“Thou Shalt Not Die in This Place”: An Ethnomethodological Approach to an Ecuadorian Hospice Through Symbolic Interactionism

Theoretical Framework

Methodology

Through thematic analysis, this study presents themes related to the way that individuals, in a local hospice in Ecuador, describe death. Through ethnographic method, the study provides a deeper understanding of the way that individuals make sense of “death” in their daily interactions and social roles. This study includes a total of 105 participants: health-care providers, nurses, patients, family members, friends, counselors, volunteers, spiritual leaders, and psychologists in the Ecuadorian hospice. Davis, Powell, and Lachlan (2012) define ethnography as the study of culture by the immersion in the field. This method includes data collection in a naturalistic environment, which is the hospice, and the daily interactions with people who are dying and the individuals involved in this process. Field notes, observation, and informal conversations constitute the data of this research.

The sampling for this study was purposive. The Ecuadorian hospice was chosen for two main reasons. First, it is the only hospice of its kind in the country and second, it is a place where individuals interact with death and dying on a daily basis. For the purpose of this study, I traveled to Ecuador and spent 3 months (close to 300 hours of interaction) collecting data and interacting as a volunteer/researcher in the facilities of the hospice. Based on an interpretivist approach, the stories emerging within the data guided the description of specific themes.

To guarantee reliability among the analysis, field notes and informal conversations were coded separately and then emerging themes were cross-coded. Based on peer reviews and other researchers looking at the data for credibility, the main final themes were inductively compared with the theory.

The variable was “death,” which was conceptually defined as: “the termination of all biological functions that sustain a living organism” (Suriyaprakash & Geetha, 2014, p.116). The variable was operationalized as within field notes and informal conversations within the hospice, whenever individuals talked or referred to their experiences with death or dying.

All data were coded line-by-line and through thematic analysis. Emerging themes were identified in a nominal-level measurement. As Davis et al. (2012) describe it, a nominal measurement refers to unordered categories that help us classify the variable into qualitative unique and different categories. The categories do not show any kind of order or degree of intensity (Davis et al., 2012). All categories represent themes of equal interest. All data was coded and analyzed through thematic analysis.

Analysis

Six major themes were identified in terms of how individuals, in the Ecuadorian hospice, describe and understand death. Themes were inductively compared and analyzed. In the following section, each theme is described for further analysis.

Discussion

Based on this study, we can see how individuals, in the Ecuadorian hospice, understand and describe death. The data revealed six major themes that described death as a spiritual journey, a communal experience, a process of identity construction, not the end but an ongoing existence, a process that demands respect and reverence, and certain qualifications that can make death a “good death.”

Through the theoretical lens of symbolic interactionism, this study presents a particular understanding of death and human social behavior based on three main components (Benzies & Allen, 2001; Carlson, 2013; Meltzer, 2003; Reynolds, 2003; Smit & Fritz, 2008). First, as stated by symbolic interactionism, people act according to the meaning that things have for them (Benzies & Allen, 2001; Carlson, 2013). In this particular case, we can see how individuals behave according to their own understanding of death. They honor and revere death because they describe it as a spiritual journey and a sacred experience in which the spiritual leader has to take the lead. The process of dying is elevated to a spiritual ritual in which the health-care provider does not have the last word. The dynamics of interaction shift and the spiritual leader, in this particular case the priest, takes a higher role. The interaction with the living and the dead reveals a hierarchical order in which spirituality takes the lead. The entire performance shows the understanding of death.

Second, according to symbolic interactionism, meaning arises in the process of interaction among individuals. Meaning changes constantly and it becomes a dynamic process (Benzies & Allen, 2001; Carlson, 2013; Meltzer, 2003; Reynolds, 2003; Smit & Fritz, 2008). Therefore, meaning emerges from our interactions and the way other individuals act around us. In this study, we can see how interactions promote social agreements about the meaning of death. Death is constructed in the hospice by the interaction with others. With the lack of a spiritual leader, death may take a different meaning; but because there is a spiritual figure, individuals elevate death to a collective experience where the priest guides the encounter. No matter what role individuals play inside the Ecuadorian hospice (nurse, volunteer, family member, etc.), they all have agreed that death is a communal/spiritual experience. Death involves every member of the hospice’s community and it is expressed through companionship. Death brings people together. In this study, death should not be faced alone. Being with others and dying in the presence of the community are required in order to achieve a good death.

Third, from a symbolic interactionism point of view, meanings are assigned and modified through an interpretive process that changes and redefines itself constantly. Individuals’ choices are severely restricted by social and cultural norms (Benzies & Allen, 2001; Carlson, 2013; Meltzer, 2003; Reynolds, 2003; Smit & Fritz, 2008). In this particular case, we can see how the meaning of death sets the boundaries for interactions. Individuals mentioned that they do not use the word death in their conversations with patients. This kind of attitude creates a cultural environment in which certain behaviors are allowed or restricted. Interactions are limited by the way individuals make sense of death. This particular understanding is reflected by avoidance and rejection of death itself in the presence of patients. Health-care providers do not talk about death with their patients, they talk about life.

By selecting and interpreting the world around us, individuals shape their behavior (Reynolds, 2003; Smit & Fritz, 2008). In the hospice, individuals interpret death as a sacred and spiritual journey that needs to be respected. Using the wrong words or having the wrong conversations may be understood as disrespectful acts. Death requires respect and hope, hope to understand the holy and the sacred, and hope to expect an ongoing existence. Language is used in order to negotiate meaning (Benzies & Allen, 2001; Carlson, 2013). Individuals avoided talking about death with patients and some referred to it as inappropriate. Therefore, individuals used the word life instead of death during their interactions with the dying. Language was used as a tool in order to construct and negotiate meaning. This particular aspect could guide further analysis about specific conversations that patients are allowed or not to have with their health-care providers.

From a symbolic interactionism standpoint, individual interpretation of reality is related to a specific social context (Benzies & Allen, 2001; Carlson, 2013; Meltzer, 2003; Reynolds, 2003; Smit & Fritz, 2008). We should not forget that the hospice in this study is located in Ecuador and therefore, the social-cultural environment also influences the way that individuals make sense of death. The main goal of research relies on the nature of individual and collective social interactions (Athens, 2009; Benzies & Allen, 2001; Blumer, 1969; Kuhn, 1964). It is important to understand death from the point of view of a particular individual and his or her social groups. We need to consider that people in Ecuador are primarily Roman Catholic. About 89.60% of the Ecuadorian population describe themselves as Roman Catholic (Ecuador, 2014). The role of religion, in this particular hospice, may influence the way that people understand death.

According to symbolic interactionism, the development of the self takes place in a social context in interaction with others. The self evolves from interaction between individuals in the specific group one wants to become part of (Benzies & Allen, 2001; Carlson, 2013). In this study, the self was constructed through the identity of a religious group: Catholics. Individuals reframed their identity as believers of God and identified themselves with a specific group of Catholics: Los Camilianos (believers of Saint Camilo). The role, described by symbolic interactionism, is formed by the rights and duties attached to any given social position (Benzies & Allen, 2001; Carlson, 2013). In this hospice, we can see how individuals are given certain expectations of how they should behave. For example, the Father is expected to be the one who lifts up the soul of the deceased while nurses and doctors become spectators of a holy ritual. Others influence the way we understand ourselves and the way we behave.

Finally, symbolic interactionism argues that the main focus of research is on the nature of individual and collective social interaction (Athens, 2009; Benzies & Allen, 2001; Blumer, 1969; Carlson, 2013; Meltzer, 2003). Through this study, therefore, we can see individuals in their daily encounters with death and how their interactions shape meaning. Death was described as an event that affects the community and promotes the need for affiliation. We do not die alone, we die in a community, as members of a social group, and our death affects the group’s dynamics.

Limitations

This study presented several limitations. The first one was related to the sampling. Although the hospice chosen for this study was the only one of its kind in Ecuador, it does not mean that other institutions do not face death on a daily basis. Actually, many hospitals and nursing homes have recently introduced palliative care units and many Ecuadorians die in these types of institutions. Also, the hospice in this study was relatively new in the country (less than 3 years). Staff and volunteers were still in training, and the main economic contributor was a Catholic institution. The hospice survives with the generous contributions of the “San Camiliano’s Catholic division.” Future research could include more institutions in order to see and compare the way that death is understood in different cultural, social, and organizational environments.

The second limitation was related to the method of research. This study was based on ethnographic methods (field notes, informal conversations, and observation) in a natural setting. Research was done in vivo with doctors, nurses, spiritual leaders, psychologists, volunteers, family members, and patients interacting. However, it did not include self reports from specific groups. For further research, formal interviews and focus groups could be included in order to hear the voices of all participants, as the meaning of death may differ from smaller social groups inside the hospice. For example, doctors may interact in a different way than volunteers or spiritual counselors. Inside every institution, there are mini-social groups that also need to be considered.

Conclusion

This study brings into consideration the different ways that individuals understand and interact with death. In a country in which hospice is a new concept, this study introduces ways in which Ecuadorians may make sense of death. Although this research does not aim to generalize the findings presented here, this kind of study could help the promotion of quality of care by the end of life and facilitate relevant information in order to train health-care providers, volunteers, and general staff at Ecuadorian hospice. Also, by introducing research at a hospice in Ecuador, this study provides an international perspective about death and how social and cultural contexts influence our understandings and behaviors. For future research, other Ecuadorian institutions should be studied in order to analyze the meaning of death in specific contexts.

Silence. I walk into the Hospice and everything is quiet. The white walls stare at me while I step into the chapel.