A Matter of Life and Death: Teaching Undergraduates About the End of Life

“Curating” the Class

Death and dying are difficult, if not taboo, topics to discuss, and for many students, these topics resurface painful experiences of loss. I implement a few strategies into my course to put students at ease with me, their professor, as well as with their fellow students. Conveying warmth and sensitivity is key. On the first day of class, I inform students that some topics in the class may be particularly difficult due to their own experiences with loss. I ask students to inform me if they opt to miss class because of a specific topic and build in no-penalty “skip” days for that reason. In my experience, suicide is the class topic that’s most sensitive for students. However, some students may lose a friend or family member during the semester, and coming to a class focused on death in general is especially difficult. In a typical semester, three or four students usually take advantage of these no-penalty “skip” days, and they often express gratitude for the sensitivity I’ve built into the course.

I also integrate “getting to know you” activities early in the semester so students feel more comfortable with their classmates and with me. Icebreakers work well, such as asking students to interview other classmates about their experiences with loss or their motivation for registering for the course. I have also recently begun inviting students to an ice-cream social where they can socialize with each other and with me. These experiences help acclimate students to an atmosphere of openness and sharing, helping to dismantle any “walls” students have when it comes to the topic of death. I also stress throughout the course that students are “living textbooks” with valuable insights to share from their own lived experiences.

Finally, I have centered my class on an accessible text: Gawande’s (2014) Being Mortal. This book covers most of the topics I structure into the class (e.g., cultural differences in elder care, the stigma of aging, quality vs. quantity of life, nursing homes and assisted living, advanced directives) and it integrates empirical research in an engaging read. I couple readings from Being Mortal with other empirical articles and, sometimes, with other types of content. For example, an excerpt from the novel Infinite Jest (Wallace, 1996) pairs well with scientific research on suicide. Portions of Didion’s (2006) The Year of Magical Thinking provide firsthand insight into the literature on grief and bereavement. I’ve also used Notaro’s (2013) stand-up comedy routine Live to provide a humorous mirror on research into coping with one’s mortality. When discussing caretaking, Chast’s (2014) Can’t We Talk about Something More Pleasant? presents the reality of the cartoonist’s lived experiences with her aging and dying parents in the form of a graphic memoir, which students respond to especially well. I aim to balance the accessibility and rigor of the course content, while also emphasizing the ways in which content from multiple disciplines are “in dialog” with each other.

The Stigma of Aging

I begin the semester with an activity that forces students to recognize their own biases and prejudices toward aging populations. We begin with a service activity at a local nursing home. Many, if not most, students exhibit visible discomfort, preferring to keep a distance from nursing-home residents. To debrief, we examine how students reacted in that setting amongst older adults, then I probe whether students would react the same way if surrounded by college-aged peers. Students begin to recognize that they’ve shown disrespect, however unintentionally. Many realize that they had assumed impairment on the residents’ part, thinking that residents wouldn’t notice the active avoidance strategies they employed. As a class we discuss how these behaviors reflect our attitudes and biases about older adults.

“Living the End”

To grasp the lived experiences of individuals at the end of life, meaningful interactions with such populations are key. A central part of my course involves community partnerships with nursing homes and hospice services. Students are paired with an elderly nursing-home resident or a terminally ill person currently receiving hospice services. Through weekly visits with that partner, students develop authentic, on-the-ground insight into the lived experience of the oldest old and the dying. Students then journal their experiences and insights, which funnel into structured classroom discussion. As students share those experiences with each other, they come to realize the diversity that exists within older adulthood. Additionally, this semester-long activity facilitates students’ development of empathy for the aging and the dying. In fact, many students remain attached to their community partner, continuing to visit even after the class has ended.

Complexity of Medical Decisions

To acclimate students to the complexity of medical decision making at the end of life, I begin by showing an episode of PBS’s Frontline, “Facing Death” (Navasky & O’Connor, 2010), which includes a range of individual, familial, and medical contexts in which medical decisions are navigated. This sparks discussions of what types of decisions individuals and their families must make at the end of life and introduces students to the diversity of end-of-life scenarios that individuals may encounter. Following this film, an expert from the community (typically a geriatric nurse practitioner) attends the class as a guest speaker, sharing their professional experiences with complex end-of-life medical decision making. As an assignment, students must then contemplate what medical decisions they’d like made on their behalf if they aren’t able or competent to do so. This results in students completing an advanced directive. Afterward, students must also identify a family member for whom they could conceivably act as a medical proxy, then through collaboration with that loved one, complete an advanced directive for that individual.

“Death With Dignity”

As part of the course, I introduce students to major end-of-life issues at the intersection of medicine and ethics. One such activity involves a discussion of “death with dignity” (also known as aid in dying, and perhaps more commonly by the pejorative “physician-assisted suicide”), which is illegal in most U.S. states. Documentary films (e.g., How to Die in Oregon [Richard, 2011], The Right to Die [Gandhi et al., 2017]) can provide deep insight into the lives of individuals and their families grappling with whether to take advantage of “death with dignity” laws in jurisdictions where it’s been legalized. After viewing a film, we discuss the restrictions on “death with dignity” and the process for obtaining “death with dignity” medications. Then, I assign students a specific organization or advocacy group who have released positions on the issue (e.g., church organizations, the American Medical Association, hospice organizations), and in a class debate, they argue for or against the issue based on the viewpoint of their assigned organization. Finally, we conduct a mock election with “death with dignity” on the ballot, and students cast a vote based on their personal views, then justify their vote in an “exit poll” essay.

Ritualizing and Remembering

Another central component of my course involves the analysis of death rituals. I assign students to work in groups and produce a short class presentation on a death ritual from a specific culture. Oftentimes, in more diverse classes, this involves students presenting how death is ritualized within their own cultures. After presenting the range of death rituals from around the world, we then dissect the purposes and functions that death rituals serve (e.g., recognizing the reality of death, reinforcing cultural values, providing social support). With this list of functions, students then design a “death ritual” for the “death” of the class itself at the end of the semester.

Enhancing Individuals’ Interest

Beyond the set list of topics that I cover in the class, I require students to explore a topic related to death and dying that intersects with their major or future career plans as part of a culminating library research project. My course attracts students from a diverse field of majors. Students interested in medicine and nursing have explored topics such as how medical professionals cope with death of their patients and how hospice services show benefits for patients and their families; students interested in psychology have explored topics such as the detection of elder abuse and neglect, and assessment of medical decision-making capacity at the end of life; students interested in humanities have researched medical ethics and historical and cultural perspectives on death.

Outcomes

In my experience, students have responded quite positively to the course, despite the ostensible “morbidity” one may assume upon first glance. In student evaluations, the course receives consistently higher ratings than other courses at our college. Additionally, qualitative feedback has supported quantitative ratings. For example, representative student comments include “this course helped me understand why I should learn about the topic of death and dying, and how it applies to my personal life” and “the class opened my eyes up to life and death, and now I’m interested in working with older people after college.” Additionally, parents of students in my course have reached out to thank me for raising these difficult topics in the classroom and for encouraging students to begin having conversations about the end of life with family members. Though one key purpose of the course is to introduce aging and the end of life to students in hopes of motivating them to pursue careers in those areas, I understand that not all students will do so. No matter their future plans, all students leave the class with practical information and skills to employ as they face loss and death in their own lives.