Social Science & Medicine 75 (2012) 217e224

Contents lists available at SciVerse ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Acceptance of dying: A discourse analysis of palliative care literature

Camilla Zimmermann
University of Toronto, 610 University Ave., 16-712, Toronto, Ontario, Canada M5G 2M9

a r t i c l e i n f o a b s t r a c t

Article history: The subject of death denial in the West has been examined extensively in the sociological literature.
Available online 29 March 2012 However, there has not been a similar examination of its opposite, the acceptance of death. In this
study, I use the qualitative method of discourse analysis to examine the use of the term acceptance of
Keywords: dying in the palliative care literature from 1970 to 2001. A Medline search was performed by combining
Acceptance the text words accept or acceptance with the subject headings terminal care or palliative care or
Death
hospice care, and restricting the search to English language articles in clinical journals discussing
Dying
acceptance of death in adults. The 40 articles were coded and analysed using a critical discourse analysis
Palliative care
Terminal care
method. This paper focuses on the theme of acceptance as integral to palliative care, which had
Hospice subthemes of acceptance as a goal of care, personal acceptance of healthcare workers, and acceptance as
Discourse analysis a facilitator of care. For patients and families, death acceptance is a goal that they can be helped to attain;
for palliative care staff, acceptance of dying is a personal quality that is a precondition for effective
practice. Acceptance not only facilitates the dying process for the patient and family, but also renders
care easier. The analysis investigates the intertextuality of these themes with each other and with
previous texts. From a Foucauldian perspective, I suggest that the discourse on acceptance of dying
represents a productive power, which disciplines patients through apparent psychological and spiritual
gratication, and encourages participation in a certain way to die.
2012 Elsevier Ltd. All rights reserved.

Introduction
The contemporary Western attitude towards death has gener-
ally been characterised as one of denial (Aries, 1974; Callahan,
2000; Emanuel & Emanuel, 1998; Gorer, 1980). This characteriza-
tion has generated debate regarding the validity of the denial of
death thesis (Kellehear, 1984; Zimmermann & Rodin, 2004) and
whether or not we are or ever were a death-denying society
(Seale, 1998; Walter, 1991). In other publications, the lens was
shifted to include investigation not only of the concept of death
denial, but also of the discourse surrounding this subject and the
reasons for the existence of this discourse (Armstrong, 1987;
Zimmermann, 2004, 2007). However, there has not been a similar
investigation of the opposite of death denial: the acceptance of
death and dying. This is the subject that I will address in this paper,
using the method of discourse analysis to analyse how the term
acceptance is used regarding death and dying in the clinical
palliative care literature.
Discourse analysis is a method that has been approached from
several different theoretical orientations within a number of
E-mail address: camilla.zimmermann@uhn.on.ca.
disciplines (van Dijk, 1991; Fairclough, 1990; Parker, 1992; Potter &
Wetherell, 1987). The specic method that I will be using is critical
discourse analysis, as described by Parker (1992), which is based on
the poststructuralist theories of Foucault (Foucault, 1972, 1977,
1979). In this method, discourses provide frameworks for debating
the value of one way of talking about reality over other ways
(Parker, 1992, p. 5). More than just ways of speaking, discourses are
systems of thought and ways of carving our reality. They are
structures of knowledge that inuence systems of practices
(Chambon, 1999, p. 57). Discourse analysis is concerned with the
analysis of texts, which can be broadly dened as any form that
can be given an interpretative gloss (Parker, 1992, p. 6); in my
analysis the texts are journal articles. However, although I am
analysing individual journal articles, my focus is not on what that
individual author was thinking or meaning at the time the article
was written. Rather, I am interested in the structures of knowledge
that are represented by these individual statements, which become
a discourse only in their relation to each other and to broader
institutions and ideologies. Similarly, my aim is not to characterize
the many different attitudes to death that are possible and that
exist, over and above those of acceptance and denial, nor even to
discuss whether death acceptance is possible or desirable. In
focussing on acceptance, my specic aim is to examine in detail

0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2012.02.047
218 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
how this term is used, or put to use in the palliative care litera-
ture, and how this may relate to broader social structures and
practices.
In previous papers, I examined the use of the term denial in
the palliative care literature from 1970 to 2001 (Zimmermann,
2004, 2007). Two dominant themes were elucidated: denial as
a psychological coping mechanism and denial as an obstacle to
palliative care. In the rst theme (Zimmermann, 2004), denial was
represented as an unconscious psychological state that was normal
and healthy when terminal illness was rst diagnosed, but became
maladaptive and pathological when it persisted beyond
a certain span of time. I suggested that the denition of death
denial as an individual psychological coping mechanism may allow
for the labelling of patients who resist participation in the planning
of their death. In the next paper (Zimmermann, 2007), I demon-
strated how the label of denial was put to use by presenting the
theme of denial as an obstacle to palliative care. Denial was
perceived to be standing in the way of several components of
palliative care: open discussion of dying, dying at home, advance
care planning, symptom management and stopping futile treat-
ments. I suggested that rather than being an obstacle, death denial
e and indeed its very conceptualisation as an obstacle e may be
seen as a construction that is instrumental to uphold a certain way
to die represented by contemporary palliative care.
In this paper, I examine the use of the opposite of denial: the
term acceptance. Because discourses are historically situated e
changing and developing in relation to their social environment
e I have limited the search to the same period that I examined in
my previous work on denial (1970e2001), which represents the
rst three decades of the development of hospice and palliative
care.
Methods
Following the method for the previous discourse analysis on
denial of death (Zimmermann, 2004, 2007), a Medline search
(1970e2001) was performed by combining the text words accept
or acceptance with the subject headings terminal care or pallia-
tive care or hospice care and restricting the search to English
language articles. This search retrieved 180 articles, which were
further restricted to those in clinical journals discussing acceptance
of death in adults. Articles that discussed acceptance of chemo-
therapy, mechanical ventilation or other treatment, acceptance of
support groups or other therapy, or self-acceptance, without
explicit mention of the acceptance of death, were excluded. Articles
that specically discussed acceptance of euthanasia, rather than of
death and dying in general, were also excluded. After applying
these inclusion and exclusion criteria, there remained 40 articles (7
of which had also been retrieved in the denial search), for which
the references are listed in the Appendix. The articles appeared in
hospice/palliative care journals (9/40), medical journals (16/40),
nursing journals (10/40), psychiatry journals (2/40), a social work
journal (1/40), a physiotherapy journal (1/40) and a multidisci-
plinary journal (1/40; Patient Education and Counselling).
The retrieved articles were coded according to the method
described by Potter and Wetherell (1987). The articles were closely
read and themes or bodies of instances (Potter & Wetherell, 1987,
p. 167) related to the meaning and usage of the term acceptance
were identied. Categories of themes were collected by photo-
copying all the relevant pages containing a certain theme and
placing them in their own le. The pages in each le were then
analysed in greater detail, following Parkers (1992) criteria for
distinguishing discourses. The connotations, allusions and impli-
cations which the texts evoke were explored, with particular
attention to intertextuality, or how the texts embed, entail and
presuppose other discourses (Parker, 1992, p. 13) e not only within
the acceptance search, but also with the texts in the denial
search, and in relation to broader systems of knowledge.
Results
Three dominant themes emerged in the analysis: acceptance as
integral to the practice of palliative care; positive characteristics of
the acceptant patient; and acceptance of natural death. In this
paper I will provide a detailed analysis of the rst theme, which
portrayed the acceptance of death as integral to palliative care, tied
up in its clinical practice and in its philosophy. Not only was the
acceptance of dying seen as a goal or psychological destination for
patients and families, but the acceptance of the legitimacy of
death (Kennie, 1983) was also regarded as a necessary, unifying
aspect of health care workers practising palliative care. These two
subthemes are discussed below, as is the related subtheme of
acceptance as a facilitator for palliative care. The themes of
positive characteristics of the acceptant patient and acceptance of
natural death will be addressed in a subsequent publication.
Acceptance as a psychological goal
The theme of acceptance as a psychological goal has intertex-
tuality with the themes of denial as a defence mechanism and of
denial as temporary (Zimmermann, 2004). In the latter themes it
was assumed that denial may be functional in the initial process of
coping with a terminal illness, but that with time and counselling
patients could be helped to overcome this denial. The interplay of
these arguments is apparent in the following passage from an
article retrieved in both the denial and the acceptance searches:
Dying people often experience a range of strong emotions -
denial, anger, bargaining and depression - before coming to
accept the near prospect of their death. By offering support and
being prepared to listen, nurses can help patients and their
families express their feelings and possibly proceed onto
acceptance (Claxton, 1993, p. 206).
The article, entitled Paving the way to acceptance is explicitly
based on Kbler-Rosss stages of dying (Kbler-Ross, 1969).
Acceptance is a goal that can possibly be reached through the
open expression of feelings facilitated by counselling. Several other
articles also made reference to Kbler-Rosss stages of dying: it
was stated that the physician who can recognise these stages may
more easily respond to the needs and questions of a terminally ill
patient (Guthrie, 1979, p. 13); that the role of the physician (.)
needs a full understanding of the various adaptive stages involved
in facing death, from initial denial to ultimate acceptance (Friel,
1982, p. 767); and that Kbler-Rosss conceptualisation serves to
reinforce the concept of a process with different and, at times,
identiable stages (Fowler, 1994, pp. 196e197).
In another article the stages were conceptualised slightly
differently from those conceived by Kbler-Ross:
The mental state of a patient in the terminal stage of cancer
changes step by step from denial of cancer, hope for a new
treatment for cancer, suspicion of medical treatment, uneasi-
ness regarding their future life, irritation, depression and
acceptance or despair (Oyama, 1997, p. 150).
In this article, the nal outcome can be either acceptance or
despair, demonstrating intertextuality with Eriksons description of
the nal identity crisis in old age as one of ego integrity versus
despair (Erikson, 1950, pp. 268e269). According to Erikson, the
person who has achieved ego integrity is satised with life and
 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
accepts responsibility for its successes and failures; in general, this
individual will accept impending death. Conversely, despair ensues
for those who are not satised with their lives, but realise that time
is now too short for the attempt to start another life and try out
other roads to integrity (Erikson, 1950, p. 269). Kbler-Ross also
describes acceptance as an existence without fear or despair
(Kbler-Ross, 1969, p. 120). The interplay between these and other
stage theories of dying and their conceptualisation of acceptance
will be further commented on in the Discussion.
Conveying acceptance: the clinicians role
The clinicians role was not only one of recognizing and under-
standing that there are psychological stages that dying patients
go through; there was also a teaching (Morris & Christie, 1995),
facilitating (Danis, 1998), helping (Claxton, 1993) or enabling
(Carwein, 1986) role for palliative care practitioners in the process
of acceptance of dying. Here it was clear that the goal for dying
patients is the gradual acceptance of death (Rousseau, 1995, p.
832) and that the palliative care clinician could facilitate this
process. In one study published in the Journal of Holistic Nursing,
oncology, parish and hospice nurses were surveyed to explore
what nursing interventions they implement to enhance the spiri-
tuality of clients and how they learnt about these interventions
(Sellers & Haag, 1998, p. 338). Listed among the most frequently
identied nursing interventions was conveying acceptance (p.
338). This was also apparent in an article in a psychoanalytic
journal where the author recounts her experience with a patient
who contracted cancer during the course of several years of anal-
ysis. When the patient could no longer leave the home the analysis
was continued by telephone. The author reports:
The experience proved benecial for the patient and enriching
for the analyst. The patient was able to contain, work through
and integrate the meaning and consequences of her disease,
make reparations to her objects, and accept death with dignity
(Minerbo, 1998, p. 83).
The acceptance of death is the ultimate goal of the therapeutic
interaction between physician and patient, with the analyst
providing the medium by which this occurs. Similarly, another
article describes the privilege of clinicians caring for the dying in
enabling them to take that nal step in acceptance and peace
(Carwein, 1986, p. 57).
Acceptance was deemed to be important for families as well as
patients. In an article on initiating hospice care, it was stated: Just
being there, explaining, teaching and preparing the family to accept
the inevitable end will improve the familys ability to cope with the
demands of caring for their loved one at home (Morris & Christie,
1995, p. 23). In an article entitled Care of the family when the
patient is dying it was stated: Families need effective communi-
cation to help cope with and accept a terminal prognosis (Bascom &
Tolle, 1995, p. 296). In yet another paper it was suggested that
clinicians should recognize that family support and contact
between the dying patient and family facilitate decision-making and
acceptance of death (Danis, 1998, p. 110). Thus the palliative care
clinician had a clear role in guiding not only patients but also their
families, towards the psychological destination of acceptance.
Acceptance as an element of the good death
In keeping with acceptance as a goal of care, it was also regarded
as an element of the good death. In one paper, conversations of
nurses on a symptom control team with patients and relatives were
audiotaped to dene elements of scripts that they used as a basis
for their work, which implicitly or explicitly constituted attain-
ment of good deaths for the patients and rewarding outcomes for
the nurses (Hunt, 1992, p. 1298). One of these scripts was that
219
patients and relatives openly accept cancer diagnosis and prog-
nosis (Hunt, 1992, p. 1298). In a study which was published as two
papers, both of which were retrieved in the acceptance search,
semistructured interviews were conducted with patients and
health professionals (nurses and social workers) working in palli-
ative care to elicit concepts of a good death (Low & Payne, 1996;
Payne, Langley-Evans, & Hilier, 1996). Health professionals
perceived a good death as controlling the patients physical
symptoms and psychologically preparing them. Conversely, not
dealing with patients fears and a patients non-acceptance of
death were identied as factors related to a bad death (Low &
Payne, 1996, p. 237).
In the second paper, (Payne et al., 1996) perceptions of good and
bad deaths were compared among patients and health care
professionals. Of note, while lack of acceptance was identied as
one of the characteristics of a bad death according to the palliative
care staff, it was not specically mentioned by patients themselves.
Conversely, dying suddenly was identied as an element of the
good death for patients but not for palliative care staff. This
difference in perception of the importance of acceptance was
explicitly addressed in a paper written by a social worker, but from
her perspective as the caregiver of her terminally-ill husband
(Wasow, 1984). In this essay, the author contrasts the peaceful
images of dying portrayed by medical writers with the much
gloomier (Wasow, 1984, p. 265) accounts of patients and relatives
writing about their personal experiences. She questions the value
of conveying acceptance, acknowledging that when confronted
with the loss of someone dear, it can be difcult to accept positive
ideas about dying put forth by others (p. 265). Thus, the concept of
acceptance of dying as valued (Winland-Brown, 1998, p. 38), may
be of greater relevance for professional caregivers than for patients
and family members.
Measuring acceptance
Several articles referred to the measurement or judging of
acceptance. Interestingly, in all of these papers, there was no direct
input from the patient or relative whose acceptance was being
evaluated; rather, the researcher observed unobtrusively the
behaviour and interactions of the person being judged. In one
article, the effects of death education under home hospice care
(Kawagoe & Kawagoe, 2000, p. 37) were analysed for sixteen
patients who died at home in Japan:
The acceptance of death by the patients was judged according to
the way they spent their remaining time, to their attitudes and
to their hope for a life after death. Fourteen of 15 patients
appeared to accept their own death. (...) As the goal of death
education in home hospice care is the acceptance of death by
both patient and family, our methods of death education appear
to be effective (Kawagoe & Kawagoe, 2000, p. 37).
There is an assumption that patients and families need to be
educated about death, and that the goal of this education is
acceptance. Acceptance is judged according to criteria deter-
mined by the investigators. In another paper, the criteria for this
judgement were not specied; rather, the patients psychosocial
problems were explored shortly after admission, when a relation-
ship between the staff and the patient was established and the
patient was willing to disclose his problems (Sham & Wee, 1994, p.
282). The results were documented as follows:
While 53 (17.7%) patients were calm and assessed to be in the
stage of acceptance on admission to the hospice, 44 patients
expressed a lot of self-pity. They felt worthless and hopeless and
were unable to nd meaning in the nal days of their life
(p. 284).
220 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
Acceptance was measured in two other papers, this time among
patients and relatives in a home hospice setting. One paper
assessed the contribution of acceptance to the quality of life of the
patient (Hinton, 1994); the other, entitled The progress of aware-
ness and acceptance of dying in cancer patients and their caring
relatives (Hinton, 1999) documented the progression of accep-
tance, as assessed during eight weekly and then biweekly semi-
structured interviews. Consider the quotations below:
Various proportions [of patients] coped by optimism, ghting
their disease, partial suppression or denial, but 50% reached
positive acceptance. Relatives were more aware and accepting
(Hinton, 1994, p. 183).
Acceptance usually increased, with 51% of patients and 69% of
relatives becoming nearly/fully accepting. Many individuals
diverged from the average progress of awareness and accep-
tance. 18% of patients and 24% of relatives showed uctuating or
falling acceptance (Hinton, 1999, p. 19).
In the rst passage the use of the word reached implies that
acceptance is a goal or destination which is worked towards and
arrived at; in the second passage its progress is measured chro-
nologically. There is a dichotomy created between various ways of
coping and the reaching the positive endpoint of acceptance.
In these two studies, as in the others, acceptance was not
measured by openly interviewing patients and family members.
Rather:
The degree of acceptance was estimated in those aware that the
disease might be fatal, based on any statements about their
coming to terms with this prospect - or the opposite. (...) Ratings
were made unobtrusively during the interview on a 1-9 line-
ar analogue scale without interrupting rapport (Hinton,
1999, p. 21).
Rather than treating acceptance as a subjective phenomenon to
be explained by those experiencing it, it is documented stealthily
by the interviewer. The justication given for the treatment of
denial as an objective diagnosis is that it is a defence mechanism,
which must operate unconsciously in order to be effective in
reducing anxiety (Hall, 1954, p. 90) and therefore cannot be
accurately perceived by the patient. In the case of acceptance of
dying, however, there is no similar historical psychoanalytic reason
that it should be treated as a label imposed from the outside. The
clinical imperative to diagnose likely inuenced this treatment of
acceptance. Keeping in mind how acceptance is treated for patients
and families, we will now examine how it was framed for profes-
sionals working with the terminally ill.
Personal acceptance of death by health care workers
While the articles considered above discussed acceptance on the
part of patients and family members, other articles emphasised the
importance of acceptance of dying on the part of health care
personnel working with the dying. In these articles, acceptance of
death by health care workers was regarded not only as desirable
but also as tightly intertwined with the philosophy of palliative
care. In order to be able to direct patients and families towards
acceptance, the health care worker would rst need to have
accepted death, both as a personal reality and as a reality for his
or her patients. In the case of health care workers, acceptance was
treated neither as a goal to be worked towards, nor as the endpoint
of a series of stages. Rather it was regarded as an attitude towards
death in the abstract, which could be taught, or as a subjective
state that could be achieved by self-reection.
Several articles discussed the importance of the acceptance of
the legitimacy of death (Kennie, 1983, p. 770), the ability to
acknowledge the reality of death (Davies, 1980, p. 337), or the
willingness to accept mortality and view death as the logical
conclusion of life (Friel, 1982, p. 770). Acceptance of death in this
context was regarded as an attitude that could be taught and learnt.
In one article entitled Training physicians to care for the dying it is
stated:
It is hoped that such training will teach physicians to accept death
as inevitable, to recognize and acknowledge the state of dying
and, nally, to understand that appropriate care includes
appropriate death, which is one arrived at with minimal
suffering, with minimal social and emotional impoverishment,
with preservation or restoration of important relationships and
with resolution of residual conicts (Bulkin & Luskashok,
1991, p. 10).
Here, rather than being placed at the endpoint of a series of
stages, as it was for patients, physicians acceptance of death is
considered a necessary rst step in the delivery of appropriate
care for the dying, which includes an appropriate death.
Another article (Rooda, Clements, & Jordan, 1999) correlated
nurses negative attitudes towards death (Fear of Death and
Death Avoidance) with negative attitudes towards caring for
dying patients, and positive attitudes towards death (Approach
Acceptance and Neutral Acceptance) with positive attitudes
towards caring for the dying. Both attitudes to death and attitudes
towards caring for dying patients were measured by multi-item
questionnaires completed by the nurses themselves. Approach
Acceptance was dened as the extent to which a person views
death as the entry point to a happy afterlife and Neutral Accep-
tance was dened as the extent to which a person accepts death
as a reality in a neutral way (i.e. neither welcoming nor fearing
death) (p. 1685). The authors conclude:
Professionals who are responsible for designing educational
programs focussed on nurses attitudes toward caring for
terminally ill patients may want to include an assessment of
death attitudes and interventions aimed at decreasing negative
attitudes and increasing positive attitudes toward death in such
programs (Rooda et al., 1999, p. 1683).
Once again, acceptance of death is treated as an attitude that is
learnable in an educational setting. Of note, the data were gathered
by self-completed questionnaires, rather than by means of an
interview by a third party who then decided whether or not death
was accepted.
For physicians and nurses, acceptance of dying was treated as
a personal matter but one with important consequences for the
successful delivery of palliative care. In one review article, it was
stated:
Palliative care ... requires a personal acceptance of death and an
acknowledgement that dying does not denote a failure to
provide good medical care but, rather, calls for an acquiescence
that curative treatment is no longer feasible (Rousseau, 1995, p.
779, italics added).
Here the acceptance of death by physicians on an individual
level is linked to their ability to acknowledge dying on the part of
their patients without feeling that they have failed them. In another
study, family physicians who included palliative care as part of their
practice were interviewed in order to examine factors that inu-
enced this decision.
The overriding theme was a common philosophy of palliative
care focussing on acceptance of death, whole person care,
 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
compassion, communication and teamwork. (...) Participants
argued compellingly for transferring the philosophy of palliative
care to the overall practice of medicine (Brown, Sangster, &
Swift, 1998, p. 1028).
The importance of acceptance is further elaborated on:
One key aspect of their philosophy was acceptance of death.
Participants recognized death as an important part of the life
cycle. Working through their own feelings around death and
dying was paramount (p. 1030).
Keeping in mind that the objective of the article was to
examine factors that inuence family physicians decisions to
practice palliative care (p. 1028) it is a powerful nding that their
common philosophy had acceptance of dying as a key aspect.
For these physicians, the acceptance of death was of central
importance not only generally, as an important part of the life
cycle but also for themselves and for the overall practice of
medicine.
The preceding subsections have discussed the conceptualisation
of acceptance of dying as being integral to the practice of palliative
care, both as a psychological goal for patients and their families, and
as a unifying ideology for practitioners of palliative care. The next
section will shed light on a possible reason why the acceptance of
death is deemed to be so important.
Acceptance as a facilitator in the provision of end-of-life care
The close relationship between acceptance as a goal in care and
acceptance as helpful in the provision of end-of-life care is exem-
plied in this statement:
We stress the role of hospital staff and general practitioners in
helping patients accept a terminal prognosis, so that better-
planned care can proceed (Seale & Kelly, 1997, p. 93, italics added).
Here the reason given that patients should accept that they are
dying is so that they can plan for the future. The use of the word
proceed is interesting in that it refers to going forward with
carrying out a process. The process of managing individuals and
their deaths is impeded if they are not ready to accept that they
are dying. The ultimate goal is better-planned care, and accep-
tance is a precondition for the achievement of this goal.
Another article sheds a different light on the acceptance of
dying, examining its helpfulness on the giving rather than the
receiving end of care. The article, published in the American Journal
of Critical Care examined critical care nurses perceptions of
obstacles and helpful behaviours [also referred to as helps] in
providing end-of-life care to dying patients (Kirchhoff &
Beckstrand, 2000, p. 96). Here the focus was explicitly on the
nurse rather on the patient; nurses were asked what impeded or
facilitated their care for patients.
Six of the top ten obstacles were related to issues with patients
families that make care at the end of life more difcult, such as
the familys not fully understanding the meaning of life support,
not accepting the patients poor prognosis, requesting more
technical treatment than the patients wished and being angry. ...
Most helps were ways to make dying easier for patients and
patients families, such as agreement among physicians about
care, dying with dignity, and families acceptance of the prog-
nosis (Kirchhoff & Beckstrand, 2000, p. 96).
Although this article was not retrieved in the denial search, it
contributes to the narrative elaborated in the denial results of
denial as an obstacle to proper patient care (Zimmermann, 2007),
drawing an explicit dichotomy between helps and obstacles. Lack
221
of acceptance is included explicitly as an obstacle to the provision of
care by nurses, as are families misunderstandings, requests for
technical treatment and anger. Helps, on the other hand, are
related to themes associated with the acceptance of dying: families
acceptance of the prognosis and dying with dignity are both listed
as helps, which not only make dying easier for the patient and
his or her family, but also facilitate care of the dying patient by the
nursing staff.
Several other articles explicitly acknowledged that acceptance of
death makes the process of caring for the dying easier for palliative
care staff. In one article examining the relationship between truthful
communication with terminal cancer patients about their disease
and patients psychological well-being, it was stated:
Patients who accept their condition can formulate realistic
demands in accordance with their situation, making the task of
the staff much easier and in turn favouring satisfactory consensus
with respect to treatment and the objective of hospitalization
(Bishara, Loew, Forest, Fabre, & Rapin, 1997, p. 20).
In another article written by an internist specializing in critical
care medicine, entitled Help your patients families accept the
inevitable, ve categories of families are described: the hostile
family, the guilt-racked family, the hear-no-evil family, the
divided family and, lastly, the accepting family. This last cate-
gory is described as follows:
Reaching agreement with this sort of family should be relatively
easy. They are accustomed to relying on the doctors judgement.
And even with their limited knowledge of medicine, they realize
that Grandma isnt doing well, and the last thing they want to do
is prolong her agony (Reisman, 1989, p. 183).
And in another article it is explicitly stated:
To some degree, self-interest can also determine attitude
formation. For example, a caregiver may nd her job easier
when she deals with a calm, accepting patient who requires
little effort (Murray & Neilson, 1994, p. 34).
A colleague of these authors is quoted as having said:
Mrs. X is a wonderful patient. She is a Christian who believes in an
afterlife where she will be one with Christ. She accepts death with
faith that a better world lies beyond. Her family shares that belief
and has a calm, accepting attitude. She makes my job so easy that I
look forward to visiting her. (Murray & Neilson, 1994, p. 35).
Thus, while some articles emphasise that acceptance helps to
promote an easier death for the patient and family, others demon-
strate the ease of care that this acceptance generates for palliative care
providers themselves. The tension and overlap between these two
outcomes of acceptance will be addressed in the Discussion.
Discussion
The binary opposition of acceptance and denial of dying is pre-
sented explicitly by psychiatrist Avery Weisman: denial cannot be
diagnosed without at least an implicit assessment of acceptance.
Denial and acceptance are always counterpoised, so that the signif-
icance of one is automatically drawn from the appraisal of the other
(Weisman, 1972, p. 79). This dichotomy was apparent in the inter-
textuality between the current acceptance search and the previous
denial search (Zimmermann, 2004, 2007). While denial was
regarded as a transitional psychological state, the acceptance of
death and dying was integral to palliative care: a psychological goal
for patients and families, and a central, unifying aspect of the
philosophy of palliative care for health care workers. While denial
222 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
was seen as an obstacle to care, acceptance was conceived as
a facilitator in the provision of end-of-life care by health care
workers, with accepting patients being easier to manage and provide
better planned care for. These discourses on acceptance and denial
stand at opposite poles of the same discourse: together, they both
presuppose and contribute to the construction of a larger discourse
on a correct way to die, which is closely linked with changes in the
practice of medicine and idealised in the construct of the good
death. The necessity of planning for the future, of discussing end-
of-life decisions such as where to die, whether or not to resuscitate,
whether or not to feed, whether or not to hydrate, creates an
imperative for patients to openly discuss and accept that they are
dying. The model of aware dying (Glaser & Strauss, 1965) is not
only a modern psychological ideal; it is a medical necessity of
a system that relies on open discussion for the efcient management
of the dying person. The acceptant patient is favoured because this
attitude is concordant with institutional practices and makes dying
easier not only for the patient and family, but for those caring for
the dying and for the systems supporting these practices.
A brief review of the history of hospice is necessary in order to
further place these themes in their historical context. The hospice
movement was conceived between 1957 and 1967 (Clark, 1998),
and developed a global inuence over the following three decades
(Clark, 2002). St. Christophers Hospice, the worlds rst hospice
and the epicentre of the movement (Clark, 1998, p. 43), was
founded by Cicely Saunders in 1967 and directed by her until 1985.
Other key gures e all inuenced by Saunders e were Canadian
Balfour Mount, who coined the term palliative care and opened
the Royal Victoria Palliative Care Unit in 1975; Florence Wald, Yale
Dean of Nursing, who founded the rst American hospice program
in 1974; and Elizabeth Kbler-Ross, who in addition to publishing
On Death and Dying in 1969, lobbied in favour of the Medicare
Hospice Benet in the United States, which was eventually estab-
lished in 1982. The inuence of Cicely Saunders as founder of the
hospice movement was paramount. In addition to being trained as
a nurse, social worker and physician, Saunders was also deeply
religious, with a strong Christian faith. Thus she personied the
interdisciplinary, whole-person, bio-psychosocial-spiritual care
of the dying that was central to her philosophy.
The tendency to conceptualise adjustment to dying as occurring in
stages has psychological roots, (Kbler-Ross, 1969; Pattison, 1977)
although it was subsequently taken up in the clinical literature on
patient-clinician communication (Buckman, 1998). The stage of
acceptance is last in all the stage formulations; reaching this stage
requires psychological work, so that the intrinsic fear and denial of
death may be overcome. According to Kbler-Ross (1969), the stage of
acceptance should not be mistaken for a happy stage. It is almost void
of all feelings (p. 113). It is the end of a process of gradual separation
(decathexis) where there is no longer a two-way communication (pp.
119e120). Pattison (1977) describes the terminal phase where it is
possible to give up ones grappling with life, and an acceptable
regression occurs where the self gradually returns to the state of
nonself. Both of these formulations bear resemblance to disengage-
ment theory (Cumming & Henry,1961), where ageing entails a gradual
withdrawal of the self from societal interactions, which is functional
for leave-taking (Marshall, 1980, pp. 80e82). Throughout the 1980s
and 90s there were many critiques of the stage concept and of Kbler-
Rosss work (Charmaz, 1980; Littlewood, 1993; Marshall, 1980), and
Buckman, who was an oncologist rather than a psychologist, included
a caveat that acceptance is not an essential state provided that the
patient is not distressed, is communicating normally, and is making
decisions normally, for example, concerning treatment or social
arrangements (Buckman, 1998, p. 146). This caveat is in keeping with
the results of this paper: acceptance is not essential as long the
patients lack thereof does not interfere with care; its function is not
only psychological, but extends into the practical realm of medical
decision-making.
Acceptance has been conceived as a task that is not only
psychological and functional, but also religious and/or spiritual.
Indeed the theme regarding personal acceptance of palliative care
staff e the necessity of rst having accepted in order to enable and
facilitate acceptance in others e resembles missionary work rather
than medical work. This is not surprising given the Christian origins
of the hospice movement (Garces-Foley, 2006). Cicely Saunders felt
strongly that her work in palliative care was a calling that had both
medical and spiritual dimensions. In a letter written in 1960 to
a church consultant, she wrote: . in this work the medical and
spiritual are inextricably mingled. I long to bring patients to know
the Lord and to do something towards helping many of them to hear
of Him before they die, but I also long to raise the standards of
terminal care throughout the country from a medical point of
view. (cited in Clark, 2001, p. 356). This blending of the medical
and the spiritual, exemplied in Saunders concept of total pain
(Clark, 1999), remains a central component in contemporary palli-
ative care (Sinclair, Rafn, Pereira, & Guebert, 2006). Aside from its
obvious association with interdisciplinary care of the whole patient,
this blend allows the construction of a moral foundation for practical
concerns. The goal of acceptance is generally represented as better
for the patient and family, enabling a peaceful death. However, care
of the acceptant patient is easier not only spiritually and psycho-
logically, but also medically and socially; not only for the patient and
family, but also for the professionals who provide care for them.
The Christian charisma of early hospice development has often
been counterpoised with the modern bureaucracy that hospice is
said to have succumbed to. Bradshaw (1996) blames the routinisa-
tion and bureaucratization of hospices on the loss of the original
Christian charisma of hospice, observing that the original Chris-
tian calling for palliative care, exemplied in the Christian origins
of the hospice movement and the strong Christian faith of Cicely
Saunders, has been lost. For Bradshaw, the religious faith that
upheld the ideas of hospice has been replaced by a secular spiritu-
ality, hospice workers who had a calling are replaced by careerists
who see palliative care as just a job, and death is no longer a truth
to be confronted but a process to be managed (Bradshaw, 1996, p.
418). However, James and Field (1992) have pointed out that from
a Weberian perspective, routinisation is a necessary and inevitable
development in movements which are to survive their initial char-
ismatic leadership (p. 1373). I would argue further, from a Fou-
cauldian perspective (Foucault, 1977, 1979), that the Christian
charismatic appeal to accept ones death cannot be separated from,
and indeed facilitates, the bureaucratic imperative to manage the
dying. There was never a time when death was not a problem to be
managed; however, the manner in which it exists as a problem and
the way its management occurs is historically and culturally
contingent and reects contemporary power relations. Power, as
conceptualised by Foucault, is not only able to suppress discourse
but also able to produce it (Lupton, 2003). This incitement to
discourse (Armstrong, 1987; Foucault, 1977) e speaking about
dying e is a necessity for the modern planned death. The
acceptance-denial dichotomy is an important component of this
discourse, represented on one pole by the negative label of denial,
and on the other by the spiritual charisma of acceptance.
The good death exemplied by hospice care is often portrayed
as having arisen in reaction to a medicalised, isolated death (Elias,
1982; Kbler-Ross, 1969; Sudnow, 1967). However, as McNamara,
Waddell, and Colvin (1994) have pointed out in their examination
of the good death ideal in UK hospices, the hospice environment
provides for a different mode of socialisation to dying, which
benets not only the individuals involved, but also the organisa-
tions that maintain the service. Similarly, Hart, Sainsbur, and Short
 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224
(1998) pointed out that the ideology of the good death legiti-
mates a new form of social control over dying people; their choices
are powerfully shaped and controlled to this end (p. 75). And
Timmermans (2005) describes how hospice staff broker this death
through active management of both the physical condition of the
patient and the actions and expectations of the dying and their
relatives (p. 998). I suggest that this control is achieved not only by
hospice staff, but also by patients and families themselves, who are
important participants in the power structure. Through the process
of accepting impending death e either their own death or the death
of the family member they are caring for e they are made subjects
of a larger discourse on dying, which is in conformity with the
requirements of modern health care systems.
Thus the imperative to accept death, tightly connected with the
quest of hospice and palliative care to relieve physical, psycholog-
ical, social and spiritual suffering, also cannot be separated from the
institutions of hospice and palliative care and the structure of
broader health care systems. For it is through the acceptance of
death itself and of the state of dying that death can be managed and
controlled. The discourse on acceptance and the denial-acceptance
dichotomy sustain an ideal of a preferred way to die. This way to
die, which represents a public interest in the dying process and its
management, is supported by the discourse of a personal spiritual
quest for death acceptance on the part of the dying and their
families. Consistent with Foucaults conception of power as disci-
plining rather than only coercive (Foucault, 1979), dying individuals
and their families are made to see themselves as individuals who
deny death, and as being capable of transformation through
acceptance, with help from empathic health care workers. The
players appear to be caught in a disciplinary web, where acceptance
is rewarded and resistance results in the label of denial and an
offer of psychological assistance (Zimmermann, 2004, 2007).
Is there a way out of this web? The discourse on euthanasia e
a weighty topic worthy of separate investigation e would seem to
stand in radical opposition to the ideals of the hospice movement
(Pereira et al., 2008), although there are also signs of its possible
incorporation into this movement (Addington-Hall & Karlsen, 2005;
Seale & Addington-Hall, 1995). As well, the expansion of palliative
care outside the traditional domain of cancer into non-cancer diag-
noses, where death is not as easily predicted (Chattoo & Atkin, 2009;
Seamark, Seamark, & Halpin, 2007), and earlier into the course of the
illness (Temel et al., 2010), will both reect and inuence discourses
on the correct attitude to death. In the end, however, discourse
cannot stand outside itself (Armstrong, 1987, p. 656), and its
meandering path can be traced to the institutions it supports, the
ideologies it creates and the power relations it reproduces. The
societal management of death will continue to rely on available
ideals for its support; whether the acceptance-denial dichotomy will
remain relevant will only be apparent with time.
Acknowledgements
I would like to thank Richard Wennberg for his comments on
earlier drafts of this manuscript.
References
Addington-Hall, J. M., & Karlsen, S. (2005). A national survey of health professionals
and volunteers working in voluntary hospice services in the UK. I. Attitudes to
current issues affecting hospices and palliative care. Palliative Medicine, 19,
40e48.
Aries, P. (1974). Western attitudes toward death: From the middle ages to the present.
Baltimore: Johns Hopkins University Press.
Armstrong, D. (1987). Silence and truth in death and dying. Social Science &
Medicine, 24, 651e657.
Bradshaw, A. (1996). The spiritual dimension of hospice: the secularization of an
ideal. Social Science & Medicine, 43, 409e419.
223
Buckman, R. (1998). Communication in palliative care: a practical guide. In D. Doyle,
G. Hanks, & N. MacDonald (Eds.), Palliative medicine (2nd ed.). (pp. 141e156)
Oxford: Oxford University Press.
Callahan, D. (2000). Death and the research imperative. New England Journal of
Medicine, 342, 654e656.
Chambon, A. (1999). Foucaults approach: making the familiar visible. In Reading
Foucault for social work (pp. 51e80). New York: Columbia University Press.
Charmaz, K. (1980). The social reality of death. Reading: Addison-Wesley.
Chattoo, S., & Atkin, K. M. (2009). Extending specialist palliative care to people with
heart failure: semantic, historical and practical limitations to policy guidelines.
Social Science & Medicine, 69, 147e153.
Clark, D. (1998). An annotated bibliography of the publications of Cicely
Saunderse1: 1958e67. Palliative Medicine, 12, 181e193.
Clark, D. (1999). Total pain, disciplinary power and the body in the work of Cicely
Saunders, 1958e1967. Social Science & Medicine, 49, 727e736.
Clark, D. (2001). Religion, medicine, and community in the early origins of St.
Christophers Hospice. Journal of Palliative Medicine, 4, 353e360.
Clark, D. (2002). Cicely Saunders: Founder of the hospice movement. Selected letters
1959e1999. Oxford: Oxford University Press.
Cumming, E., & Henry, W. (1961). Growing old: The process of disengagement. New
York: Basic Books.
van Dijk, T. (1991). Racism and the press. London: Routledge.
Elias, N. (1982). The loneliness of the dying. Oxford: Blackwell.
Emanuel, E. J., & Emanuel, L. L. (1998). The promise of a good death. Lancet, 351, 21e29.
Erikson, E. (1950). Childhood and society. New York: Norton & Company.
Fairclough, N. (1990). Discourse analysis. Cambridge: Polity Press.
Foucault, M. (1972). The archeology of knowledge and the discourse on language. New
York: Pantheon.
Foucault, M. (1977). The history of sexuality. An introduction, Vol. 1. New York: Vintage.
Foucault, M. (1979). Discipline and punish. New York: Vintage.
Garces-Foley, K. (2006). Hospice and the politics of spirituality. Omega (Westport),
53, 117e136.
Glaser, B. G., & Strauss, A. (1965). Awareness of dying. Chicago: Aldine.
Gorer, G. (1980). The pornography of death. In E. Shneidman (Ed.), Death: Current
perspectives (pp. 47e52). Palo Alto: Mayeld.
Hall, C. S. (1954). A Primer of Freudian Psychology. New York: Harper & Row.
Hart, B., Sainsbur, P., & Short, S. (1998). Whose dying? A sociological critique of the
good death. Mortality, 3, 65e77.
James, N., & Field, D. (1992). The routinization of hospice: charisma and bureau-
cratization. Social Science & Medicine, 34, 1363e1375.
Kellehear, A. (1984). Are we a death-denying society? a sociological review. Social
Science & Medicine, 18, 713e723.
Kbler-Ross, E. (1969). On death and dying. New York: MacMillan.
Littlewood, J. (1993). The denial of death and rites of passage in contemporary
societies. In D. Clark (Ed.), The sociology of death (pp. 69e84). Oxford: Blackwell
Publishers/The Sociological Review.
Lupton, D. (2003). Power relations and the medical encounter. In Medicine as culture
(2nd ed.). (pp. 113e141) London: SAGE.
Marshall, V. W. (1980). Last chapters: A sociology of death and dying. Monterey:
Brooks/Cole.
McNamara, B., Waddell, C., & Colvin, M. (1994). The institutionalization of the good
death. Social Science & Medicine, 39, 1501e1508.
Parker, I. (1992). Discourse dynamics. Critical analysis for social and individual
psychology. London: Routledge.
Pattison, M. (1977). The experience of dying. Englewood Cliffs, N.J.
Pereira, J., Anwar, D., Pralong, G., Pralong, J., Mazzocato, C., & Bigler, J. M. (2008).
Assisted suicide and euthanasia should not be practiced in palliative care units.
Journal of Palliative Medicine, 11, 1074e1076.
Potter, J., & Wetherell, M. (1987). Discourse and social psychology: Beyond attitudes
and behaviour. London: Sage.
Seale, C. (1998). Constructing death. Cambridge: Cambridge University Press.
Seale, C., & Addington-Hall, J. (1995). Euthanasia: the role of good care. Social
Science & Medicine, 40, 581e587.
Seamark, D. A., Seamark, C. J., & Halpin, D. M. (2007). Palliative care in chronic
obstructive pulmonary disease: a review for clinicians. Journal of the Royal
Society of Medicine, 100, 225e233.
Sinclair, S., Rafn, S., Pereira, J., & Guebert, N. (2006). Collective soul: the spirituality
of an interdisciplinary palliative care team. Palliative & Supportive Care, 4, 13e24.
Sudnow, D. (1967). Passing on: The social organization of dying. Englewood Cliffs, N.J:
Prentice-Hall.
Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A.,
et al. (2010). Early palliative care for patients with metastatic non-small-cell
lung cancer. The New England Journal of Medicine, 363, 733e742.
Timmermans, S. (2005). Death brokering: constructing culturally appropriate
deaths. Sociology of Health & Illness, 27, 993e1013.
Walter, T. (1991). Modern death: taboo or not taboo? Sociology, 25, 293e310.
Weisman, A. (1972). On dying and denying. New York: Behavioural Publications.
Zimmermann, C., & Rodin, G. (2004). The denial of death thesis: sociological
critique and implications for palliative care. Palliative Medicine, 18(2),
121e128.
Zimmermann, C. (2004). Denial of impending death: a discourse analysis of the
palliative care literature. Social Science & Medicine, 59, 1769e1780.
Zimmermann, C. (2007). Death denial: obstacle or instrument for palliative
care? An analysis of clinical literature. Sociology of Health & Illness, 29,
297e314.
224 C. Zimmermann / Social Science & Medicine 75 (2012) 217e224

Appendix: Articles included in discourse analysis Kirchhoff, K., & Beckstrand, R. (2000). Critical care nurses perceptions of obstacles
and helpful behaviors in providing end-of-life care to dying patients. American
Journal of Critical Care, 9(2), 96e105.
Bascom, P., & Tolle, S. (1995). Care of the family when the patient is dying. Western
Low, J., & Payne, S. (1996). The good and bad death perceptions of health profes-
Journal of Medicine, 163(3), 292e296.
sional working in palliative care. European Journal of Cancer Care (English
Bishara, E., Loew, F., Forest, M., Fabre, J., & Rapin, C. (1997). Is there a relationship
Language Edition), 5(4), 237e241.
between psychological well-being and patient-carers consensus? A clinical
McHue, J. (1995). The naturalness of dying. The Journal of the American Medical
pilot study. Journal of Palliative Care, 13(4), 14e22.
Association, 273(13), 1039e1043.
Brown, J., Sangster, M., & Swift, J. (1998). Factors inuencing palliative care. Qual-
Minerbo, V. (1998). The patient without a couch: an analysis of a patient with
itative study of family physicians practices. Canadian Family Physician, 44,
terminal cancer. International Journal of Psycho-Analysis, 79(Pt 1), 83e93.
1028e1034.
Morris, R., & Christie, K. (1995). Initiating hospice care. Why, when and how. Home
Bulkin, W., & Luskashok, H. (1991). Training physicians to care for the dying.
Healthcare Nurse, 13(5), 21e26.
American Journal of Hospice and Palliative Care, 8(2), 10e15.
Murray, M., & Neilson, L. (1994). Denial: coping or cop out? Canadian Nurse, 90(2),
Burgess, D. (1994). Denial and terminal illness. American Journal of Hospice and
33e35.
Palliative Care, 11(2), 46e48.
Oyama, H. (1997). Virtual reality for the palliative care of cancer. Studies in Health
Carwein, V. (1986). Home hospice care in Britain and the United States. Caring,
Technology & Informatics, 44, 87e94.
5(10), 54e57.
Payne, S., Langley-Evans, A., & Hilier, R. (1996). Perceptions of a good death:
Claxton, J. (1993). Paving the way to acceptance. Psychological adaptation to death
a comparative study of the views of hospice staff and patients. Palliative
and dying in cancer. Professional Nurse, 8(4), 206e211.
Medicine, 10(4), 307e312.
Danis, M. (1998). Improving end-of-life care in the intensive care unit: whats to be
Reisman, R. (1989). Help your patients families accept the inevitable. Medical
learned from outcomes research? New Horizons, 6(1), 110e118.
Economics, 66(8), 178e180, 182e4.
Davies, B. (1980). Physiotherapy in the care of the dying. Physiotherapy Canada,
Rooda, L., Clements, R., & Jordan, M. (1999). Nurses attitudes toward death and
32(6), 337e342.
caring for dying patients. Oncology Nursing Forum, 26(10), 1683e1687.
Donnely, S. (1999). Folklore associated with dying in the west of Ireland. Palliative
Rousseau, P. (1995). Hospice and palliative care. Disease-A-Month, 41(12), 779e842.
Medicine, 13(1), 57e62.
Seale, C., & Kelly, M. (1997). A comparison of hospice and hospital care for people
Fowler, J. (1994). Welcome focus on a key relationship. Using Peplaus model in
who die: views of the surviving spouse. Palliative Medicine, 11(2), 93e100.
palliative care. Professional Nurse, 10(3), 194e197.
Sellers, S., & Haag, B. (1998). Spiritual nursing interventions. Journal of Holistic
Friel, P. (1982). Death and dying. Annals of Internal Medicine, 97(5), 767e771.
Nursing, 16(3), 338e354.
Guthrie, D. (1979). The hospice movement e Dr. Kbler-Ross: a positive acceptance
Sham, M., & Wee, B. (1994). The rst year of an independent hospice in Hong Kong.
of death. Bulletin of the American College of Surgeons, 64(4), 12e13.
Annals of the Academy of Medicine, Singapore, 23(2), 282e286.
Heim, E., Augustiny, K., Schaffner, L., & Valach, L. (1993). Coping with breast cancer
Stern, S., & Orlowski, J. (1992). DNR or CPR e the choice is ours. Critical Care
over time and situation. Journal of Psychosomatic Research, 37(5), 523e542.
Medicine, 20(9), 1263e1272.
Hinton, J. (1994). Can home care maintain an acceptable quality of life for patients
Taylor, C. (1994). Ministering to persons who face death. Practical guidance for
with terminal cancer and their relatives? Palliative Medicine, 8(3), 183e196.
caregivers of persons making end-of-life treatment decisions. Health Progress,
Hinton, J. (1999). The progress of awareness and acceptance of dying assessed in
75(4), 58e62.
cancer patients and their caring relatives. Palliative Medicine, 13(1), 19e35.
Thorpe, G. (1993). Enabling more dying people to remain at home. British Medical
Hughes, N., & Neal, R. (2000). Adults with terminal illness: a literature review of
Journal, 307(6909), 915e918.
their needs and wishes for food. Journal of Advanced Nursing, 32(5), 1101e1107.
Wasow, M. (1984). Get out of my potato patch: a biased view of death and dying.
Hunt, M. (1992). Scripts for dying at home e displayed in nurses, patients and
Health & Social Work, 9(4), 261e267.
relatives talk. Journal of advanced Nursing, 17(11), 1297e1302.
Winland-Brown, J. (1998). Death, denial and defeat: older patients and advance
Kawagoe, H., & Kawagoe, K. (2000). Death education in home hospice care in Japan.
directives. Advanced Practice Nursing Quarterly, 4(2), 36e40.
Journal of Palliative Care, 16(3), 37e45.
Zylicz, Z. (2000). Ethical considerations in the treatment of pain in a hospice
Kennie, D. (1983). Good health care for the aged. The Journal of the American Medical
environment. Patient Education and Counseling, 41(1), 47e53.
Association, 249(6), 770e773.