Table Of ContentTIME FOR
DYING
A series edited by Howard S. Becker
.tllla Northwestern Un1vers1ty
M
ø
s
e
E FO
BY
Barney G. Glaser
AND
Anselm L. Strauss
UNIVERSITY OF CALIFORNIA
ALDINE PUBLISHING COMPANY/ Chicago
Copyright © 1968 by Barney G. Glaser and Anselm L. Strauss
All rights reserved. No part of this publication may be
reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording, or
any information storage and retrieval system, without
permission in writing from the publisher.
First published 1968 by
Aldine Publishing Company
529 South Wabash Avenue
Chicago, Illinois 60605
Second Printing, 1974
Library of Congress Catalog Card Number 67-17601
Designed by Bernard Schleifer
Printed in the United States of America
To
HELEN NAHM,
colleague and good friend
This book, like our preceding book (Awareness of Dying), is
directed to two audiences. Because we wish to contribute toward
making the management of dying-by health professionals, fami
lies and patients-more rational and compassionate, we have
written this book, first of all, for those who must work with and
give care to the dying. Our discussion is, however, not simple
narrative or description; it is a "rendition of reality," informed by
a rather densely woven and fairly abstract theoretical scheme. This
scheme evolved gradually during the course of our research. The
second audience we anticipate for this volume, therefore, is social
scientists who are less interested in dying than they are in useful
substantive theory. Our central theoretical concern is with the
temporal aspects of work. We believe, and shall indicate in the
concluding chapter, that the theory presented here may be useful
to social scientists interested in areas far removed from health,
medicine, or hospitals.
In 1963, 53 per cent of all deaths in the United States oc
curred in hospitals, and many others in nursing homes.1 That figure
points up a little noted but significant trend characteristic of eco
nomically advanced nations. In so-called less developed countries,
people typically die at home, at least when they die naturally, but
the health practices and medical technology of Western Europe
and the United States seem destined to bring about increasing
institutionalization of dying in those regions.
The extent of the trend, but not its full significance, is sug-
9e,st7d by the bare fact of the changing character of locales wlwre
people die. Nursing homes, for example, are becoming less cus-
l. Robert Fulton, "Death and Self," Journal of Religion and Health,
3: (July, 1964), p. 364.
vii
viii Preface
todial and more medical, and unquestionably will continue to
evolve along these lines. Along with improved medical technology
and changing disease patterns, hospitals, too, are assuming a new
look. Whereas they used to be either custodial institutions or places
where the poor were taken to die, during the past three decades
they have increasingly evolved into workshops where complete or
partial recovery from illness can be achieved. In turn, medical
progress has also altered the patterns of disease: chronic illness,
rather than acute illness, now predominates. This and the increas
ingly medical character of hospitals have transformed the medical
care provided in hospitals. There is far less shoulder-to-shoulder
fighting by nurse and doctor against the dangerous peaks of acute
disease. Patients with incurable chronic diseases either come to
the hospital to die, or die there because the erosion of the disease
cannot be arrested. In consequence, the relationships of hospital
staff and patients have changed considerably from the days when
patients either died quickly from acute disease, or, their conditions
being hopeless, went home to die.
That people elect to die in such institutions-or that their
families make such choices for them-means that outsiders to the
family have been delegated responsibility for taking care of the
dying during their last days or hours. The significance of delegated
responsibility is powerfully suggested by two contrasting situations
that we have observed. In the United States, elderly people some
times refuse to leave home to die in hospitals, and their families
often concur in the decision; but, when the progress of dying in
volves intricate nursing care or extreme deterioration of bodily
functions, the dying person is likely to be sent off to a hosp\fal or
nursing home when the family simply can no longer endure the
situation. Quite aside from simple abandonment of the dying to
strangers, the family may even yield to hospitals and nursing homes
all but small amounts of responsibility for action taken during the
dying person's last hours, agreeing sometimes to rules that restrict
visiting and even lead to their absence at the moment of death.
In contrast, families in countries like Greece, Malaya, and Italy
Preface ix
frequently still request or insist that their dying relatives be moved
from hospital to home when near point of death.
The delegation of responsibility, whether partial or total, is of
immense importance for everyone concerned: for patients, families,
and, of course, for the hospital staffs. The last take thefr responsi
bilities with the utmost seriousness, in accordance with the direc
tives of professional practice and the dictates of conscience. But
close scrutiny of terminal care quickly suggests that only the more
strictly medical or technical aspects are professionalized.
As we noted in an earlier volume,2 the training of physicians
and nurses equips them principally for the technical aspects of
dealing with illness. Medical students learn not to kill patients
through error, and to save lives through diagnosis and treatment.
But their teachers put little or no emphasis on how to talk with
dying patients; how-or whether-to disclose an impending death;
or even how to approach the subject with the wives, husbands,
children, and parents of the dying. Similarly, students of nursing
are taught how to give nursing care to terminal patients, as well
as how to give "post-mortem care." But the psychological aspects
of dealing with the dying and their families are virtually absent
from training. Hence although physicians and nurses are highly
skilled at handling the bodies of terminal patients, their behavior
to them otherwise is actually outside the province of professional
standards. Much, if not most, nontechnical conduct toward, and
in the presence of, dying patients and their families is profoundly
influenced by "common sense" assumptions, essentially untouched
by professional or ever rational considerations or by current
advancement in social-psychological knowledge.
It is also important that the institutionalization of terminal
care occurs within a place of work-for such care is "work" where
usually the hospital st< ff must give care simultaneously to dying
and recovering patients. Even casual scrutiny of terminal c~re
from the perspective of work shows that the staff's conditions of
work can profoundly affect the specific care they provide. Although
2. Awareness of Dying (Chicago: Al<Vne Publishing Company, 1965).
x Preface
professional canons govern the more technical aspects of such
care, even those are far from unaffected by the nature of the
hospital as an organization for work.
It is safe to predict that the shift in delegation of responsibility
from family to hospitals, nursing homes, and other institutions yet
to be invented will bring about an increasing examination of what
happens as patients lie dying in those institutions-what happens
not only to patients but to everyone implicated in the dying. We
conceive of this book as a venture in this exploration. It carries
one step farther our previous examination of hospitalized terminal
care in Awareness of Dying. In that book, we focused upon the
consequences of who did or did not recognize that the patient was
dying. In the present book, the emphasis is on dying as a temporal
However swiftly some deaths may come, each takes place
"over time," frequently over quite a bit of time. Since the speed
process; "awareness" is a secondary consideration.
of dying and the events that accompany it can vary so greatly, our
focus on the temporal aspects of dying must not fail to capture
this rich variation in temporality. It must not neglect, either, to
note that the process of dying in hospitals is much affected by
professional training and codes, and by the particular conditions
of work generated by hospitals as places of work. A third impor
tant consideration in interpreting dying as a temporal process is
that dying is a social as well as a biological and psychological
process. By the term "social" we mean especially to underline that
the dying person is not simply leaving life. Unless he dies without
kin or friends, and in such a way that his death is completely
undiscovered his death is noticed or recorded. His dying is in
extricably bound up with the life of society, however insignificant
his particular life may have been or how small the impact his
death makes upon its future course. This aspect of dying will be
treated especially in relationship to what we shall call "status
passage."
We take as the task of our book, then, an illuminfi'tion of the
temporal features of dying in hospitals-as related both to the
work of hospital personnel and to dying itself as a social process.
