17.4 Life Review, Successful Life, and a Good Death

Autonomy and Competence

The themes of autonomy and competence come up in Erikson’s psychosocial stages and Bandura’s concept of self-efficacy. In self-determination theory, however, autonomy primarily refers to the freedom to make our own choices, not necessarily the ability to perform tasks without assistance. Both autonomy and competence appear to be associated with achieving ego integrity (Filip et al., 2020) and better mental and physical well-being (Chen et al., 2015; Van Hiel & Vansteenkiste, 2009). However, autonomy isn’t equally valued across cultures, which raises the question of whether it’s truly associated with successful psychosocial outcomes. Some research has shown that in collectivistic cultures, being able to choose our own life experiences and make important decisions isn’t strongly linked to having a positive view of our life (Choi et al., 2023; Lambert et al., 2022). However, other research suggests this connection is more complex. Cross-cultural studies indicate that Chinese, European, South American, and North American teenagers and adults all associate autonomy with well-being regardless of whether their larger culture values personal choice (Chen et al., 2015).

Feelings of competence don’t come only from success. After being diagnosed with terminal cancer, computer science professor Randy Pausch delivered a life lessons speech known informally as “The Last Lecture.” In it he described a situation in which his childhood football coach had pushed him hard during one practice, making him drill repeatedly:

And when it was all over, one of the other assistant coaches came over and said, yeah, Coach Graham rode you pretty hard, didn’t he? I said, yeah. He said, that’s a good thing. He said, when you’re screwing up and nobody’s saying anything to you anymore, that means they gave up.... Your critics are your ones telling you they still love you and care (Pausch, 2007, p. 5)

Rather than interpreting criticism as a sign of failure and becoming discouraged, Pausch realized this feedback provided an opportunity to increase his competence and was able to use that insight throughout his life to achieve his goals and increase his chances of evaluating his life as successful.

Relatedness

Relatedness, the feeling of being connected to others, is also commonly viewed as part of a successful life (Figure 17.20). Our relationships include not only contact with others, but also the emotional connections we build and the extent to which we feel other people understand us. For example, in the excerpt from Pausch’s speech, the coach’s words sent the message that Pausch was respected, valued, and worthy of an honest opinion. This broad definition matters because it accounts for the variety of bonds in adult lives. Isolation, physical or emotional, may prevent people from feeling they have lived successful lives, perhaps because it makes them more likely to dwell on negative life events without being able to get reassurance from others (van der Keep-Deeder et al., 2022).

Figure 17.20 Relationships of every kind matter throughout our lives and help contribute to the sense that we have had a successful life. (credit: modification of work “Elderly Couple” by “foooomio”/Flickr, CC BY 2.0)

“Mr. J.” was a fifty-three-year-old terminally ill man being interviewed for Kübler-Ross’s research regarding the themes of grief when he said the following:

You know, it’s a wonderful feeling, but everywhere I have been and all through my life, people have liked me. I am profoundly thankful for that. I am humbly thankful. I have never gone out of my way, I don’t think, to be a do-gooder. But I can find any number of people in this city who could point out times on various jobs that I helped them out. . . . But by the same token everybody I have ever known has helped me. I don’t believe I have an enemy in the world. (Kübler-Ross, 1969, p. 135)

Mr. J looked back with satisfaction not only on what he had done for others, but also on what others had done for him. He clearly felt he had been successful at establishing connections throughout his life.

Pain and Suffering

The desire to be free of pain and suffering is a common theme in a good death in Korean (Kim, 2019), Buddhist (Dorji & Lapierre, 2022), Swiss (Borrat-Besson et al., 2022), Chinese (Liu & van Schalkwyk, 2018), and South African cultures (Daniels-Howell, 2022) as well as in diverse populations of elders in the United States (Cain & McClesky, 2019). There is no universal agreement about how this freedom should be accomplished, however.

In one study, Black and Latino adults in the United States viewed medical aid in dying (MAID) negatively, perhaps because their religious backgrounds emphasize suffering as spiritually necessary or because they were concerned about this aid being overused with minority populations (Cain & McClesky, 2019). Similarly, Buddhists and Muslims regard death as unavoidable and may reject aid in dying because they feel it violates that aspect of their faith (Dorji & Lapierre, 2022; Nadeem et al., 2017). Given the Christian belief that events are “in God’s hands,” aid in dying may be viewed as going against God’s plan (Daniels-Howell, 2022). Kim (2019) cites data indicating that 90% of Korean elders support end-of-life measures and don’t want to prolong life artificially; however, the Korean culture frowns on suicide, which may affect the way aid in dying is perceived. Judaism emphasizes the value and sacredness of human life, which may lead Jewish doctors to recommend more aggressive medical treatments and Jewish patients and families to request them (Braun et al., 2014). “In defining a good death across research on patients, loved ones, and health care providers, 81% feel that being free of pain is a top priority (Meier et al., 2016).

Autonomy

The related question whether a sense of control or autonomy is associated with a good death doesn’t have a consistent answer either. In collectivistic cultures such as Japan’s, the patient’s specific wishes may not be solicited or heeded (Terunuma & Mathis, 2021), but in more individualistic cultures, respecting the patient’s autonomy and individual preferences is seen as a fundamental part of a good death (Lang et al., 2022; Vanderveken et al., 2019, Borrat-Besson et al., 2022; Cain & McClesky, 2019).

In religious traditions that emphasize the inevitability of death, such as Buddhism and Islam, personal choice in the matter may be viewed as irrelevant (Dorji & Lapierre, 2022; Nadeem et al., 2017). In contrast, Israeli doctors indicated in one study that they feel their primary duty is to preserve life, which may cause them to place less emphasis on patient autonomy in end-of-life decisions (Braun et al., 2014). However, many cultures share the desire to be prepared for death—whether simply emotionally or tangibly, such as by making a will (Borrat-Besson et al., 2022; Dorji & Lapierre, 2022; Liu & van Schalkwyk, 2019; Nadeem et al., 2017) (Figure 17.21).

Figure 17.21 Many cultures share the ideal that a person should be emotionally ready to consider their own death. (credit: “Elderly Man Red Turban” by Amaury Laporte/Flickr, CC BY 2.0)

Respect

A good death can also include respectful treatment after death. In their recent study of COVID-19 pandemic deaths, Hernández-Fernández and Meneses-Falcón (2023) noted that health-care and funeral workers expressed concerns about not being able to treat bodies respectfully after death, partly because of practices intended to prevent the spread of disease (such as spraying the body with disinfectant), but also because the sheer number of deaths during the first year of the pandemic overwhelmed them.

Connections

Family relationships and friendships are another common theme across cultures. For example, Swiss, Chinese, and Korean research participants indicated that being with loved ones, especially children and grandchildren, was a high priority during the dying process (Borrat-Besson et al., 2022; Kim, 2019; Liu & van Schalkwyk, 2018). However, this isn’t always possible. During the pandemic, many people died separated from their families, and even if families were present, they were likely wearing masks and other protective equipment, which may have created a sense of distance and increased distress for everyone.

The impact of the person’s death on their family is also relevant. In the Confucian value system common to countries like Korea and China, having a good death includes feeling you have been a good parent and are not a burden to your family (Kim, 2019). For Muslims and others living in India and Uganda, a good death requires ensuring that the surviving family will be financially secure (Krikorian et al., 2020; Nadeem et al., 2017).

The Age of the Deceased

The concept of a “good death” often assumes that death happens in older age. However, that is not always the case. Parents of terminally ill children often experience distress at not being able to alleviate their child’s pain and report not always receiving good communication from medical staff. Health-care workers report avoiding discussions about the child’s impending death in a well-meaning but often unsuccessful attempt to prevent further distress (Daniels-Howell, 2022).

Children have less autonomy and understand death differently than adults, so we can’t assume that adult standards for a good death apply to them. Studies suggest that health-care workers can improve the death experience for sick children and their families by treating the child not as a patient or diagnosis but as a person (including allowing everyday childhood activities such as attending school and playing), communicating clearly with families, and providing as much family time as possible, such as by allowing parents and siblings to participate in the child’s care if feasible (Broden et al., 2020; Daniels-Howell, 2022) (Figure 17.22).

Figure 17.22 Sick or dying children often benefit from spending as much time as possible with their family. (credit: “American medics treat a child in Camp Pannonia, Afghanistan” by Joseph Swafford, ISAF Headquarters Public Affairs Office/Wikimedia Commons, CC BY 2.0)

Spirituality and Religion

Religious and spiritual views may also help define a good death, regardless of what that religion is. Many religious and spiritual perspectives regard death as inevitable and controlled by a force outside the individual, and therefore not to be feared (Cottrell & Duggleby, 2016; Krikorian et al., 2020). In Buddhism, for example, death is a natural event to be approached calmly. Performing altruistic acts during life is believed to enhance progression toward enlightenment, so we are constantly preparing for death by being alive (Dorji & Lapierre, 2022). Engaging in specific religion-related practices may also contribute to a good death. In Hinduism, a good death is associated with rituals such as moving from the bed to the floor and fasting. These deeply held traditions are meant to prevent misfortune from happening to the dying person’s family but may be hard to accomplish in hospital settings (Kim, 2019). However, lack of religious or spiritual beliefs does not necessarily indicate a “bad death.” In fact, people at extreme ends of the religiosity continuum (i.e., people who are either very religious or very nonreligious) show similar acceptance of and lack of anxiety about death (Spitzenstätter & Schnell, (2023). People who are agnostic or atheistic tend to regard death simply as the end of existence, with no afterlife to be concerned about, and to regard life as being meaningful and valuable as a result. They may be distressed because they feel the language and rituals surrounding death have unwanted religious overtones, but do not typically adopt religious views in response (MacMurray & Fazzino, 2017).