a i n s i
-tuation influences strongly on how we define that si-tuation. Frame refers to pr i nci p l es of o r g a n i z ati on gov er n i n g e vents at han d and our sub ject ive inv olvement in them. Anthony G i d d e n s [1 984, p. 8 7 ] follows Gof fma n and says that "fr ames are c lu ster s of rules which help to con st it ute and reg ulat e activities, d e -fining them as ac t i vit ies of certain sort and as a subject to a given range of sanctions".
Taken together, the d e f init i ons of frame by G o f f m a n and by Giddens point to three things. First, frames c onsist of d i f f e re nt kinds of explicit and implicit social rules, those of i n t e r -pr e ta t i o n (co nsit utive rules) and normative, r eg u l a t i v e ones. The staff m e m b e r s ’ rules related to d eath and d y i ng are include d in 20 principles. Each pri n c i p l e is c om po se d of several ind efinite rules. These rules can be gro u ped as' clusters, for min g frames. Secondly, frame refers to the p r i nc ip les of o r g a n i z a t i o n govern- ing e v e n t s . As I und er st and this, it re fers to what p eo ple are
7 G o f f m a n ’s frame ana lysis has been s u c c e s f u l l y app lied in the field of m ed ical s o c i olo gy by P. M. S t r о n g 1 1 9 7 9 ] in his study on the int e r a c t i o n be t w e e n p h y s i c i a n s and p ar ents with sick children. My way of u s i ng the c o n c e p t of frame is sli ghtly d i f f e r e n t from S t r o n g ’s.
doing in a given moment, and in which context. This course of activity makes them see events around them from a given p e r -spective. And thirdly, frame refers to the degree and type of in-volvement in events at hand. People with dif fere nt kind of in-vol veme nt see (things 'differently.
What makes some rules belong together, form a c l u ster ? The rules that bel ong together are the ones applied in occ asions where there is similar o r g aniz ation gov erni ng events, and people h av ing s im ilar involvement in them. Thi3 means that the framing of a s i t u a t i o n may be seen as an important factor e l u dica ting the sel ecti ve use of the pri ncip les and rules c o n t ain ed by them. To put it in the simplest pos sible way: the staff m e m b e r s ’choice b et ween the con f l i c t i n g pri ncip les and rules depends on what they are doing.
I think that the ref lection of the m e a ning s of death in terms of frame ana lysis has two advantages. First, it helps to find the con n e c t i o n s b et ween the social stock of kno wled ge related to d eath and the practical actions of the staff [cf. S i l v e r -m a n , 1905, pp. 172-1733. And secondly, it helps to u n d e r -stand the c o n f l i c t i n g nature of the mea ning s of death in hospital. Some of the co n f l i c t s bet ween the dif fere nt p r i n cip les related to d ea th are due to the exi sten ce of the dif fere nt frames of death.
Whe n the clu ster s of rules are formed, It turns out that one pri ncip le in some cases con tain s rules b e l o ngi ng to different frames. This makes the ove rall pi c t u r e quite complicated. But I will try to e x p l ici te it.
Fo l l o w i n g these lines of thought, four d i f f ere nt frames of death, p r e v a i l i n g in a mod ern hospital, can be identified. The frames are the pra ctical frame, the biomedical frame, the lay
Q
frame, and the se m i - p s y c h i a t r i c frame . Each frame opens its pe culiar p e r s p e c t i v e to death; the m ea ning of death is dif ferent in each.
Q
As S p y b e y [1984, p. 3 1 9 ] has noticed, any o r g a n i z a -tion is likely to c on tain several frames. This is the case also in hospital. Here I refer only to those frames that are a c t u a -lized In the care of the dying patients. Bes ides these there may be others h a v ing no r e l e van ce In the issues of death and dying.
The first of these p e r s p e c t i v e s refers to the practical fraae
of death. Seen from this point of view, dea th and d yi ng mean the set of p r a c t i c e s enf orce d when s o m ebod y is d yi ng at the ward. These p r a c t i c e s include items like heavy n u r s i n g care, c l e anin g and dre s s i n g the body after the death, a n n o u n c e m e n t s to the family of the deceased, w ri ting the d ea th cer ti f i c a t e , c o n t a c t i n g the pat holo gist, etc. All d i f iere nt p r o f e s s i o n a l g r o u p s have their own tasks. The p r i ncip le of o r g a n i z a t i o n g o v e r n i n g the e v e nts in this frame is eve ry d a y l i k e m e a n s - e n d rationality. E v e rybo dy does her or his job fol lowing the w e l l - l e a r n e d h ab its trying to get through the wo r k i n g day with a rel ativ ely low strain. The s u b -jective inv olve ment in the tasks is rather low. The c en tral rules in this frame are implied esp e c i a l l y by the p r i n c i p l e s 0 ( P r i -mar ily of the everyday pra ctic al affairs) and 10 ( A v oidi ng d r a -matic scenes) and 7 (Di stan ce from the dying). Be s i d e s these, the practical frame has as its c o n s t i t u e n t s n u m erou s rules def inin g in detail all the pra ctical tasks that hav e to be done in the
9 case of dea th .
Another frame is the biomedical one. Seen from this p e r s p e c -tive, dea th and dyi ng mean b i o logi cal pr o c e s s e s in the p a t i e n t ' s body, w hi ch cannot be rev erse d by the the r a p e u t i c action. Wit hin this frame, the central act ivity is to def ine the p a t i e n t ’s sit uati on in b i o medi cal terms, and to dec ide on the c o u rse of the the rape utic action. Di a g n o s e s made d ur ing the l i f e-ti me of the pat ient are u su ally followed by the c o n c l u s i o n s mad e by phy s i c i a n s
0. S u d n o w [ 1 9 6 7 ] has of f e r e d a very d e t a i l e d a n a l y s -is of the impact of the pra ctic al work c o n s i d e r a t i o n s of hos pita l staff to the cat e g o r i e s of h o s pita l life, suc h as illness, dying and death. He sum m a r i z e s his poi nt as follows: such cat e g o r i e s "are to be seen as c o n s t i t u t e d by the p r a c t i c e s of hos pita l p e r -sonel as they e n g age in their dai ly ro u t i n i z e d i n t erac tions wi t hin an o r g a n i z a t i o n a l m i l i e u “ . This p e r s p e c t i v e has then been app lied by M u r c o t t С 1 9 8 1 J to the t y p i f i c a t i o n of "bad patiens", and by P e t e r s o n [ 1 9 8 1 3 to an ana lysi s of the work of the ki t c h e n m a i d s at hospital. The t y p i f i c a t i o n of bad patients, and the c a t e g o r i e s r el ated to hos pita l food, are de r i v e d from the s t a f f ’s int erest to get thr ough the days work. My idea of the pra ctic al frame a pp lies this p e r s p e c t i v e , too. But from my point of view the whole story can not be r e s t r i c t e d to the limits of the pra ctic al frame. The sense and m e a n i n g of dying and dea th is de r i v e d also from oth er sources, in the cas e of the three oth er frames.
after rev iewi ng the results of the autopsy. Inv olve ment in the events is low, and of neutral s c i enti fic nature. Central rules within this frame are con tained first of all in the pri ncip le 2 (Oeath as a result of underlying, identifiable phy sical pro cesses) and also in p r i ncip les l(P ostp oning death), 3(Time of death as an object of pro fess ional knowledge), 4(Active interve ntion ) and 17(Death as a natural fact). Bes ides these, the bio medi cal frame is con s t i t u t e d by all those i nt erpr etati ve rules, by the help of which p h y sici ans and nurses make their infrences about the patients* medical c o n d i t i o n 1 0 .
The third frame to be c o n side red here is the lay frame. It is a l a y m a n ’s aff ective p e r spec tive to the affairs of death and dying. In oth er words, within this frame dea th mea ns to the hospital staff the same as it mea ns to people not wor king in hospitals an ups etin g and exi s t e n t i a l crisis, and a call to human communion. Involvement in the dying p e r s o n ’s s i t uati on is high, and of an aff ecti ve nature. Oeath is a c c ompa nied by feelings of shock, anxiety, grief, fear, and perhaps relief. The rules c o n -sti tuti ng this frame stem from several pri ncip les, namely K P o s t p o n l n g death), 5 ( M lnim lzlng the suffering), 6(Close c o n -tact with the dying), 9(Death as a source of neg a t i v e feelings), 12(Hope and struggle), 13(Fear of death), 14(Impo rtanc e of pain), i>(Oylng pa t i e n t as a member of his family), 16(R ight to a full
life cycle), 18(Harmony In death), and 19 (Horror of death).
D. A r m s t r o n g [ 1 9 6 7 ] has in a recent article given a historical acc ount about the f o r mati on of the bio medi cal frame
of death. "In the mid 19th c en tury the ana lytic space on which dis cour se foc ussed was e s t a b l i s h e d as the bio logi cal rea lm of the human body. It was the body which had to be scr u t i n i z e d for the secrets of dea th [...]" (p. 655). But A r m stro ng con tinu es by saying that after the mid dle of this century this dis cour se was caught by a crisis: the Ideas of def init bio logi cal cau se and m e c h a n i s m of dea th had to be abandoned. "Death cer ti f i c a t e s and m o r tali ty rec ords mov ed from b e i n g the hard bed -roc k of med icin to bei ng a c o m b i n a t i o n of s u b ject ive impression, arb itrary rule and pro fes s i o n a l consensus". A c c ordi ng to Armstrong, the crisis led to the dev e l o p m e n t of a new d i s c o u r s e on death, one which poi nted to the Int eraction b et ween the dying man and his e n tourage, to the a n t icip atory grief of the dying and to the p s y -cho logi cal support to be off ered to him. This new d i s c o u r s e r e -fers to what I have called the s e m l - p s y c h l a t r l c frame of death. Arm stro ng sees these two cis c o u r s e s as fol lowi ng each other histori cally . One rises when the other declines. On the contrary,
In the fourth- p e r s p e c t i v e , w it hin the s e m i - p s y c h i a t r i c frame, the issue is the exp e r i e n c e of the patient, the family and the staff itself, con s t i t u t e d w it hin the lay frame. But the i n v o l v e -ment is dra mat i c a l l y dif ferent. The d e f i n i t i o n s and fee lings sha ped in the lay frame are now treated in a d e t a c h e d manner. They are int erpr eted and ma n a g e d in terms of s e m i - p s y c h i a t r i c concepts, like r e p ress ion of feelings, denial of death, acting out o n e ’s anger, and the like. The central act i v i t y w i t h i n this frame is d e f inin g and c o n t r o l l i n g the ten sion s cr e a t e d within the lay frame. In this case, death means e m o tion al p r o c e s s e s which can be identified, con t r o l l e d and managed. The rules of this frame come g e n eral ly from the same pri n c i p l e s as the rules of the lay frame, b ec ause the s e m i - p s y c h i a t r i c frame is n e s t e d in the lay frame. In add itio n to them the s e m i - p s y c h i a t r i c frame gets its rules from the p r i ncip le 4 (Active i nt erve ntion ), 10 ( A v o i d -ing dra mati c scenes) and 11 (Ad just ment to death), and 20 ( R e -ligion as a help for the dying).
Eve rybo dy p a r t i c i p a t i n g in the s i t uati on w h e r e a p at ient is dying - physicians, nurses, p a t ient s and their fam ilie s - is acq uint ed with all of the above m e n t i o n e d frames. The s e m i-ps y- chi atri c frame however, may be rather s tr ange for a part of the pat ient s and family members. O i f fere nt g ro ups of p e o ple have dif fere nt sta tuse s in d i f fere nt frames. P h y s i c i a n s d o m i n a t e in the bio medi cal frame, nurses in the p r a ctic al frame, and p a t i e n t s w it h their fam ilie s in the lay frame. But still all u n d e r s t a n d the action w it hin each frame, and can p a r t i c i p a t e in it. For example, pat i e n t s at the leu kaem ia ward adopt q ui te soon the b i o -medical p e r s p e c t i v e when st a y i n g in hospital. They learn to talk about the last res ults of d i f f e r e n t tests made of them - also with other pat i e n t s and even with their f a m i l i e s 1 1 .
my o b s e r v a t i o n s show that they both exist side by side in the eve ryday life at hospital. The b i o logi cal d i s c o u r s e may be a b a n -doned in the sci e n t i f i c d i s c u s s i o n s d e a l i n g with d ea th - but in the eve ryda y talk among the hospital staff it still is very p o w -erful .
11 r л
E. M i s h l e r L 1984 J has rec entl y p r e s e n t e d a s e n s i -tive analysis about the p r o b l e m a t i c r e l atio n b e t w e e n the b i o m e
-dical and lay frames, whi ch he cal ls the voice of m e d i c i n e and the voice of the lif eworld. In his study on me d i c a l int e r v i e w s M is hler i d e ntif ies the voice of the l i f e w o r l d m os tly in p a t i e n t ’s
The dyn amics of interaction at hospital is cha r a c t e r i z e d by constant shi fting from one frame to another, and also by mixing the frames. Not even a short period of activity usually does take place within one frame only [cf. G о f f m a n, 1974, p. 561]. Let us consider for a while the next, very usual occ urre nce at the leukaemia ward.
The room of an unc onsc ious ‘Pre senc e of the fam patient a p p roac hing death,
att ended by her hus band and
Lay frame.
mother. I have joined them. •Taking the blood Two nurses come to the room, test and talking and they make a blood test to about it:
the patient. They co- ordi nate Practical frame.
their w or king by saying brief
pra ctical comments to each ♦Talking to the other. When doing som ething to u n c onsc ious the patient, e.g. cle a n i n g her patient: s e m i -skin or pre ssin g the needle
into her arm, one of the nurses
psychiatric frame.
tells, r e g ardl ess of her »Giving reasons condition, the patient what for the blood she is doing. She also tells test: Biomedical
the family members what the frame.
blood is n e e ded for: it is • Of fering coffee ana lyze d in order to find the as a sign of b ac teria in it. After approval and fin ishing their job one of the e nc o u r a g e m e n t for nurses says to the family- the att endi ng members that if they want to
drink a cup of coffee of tea, she cou ld bring it for them.
family: Lay frame.
talk, and the voice of the med i c i n e in p h y s i c i a n s ’ way of t a l k -ing. The str uctu re of medical int ervi ews seems to be quite simple in c o m pari son with the i n t erac tion at a hospital ward. In the e ve ryday life at a ward each par t i c i p a n t uses each voice a v a i l -able for his own purposes.
In the course of everyday activity, the dif fere nt frames are laminated on each other [cf. G o f f m a n , 1974, pp. 1 5 6 - 1 6 5 J. At each moment one of them is on the foreground, and the others are on the background.
Thus there are four different realities of dea th in hospital, side by side, con stituted by different frames. Dea th means very different things in each frame. A que stio n wor th dis c u s s i n g is whether this is due to some specific features of m o d e r n hospital or modern society in general, or is it just r e f lect ing formal, invariant pro pert ies of the con stit ution of m ea ning and i n t e r -action.
An absolutely coherent and hol istic mea ning of dea th is hardly possible in any circumstances. Even in the most p r i miti ve s o c i e -ties there has always been two different ori en t a t i o n s to dying, profane and practical on one hand, and sac red on the other, says M a i i n o w s k i [1954, p. 31]. But the sharp d i f f e r e n t i a t i o n between the four frames may still be som ethi ng c h a r a c t e r i s t i c of our society.
ТЬошаз L u c k m a n n [1983, pp. 1 8 1 - 1 8 2 ] has w ri tten about the seg ment ation of the social order in a m od ern society. The functionally rational norms of the spe c i a l i z e d institutional domains have became relatively independent of the o v e rarc hing symbolic legitimations of society, and of the b i o grap hical c o n text of meaning. The per son and the bio gr a p h i c a l con text of m e a n -ing have become d i s enga ged from the individual p e r f o r m a n c e s within the different segments of the institutional order. The s e p a r a tion bet ween the lay frame on one hand, and the medical and p r a c -tical frames on the other could be seen as a m a n i f e s t a t i o n of the tendency p oi nted to by Luckmann. They lay frame refers to the bio grap hical context of meaning, and the others to the i n s t i t u -tions of med icine and hospital. If this is the case, the semi- -psychiatric frame cou ld be seen as an attempt to bri dge these two spheres, the bio grap hical and the institutional. But this is not to say that lay frame would not have its i n s titu tiona l r e -ferences as well.
2.6. Frames and institutions
In this theory of structuration. Anthony Giddens points to the i nt errelationship between social action on one hand, and s t r u c -tural and institutional pro perties of society on the other. Structures or structural pro perties are realized in in s t i t u tions. Institutions are defined by Giddens as those social p r a c -tices that recur systematically in time and space [ G i d d e n s , 1984, p. 17 J. The main point presented by Giddens here is that the social structure is an essential resource for and product of situated social action [see for example G i d d e n s , 1984, p. 323 ].
G i d d e n s ’ theory bears a strong resemblance to the ideas pre sented by Roy Bhaskar. David S i 1 v e r m a n [1985, pp. 77- 78] summarizes B h a s k a r ’s point in three propositions: 1)Interpretative procedures are central to the reproduction of social structure, 2)Social structures are real, con stra ining and enabling forces. 3)Social str uctures are the con dition of social action and are rep rodu ced and changed by it.
These views give a challenge to examine the con nect ions of the four frames of death to different social structures and in-stitutions. Which institutions with their structural . p r o p e r -ties are implicated as resource for and product of the social
action taking place within the four frames of death? Which institutions are implicated in taking care of the dying p a -tients?
First answer to the question posed above is that the twenty pri ncip les form themselves a structure of signification. In the first place it is this structure that is implicated in the a c -tion taking place within the four frames of death. But we can go still further. The str uctures of sig nifi catio n must be seen in con nect ion with other types of structures, namely the structures of dom inat ion and legitimation. And all these structures are in con nect ion to different kinds of institutional orders [ G 1 ri-d e n s, 1984, pp. 29-31].
2.7. Tentatively. I will propose the following con nect ions Action taking place within the practical frame of death i m -plicates the formal and Informal organizational structure of the hospital. The division of labour and wor king times, each g r o u p s ’s and i n d i v i d u a l ’s obl igations and tasks are the res ourc e and o u t -come of this activity.
Action taking place within the biomedical frame of death im-plicates the mode of dis course called the biomedical model [cf. V u o r i, 1979, pp. 213-216; H е 1 m a n, 1984, pp. 65-68].
This mode of discourse has its own history (the b e g inni ng of which is described by Foucault 1973) and it is now aday s s u p -ported by strong institutions of medical edu cati on and clinical practice.
The structures and institutions implied by act ion taking place within the lay frame of death are not as easy to recognize as the above mentioned. The institutional fou ndat ions of this frame are quite vague. One institutional order is e v i dent ly there:
family. Both the relevance of the family as a cat egor y closely b ou nd to the category of the dying patient, and the idea of a family - like close contact bet ween the staff and the patient point to this dir ecti on [cf. J a m e s , 1 9 B 7 ] 1 2 . The other in-stitutional order, which is much more dif ficu lt to rec ognize and to analyze, could be called the discourses of feelings. Feelings and the ways of con ceiv ing them have their own social history [cf. H e l l e r , 1979]; the feelings and tal king about them
at hospital reflect a modern dis course of feelings.
The semi-psychiatric frame shares the institu tiona l f o u n d a -tion of the lay frame and the practical frame. Because the c h a -racteristic activity within this frame is to m a n age and define the feelings con stit uted within the lay frame, it also draws upon and reproduces family and discourses of feelings as i n -stitutions. The use of the sem i - p s y c h i a t r i c int erp r e t a t i o n s of dea th in managing the feelings and tensions at the ward has a
12 The strong con nect ion bet ween the family and the death has
its own social history, ori g i n a t i n g from the Rom anti c Era [ se e A r i e s , 1982, pp. 409-558J.
functional con nect ion to the fornal and informal organizational structure of the hospital. The serai-psychiatric frame namely a s -sures the routine functioning of the hospital. But in addition to these, the semi-psychiatric frame has its own institutional connections. One is the institutions of medical and nursing edu-cation. These institutions, esp ecially the nursing ones, d i s -seminate the semi-psychiatric interpretation of death among the young staff members and those par tici patin g in further e d u c a -tion or consulta-tion. The nurses also use the semi-psychiatric frame as a means to legitimate their professional is«. The in-terpretation itself relies on social scientific discourses of human reactions, especially those derived from a popularized version of psychoa nalys is [cf. B e r g e r , 1979, pp. 48-50, 59 ]1 3 .
Thus we have identified several Institutions that are im-plicated in the care of the dying people in hospital. The in-stitutions men tion ed are those drawn upon, when people face death profess ional ly in our society today. Besides the hospital o r g a -nization and the biomedical discourse, several other in s t i t u -tional orders are represented here. There seems to be a carry over of institutionalized meanings from the sphere of family, discourses of feelings, and even from the social scientific d i s -courses, to the taking care of the dying people.
3. The use of the social stocks of knowledge in practice
The eth nome thodo logis t ethnographers, like Lawrence W i e -d e r [1974], Insist that a sociologist shoul-d not be content with just des crib ing the conceptual models in the collectives
13 A r m s t r o n g [1987, p. 6 5 6 ] says that the new d i s -course on death, which pointed to the open interaction between the dying and his entourage, and to the psy chol ogica l support offered to him, also brought with it a more pen etra ting power of medical interrogation. This is a very important point of view. From a Fou caul tian perspective [cf. F o u c a u l t , 1977, esp. p. 224; L e m e r t , G i l l a n , 1982, pp. 5 7 - 9 2 ] the semi- -psychiatric frame of death can be seen as a recent example of the fusement of power and knowledge in ins titu tiona lized p r a c t i -ces. The sem i-ps ychia tric frame of death has its own - until now r a t h e n simple ' but dev elop ing - body of knowledge or discipline, which is used in the control and man agem ent of the dying.
studied. The models in themselves do not "cause" behaviour. As S i l v e r m a n [-1985, pp. 45-46 3 bas pointed out, with r e -ference to Moerman, the aim of social sci enti fic studies should
be to show, how people in their natural settings use the c a -tegories and explanatory models that they have.
D ep icti ng the frames of death does not fulfill the r e q u i r e -ments set by e t h n o m e t h o d o l o g i s t s . The frames are still too a b -stract constructions.
Showing how the members use the frames and pri ncip les in finding and sustaining the character of the events they p a r -ticipate in can take place only through a det aile d analysis of the concrete everyday activity. That kind of analysis of my data 1 have not yet sys tematically made. Thus I can offer only a cou ple of examples which may give an idea what it could be.
3.1. The pro blem of "too intensive" treatment
I have been astonished by the amount of c r i t i c i s m that the staff itself directs to the active therapeutic line in the cases of mortally ill patients. It was almost c o m monp lace among the nurses to say that if I had cancer, I wou ld never let myself be treated wit h che moth erapy and radiotherapy аэ hea vily as the pat ients here are treated. Also the phy sici ans often showed c r i
-tical attitude towards too intensive treatment - alt houg h it is they themselves who make the dec isions about the care. How is it pos sible that the active line of treatment still goes on,
14 when almost everybody seems to be somehow against it?
There must be many reasons for that, and I will point to one. Some light to this puzzle can be attained from the conception of different frames related to death. The policy of active t r e a t -ment is quite reasonable when eva luat ed wit hin the biomedical frame. Within it the medical int erve ntion into the p a t i e n t ’s body is something taken for granted. It is wit hin this frame that the dis cuss ion leading to the dec isio ns on treatment usually
14
Actually there has been some change.' The general policies of treatment of patients with no hope are no more as aggressive as 10-15 years ago. But still there is a great gap between what is said and done.
takes place. But when nurses and physicians criticize active p o licies, e.g. informally talking to one another or to the e t h n o -grapher, they act within another frame, namely the lay frame. According to the rules of this frame, death and dying are to be evaluated in terms of being horrible or peaceful. Intensive treatment obviously tends to make dying h o r r i b l e 1 5 .
The example con sidered makes evident that different actors at hospital do not give their support to certain, coherent p o -licies of treatment of terminally 111 people. We cannot say that this doctor or nurse is for "cure" orientation and that doctor or nurse is for "care" orientation. In differently framed s i t u a -tions they all can follow and support very different policies. That's because they use different principles and rules in d i f -ferently framed situations. - Naturally this does not mean that there wouldn't be also individual differences. The individuals do differ in their way of using the various principles and f r a m e s .
The fact that different frames of death are so sep arated from each other seems to perpetuate active policies of treatment in spite of all criticism. A hypothesis can be gen eralized from this: р зр агatedness of different frames makes power immune to many potential attacs. When the attacs and their target belong to d i f -ferent frames, then the power attacced will not be attained by 1 ts c r i t i c s .
3.2. Involvement in the feelings of the dying
Another problem that the staff, especially the nurses, very often faces is the emotional involvement In the situation of the dying and their families. The s t a f f ’s response seemed to be very ambivalent. On one hand they showed and told about strong geel- ings and difficulties to cope with them. On the other hand there
This is not to say that the intensive treatment could not in many cases be preferred when evaluated within the lay frame as well. Prolongation of life is a central value also in that perspective. But it is accompanied by the rules referred to above, and in several cases, the latter weight more.
was an evident feeling of guilt for not having enough affection. On one hand there was a strong mot ivat ion to come near to the dying patient and to win her or his confidence, but then again there was a tendency to keep distance between oneself and the
patient.
This amb ivalence can be made understandable in the light of the conception of different frames of dying. The strong feelings experienced, the affirmed obligation to have affection, and the will to be near the patients are responses c o n stit uted within the lay frame. The tendency towards a routinized, non emotional and distant response is con stituted within the practical frame. These two responses, in spite of their logical conflict, live side by side in the world of the hospital staff. And nowadays even a third one has grown there. It is constit uted within the semi-psychiatric frame, and its core is conscious man agem ent of feelings. It is needed because the feelings constit uted within the lay frame are so massive that without special management they make working very hard and tend to disturb the activities taking place in other frames.
3.3. Mai ntaining the tremendous character of death ł
Most of the writings about dying at the hospital deal with the detached attitude of the hospital staff to the events s u r -rounding death. Within the practical frame - whi ch in some wards and hospitals evidently strongly dominates - the dying actually is a routine event among other routine events. But another facet of death is its tremendousness. The tremendous character of death is usually seen as something repressed in hospital: the standard idea is that the detached attitude is in fact an escape from the tremendousnes that cannot be borne. In the previous e t h n o -graphies of dying at hospital, the tremendous cha ract er of death has been taken as something that is marginal in the reality of the hospital. G l a s e r and S t r a u s s [ 1 9 6 5 ] w i t h -out explicating their implicit position - consider the tremendous character of death as a natural psychological fact. David S u- d n o w [1967, pp. 170 -173 ] writes that the shocking character of death is something belonging to the social mea ning -text ures
prevailing outside the hospital, from where there is occasionally a carry-over inside the hospital.
If we follow carefully G a r f i n k e l ’ s [1967, p. 33] recommendation, and try to view the social setting "as self- -organizing with respect to the intelligible character of its own appearances", we should not be satisfied with these positions. If the tremendous character of death is in one way or another a part of the social reality of the hospital, we should be able to identify some joint activities of the par ticipants of the hospital life, through which this character of death is sustained. And these kinds of activities can be identified.
We will present one Instance of the production of the tre men-dous character of death in the leukaemia ward. It is the institu-tion of viewing the dead body. Many of the nurses go to see the body of a patient who has died. This viewing takes place s i -lently. Something may be said in the room, if there is somebody else too, but voices are low. The corpse itself is neatly covered with a sheet; usually there is also a flower on the breast of the body. The following quotation is from my field notes.
An auxiliary nurse, Liisa, comes with me to the room of a female patient who has died some hours ago. When we enter the room, Liisa says to me that there are really a lot of things here. (In the room there is a radio, other things and some plastic bags belonging to the deceased). Liisa goes to the body, and uncovers her face. First I speak in my normal voice, saying that the dead look peaceful. Liisa whispers; she comments on the blue colour of the deceased. She touches the cheek and hair of the deceased; after touching the cheek she says that the body is cold. She says that it is strange that Anna-Maija is still blue. We stay silently for some time, watching the body, on one side of the bed. Elisa, a nurse, enters the room without uttering a word. She goes to the other side of the body. She watches s i -lently the face of the deceased. Liisa says to Elisa, that it is not so nice that the flower is an artificial one. (Because of the isolation rules, it is forbidden to bring natural flowers to the ward. AP) Elisa says that it still looks nice. She d o e s n ’t say anything else. After a while we all three leave the room. Lllsa covers the face with the sheet. When leaving Liisa takes my hand and presses it gently. We wash our hands in the vestibule. When we are in the coridor, Liisa says to me that the body of Anna-Maija should be taken put of the ward very soon. The problem Is that her hus band has not yet come to the hospital, and he might be willing to see his wlfee body. After a while she says that if he wants to, the husband can see her wife at the chapel of the hospital; the body shall thus be soon taken away.
This episode begins within the practical frame: Liisa notices the things in the Doom. From it we move into the lay frame, the
tremendous character of death is constru cted through our d e m e a -nour and way of talking. The dead body is made a very special object. - It is evident that L i i s a ’a demeanour is partly due to the fact the she sees me as an outsider, a novice and a layman in these matters. But anyway she acts as a «ember of staff, in one of the frames of death that the staff uses. Then we come back to everydayness. The body is not any more defined as sacred, but as an mundane object which must be taken out of the ward within the time-limits set by the rules of the hospital.
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