The Psychosocial Developmental Phases of Death (Mortality) Awareness: What Educational Therapists should know when working with Terminally Ill Clients

: This conceptual paper explores death and dying (mortality) from scientific, philosophical, and psychosocial perspectives, emphasizing its multidimensionality. Scientifically, death signifies the cessation of biological functions, while philosophically, it marks the end of conscious experience. Psychosocially, death encompasses emotional, cultural, and social dimensions, shaped by beliefs and cultural backgrounds. Educational therapists play a crucial role in navigating the psychosocial aspects of death, providing support and guidance to individuals and families coping with loss and grief. Across cultures, diverse rites and rituals as well as mourning practices aid in navigating its challenges. Focusing on death awareness from a psychosocial standpoint, this paper highlights its profound psychological implications, especially within the Eriksonian developmental theory, which is the main focus of this paper. The author has also suggested that future research could integrate interdisciplinary approaches to gain a holistic understanding of death, examining biological, philosophical, and psychosocial intersections. Practical applications could include enhancing palliative care, bereavement support, and mental health interventions, with educational therapists playing a pivotal role in these palliative endeavors. Studying cultural variations in approaching death or mortality could deepen our appreciation of human experiences. Longitudinal studies could track the evolution of individuals’ attitudes towards death and its impact on well-being. Overall, further research on death and dying, with the involvement of educational therapists, can help to enrich our current comprehension of death’s implications for humanity.


10.54392/ajir2422
Death remains a mysterious and multifaceted subject of interest to many, serving as a lens through which humankind examines its own nature and grapples with the profound mysteries of life's inevitable conclusion (Luper, 2009).
Death can be defined from scientific (Bernat, 2013;DeGrazia, 2021), philosophical (Malpas & Solomon, 1998;Veatch, 1978) and psychosocial (Johnson & McGee, 2004;Lavoie & de Vries, 2004) perspectives as follows:  Scientific (Biological) definition: From a scientific standpoint, death is often defined as the irreversible cessation of all biological or neurobiological functions that sustain a living organism.This includes the absence of heartbeat, brain activity, and respiratory functions.The specific criteria for declaring death may vary depending on cultural, legal, and medical contexts.For instance, "According to the whole-brain standard, human death is the irreversible cessation of functioning of the entire brain, including the brainstem" (DeGrazia, 2021, para. 6).Generally, this standard is associated with an organismic definition of death.In modern medicine, death is typically determined based on established clinical and physiological criteria, such as the absence of vital signs and brain activity.This offers a biophilosophical examination of death's significance prior to its declaration by physicians and it involves a four-step process: (i) Establishing consensus on paradigm conditions that guide the analysis and define the task; (ii) Delineating the definition of death, elucidating its meaning as accepted in our shared usage, which may have been obscured by technological advancements; (iii) Pinpointing the criterion of death, demonstrating the fulfillment of the definition and suitable for inclusion in a legal statute; and (iv) Formulating bedside tests for physicians to conduct, ensuring compliance with the established criterion (Bernat, 2013).
 Philosophical definition: Following the Harvard Committee's impactful 1968 (cited in Youngner & Arnold, 2001) initiative to redefine death, numerous controversies have emerged due to factors, such as the conceptual limitations of their proposal, evolving clinical experiences, and the ongoing effort to broaden the scope of potential organ donors.Death, philosophically, is often considered the irreversible cessation of conscious experience and the end of a person's existence (Malpas & Solomon, 1998).It raises questions about the nature of life, consciousness, and the potential significance or meaning of our finite existence (Veatch, 1978).
 Psychosocial definition: From a psychosocial perspective, death is a complex and multifaceted concept that encompasses not only the biological aspects but also the emotional, cultural, and social dimensions (Johnson & McGee, 2004;Lavoie & de Vries, 2004).This definition concerns the cessation of one's physical presence and conscious existence in one's community or society.According to Morgan (2020), our beliefs, attitudes as well as socio-cultural backgrounds, particularly, shape how we conceptualize to interpret the phenomenon of death and, at the same time, perceive death by becoming aware of it in order to understand it.As a result, there is a wide range of varied perspectives coming from different religious beliefs and doctrines, philosophies, and socio-cultural theories that offer a myraid of explanations and coping mechanisms for the existential and emotional aspects of death.
It is important to take note that our present grasp of death is molded by both objective scientific observations and subjective human experiences, beliefs, and socio-cultural systems.The combination of both scientific and psychosocial viewpoints has provided us a more broad-based understanding of the contemporary concept of death.

Other Definitions of Death Awareness
Apart from the definitions of death provided from the scientific, philosophical and psychosocial perspectives, there is also the definition of death from the spiritual as well as religious perspective, which according to Doka and Morgan (2016), depends on the doctrinal interpretation of each religion.Hence, one's awareness of death also involves the recognition of life's impermanence and understanding of death as a natural process that constitutes an inevitable part of the human existential experience.As a result, this has often necessitated a heightened consciousness of our own mortality through promoting introspection, raising mindfulness, and encouraging a deeper connection to the spiritual dimensions of our eartly existence (Mermann, 1992;Smith et al., 1993).
In the Christian theology, for instance, death awareness is regarded as a believer's acknowledgement of one's temporal nature of human existence here on earth.According to the sacred book of Ecclesiastes found in The Old Testament of the Holy Bible, the perishable body will eventually rot or decompose, and "return to the dust of the earth, and the breath of life will go back to God, who gave it to us" (Ecclesiastes 12:7, Good News Translation).
Interestingly, based on this author's encounter with atheists, in general, they do not share a unified perspective on existential matters.However, some atheists may approach death awareness by emphasizing the finite nature of life, focusing on the here-and-now moments rather than afterlife.For the atheists, death awareness might inspire a greater appreciation for the present, the pursuit of meaningful experiences, and the importance of leaving a positive impact on the world (see Coleman et al., 2019, for detail).It varies among individuals, as atheism itself does not prescribe a specific philosophical stance on these matters.

Death Awareness and Dying: How are the Two related?
Death awareness is intricately linked to the process of dying, shaping our perceptions, emotions, and behaviors as we confront mortality.It encompasses a spectrum of conscious and subconscious thoughts, feelings, and reactions to the inevitability of death.As humans, our awareness of death can be both a source of existential dread and a catalyst for profound introspection and personal growth.
At its core, death awareness influences how each one of us approaches the dying process -whether with fear, denial, acceptance, or even curiosity.Death can occurs anytime and its moments can be quite unexpected throughout life.In other words, our level of death awareness varies due to several key factors, such as a personal brush with mortality or an unfortunate experience triggered by a personal loss of a loved one (Krikorian et al., & Pastrana, 2020), different faiths and religious doctrines (Fan et al., 2023;Irwin, 2018) as well as philosophical contemplation (Garces-Foley, 2016), and socio-cultural values and practices (Phan et al., 2020).As a result, such moments can prompt us to question our own mortality, our meaning or purpose of life, our current existence, and certainly, what lies beyond the grave or if there is an afterlife (also see Frankl, 1984).There are also those who choose to suppress their thoughts of death because it is a taboo to many even at the mention of it.Others may choose to ponder about death, scrutinize its significance and also the implications that death carries.
It is, therefore, not a surprise, our understanding of mortality can profoundly shape our thoughts and experience.For those with a deep cultivation of death awareness may be more readily to accept the end of life with calmness and inner peace with heart and mind, and instead, choose to focus on their legacy, relationships with

The Hypothesis of Developmental Awareness of Mortality
There are already several theories relevant to death and dying mentioned in literature.For instance, the theory of disengagement (Cumming & Henry, 1961) postulated that senior adults, being freed from social norms, experienced ego change, and also chose to disengage in their response to their impending death, regardless of their place in time and space.Nickerson (2023) has argued that "[M]ost of the postulates of the disengagement theory have been disproven by empirical evidence" (para.3).Other theories include the theory or death anxiety (Tomer & Eliason, 1996), the theory of gerotranscendence (Tornstam, 1996) and the socioemotional selectivity theory (Carstensen, Isaacowitz, & Charles, 1999).
In this paper, the author has proposed his theory of the developmental awareness of mortality (DAM theory or DAMT, for short) with seven underlying factors (see Figure 1) to explain the awareness of death and dying as a hypothesis among several other theories that have already been discussed widely in the literature of thanatology.

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Kok Hwee Chia /2024 Asian J. Interdicip.Res, 7(2) (2024), 12-26 | 18  1.Foundation of existential understanding: The notion that humankind develops mortality or death awareness serves as the fundamental aspect of their existence (Slaughter, 2005).This notion constitutes the core of DAMT.According to Slaughter (2005) and Symons-Bradbury ( 2006), death awareness begins its emergence in early childhood while these young ones are still grappling with the concept of the finite nature of life.It sets as the foundation upon which through interactions with caregivers, young children are inevitably exposed to their socio-cultural beliefs and personal experiences gained from their significant others.

Cognitive maturation and comprehension of death or mortality:
How death or mortality is understood is gained over time through cognitive maturation as individuals grow, progressing through developmental milestones from one distinct stage to the next.DAMT proposes that in the early childhood phase, death is often perceived as reversible or temporary (Stambrook & Parker, 1987).However, as cognitive abilities develop, so does an individual, maturing and gradually grasping the irreversibility of death and the universality of mortality (Symons-Bradbury, 2006).Factors, such as education, intellectual stimulation and exposure to diverse perspectives, can influence and shape the individual's cognitive maturation and understanding of mortality.
3. Socio-cultural influence on mortality: According to Kastenbaum and Moreman (2018), socio-cultural elements play a pivotal role in shaping one's death awareness.As a result, DAMT places its emphasis on the impact of societal norms, socio-cultural practices as well as religious or spiritual beliefs on the attitude of individuals toward death or mortality.Moreover, through frequent social interactions within families, communities, schools, workplaces and other contexts, one's worldview of death is significantly influenced and gradually shaped over time.
4. Personal experiences and trauma: Hayslip and Hannson (2003) have pointed out that the role of one's experiences and exposure to death-related events can impact on one's awareness of mortality.In other words, traumatic experiences or close encounters with death (including near-death experiences) can elevate one's death awareness.These episodes can also prompt one to reflect on one's own mortality, leading one to ask oneself existential questions in order to delve deeper into making sense of the transient nature of life (Kamm, 2017;Kastenbaum & Moreman, 2018).This aspect has contributed to the formulation of DAMT.
5. Psychological defense mechanisms: In order to cope with stress incurred by death anxiety or the fear of death (thanatophobia), DAMT recognizes the existence of psychological defense mechanisms that individuals will employ to manage death awareness.There are several defense mechanisms (e.g., denial, rationalization, and repression) that can be used or adapted as managing strategies to deal with emotional distress associated with mortality (Arndt et al., 2000;Smith et al., 2022).How effective these strategies are depending heavily on the individuals who use them.

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Kok Hwee Chia /2024 10.54392/ajir2422 6. Existential crisis and meaning-making: DAMT recognizes that death awareness can trigger existential crisis in all of us.It prompts us to ask many questions about the meaning and purpose of life concerning our current existence (Spitzenstätter & Schnell, 2020).DAMT postulates our search for meaning in life (Frankl, 1984;Von Devivere, 2018), which is quite a natural reaction to our existential angst associated with dying, death or mortality.As a result, death awareness has initated the process of meaning-making about life and it should be seen as a psychological means, dominated by personal values, relationships and accomplishments, to mitigate our existential distress (Maffly-Kipp et al., 2021; Morgan, 2020).

7.
Interpersonal relationships and construction of legacy: DAMT underscores the importance of interpersonal relationships with others and that, in turn, can also help one to reconcile with oneself intrapersonally, and thereby, shapes one's readiness to accept the inevitable mortality or raises one's death awareness in preparation for one's eventuality (Morgan, 2020).In order to carry on a sense of continuity beyond one's own mortality, constructing one's legacy through meaningful connections with significant others has become ineluctable (King & Hicks, 2021).It is a way to transcend one's mortality with the aim of leaving behind a lasting impact on the loved ones and the community, if not, the world at large.

Developmental Phases of Death Awareness
The concept of death awareness can evolve through different developmental phases from birth to old age.It is important to note that these phases are generalized and may vary for individuals.Additionally, socio-cultural (Phan et al., 2020), religious (Küng, 2003), and personal (Krikorian et.al, 2020) beliefs can influence a person's perspective on death.
In DAMT, the author has provided a broad overview summarizing the developmental milestones of death awareness based on the developmental stages of the Eriksonian psychosocial theory (Sekowski, 2022a; also see Jones &Waite-Stupiansky, 2022, andMaree, 2022, for further detail): 1. Infancy (0-2 years) -Limited awareness: Infants have negligible awareness or maybe with a limited understanding of death.They may react to the absence of a familiar person but lack the cognitive capacity to comprehend the concept of death.
2. Early Childhood (2-6 years) -Magical thinking: Children in this phase may have a magical or animistic understanding of death, often influenced by fairy tales.Death might be seen as temporary or reversible.
3. Middle Childhood (7-11 years) -Concrete understanding: As the children of this age group mature, they start to grasp the finality of death -a biological process.No longer do they see death as something reversible when they used to watch in cartoons on TV.They might struggle in understanding the abstract concept of mortality.
4. Adolescence (12-19 years) -Personalization and identity exploration: This is the phase of adolescence during which these denarians (aged 10 to 19 years) begin to think more abstractly as they grapple with existential questions (e.g., Who am I? Is there a god?What is the meaning of life?).If they are chronically or terminally ill, death awareness becomes more personally relevant to them.It is also during this period that denarians may ponder their own mortality as well as the meaning or purpose of life (Frankl, 1984).
5. Early Adulthood (20-40 years) -Realization of mortality: During this phase, individuals in their 20s (also known as vicenarians) and 30s (also known as tricenarians) form their own philosophies and beliefs about life and death.They may also encounter notable life events (e.g., personal health problems or death of a loved one), which they have come to accept the unavoidable reality of mortality.
6. Middle Adulthood (41-60 years) -Transcendence and building of legacy: During this phase, quadragenarians (aged 40s) and quinquagenarians (aged 50s) are quite aware that life is finite.As a result, they may seek meaning and purpose in life (also see Frankl, 1984).Often their focus is on leaving behind a lasting impact to their loved ones or community through their accomplishments in life or contributions to the society as well as wonderful relationships that they have previously established with others (e.g., friends and colleagues).expressing their end-of-life wishes) as they are quite aware that death is imminent and cannot be prevented.More importantly, coming to a proper closure constitutes an important aspect of this preparation for end-oflife event, when these individuals involved in activities that provide them a meaningful or purposeful sense of completeness to their lives.9. Very Old Age (91+ years) -Spiritual exploration: These nonagenarians (aged 90s) now turn to their spiritual or religious beliefs to seek peace and solace as they approach the end of life.It is also during this phase that these individuals involve themselves in deep contemplation about their current existence and hereafter, but it also depends on individual beliefs and experiences.
10. End of Life (Terminal Phase) -Acceptance of eventual mortality and reflection: Towards the final days of one's life, individuals generally reflect on their respective lives, come to terms with their mortality, and may engage with their loved ones sharing their views about death.This final phase is also prominently peppered with spiritual and existential issues of concern.
These stages in DAMT are not cast in stone.The aim of the theory is to inform and help individuals to revisit and traverse through the different phases depending on their experiences and circumstances encountered.Additionally, cultural and religious factors can significantly influence the ways people approach and perceive death across the lifespan (Phan et al., 2020).

Death Awareness and Bereavement
Death awareness can play an important part in helping a person in grief during the period of bereavement (Hayslip & Hansson, 2003).Hence, death awareness (as well as dying) is strongly recommended to be included in school curriculum as well as grief counseling (Phan et al., 2020).Below are the author's seven main reasons why and how death awareness can help in grief management/counseling: 1. Facilitates acceptance: Death awareness can aid in acknowledging the reality of loss, allowing a grieving person to confront and accept the inevitability of death, which is an integral part of the healing process.
2. Encourages reflection: Being aware of mortality can prompt reflective thinking, enabling individuals to cherish the memories of their loved one and find meaning in the shared experiences, fostering a deeper understanding of the relationship.

Promotes emotional expression:
Acknowledging the finality of life can provide a framework for expressing emotions.This comes with an acceptance of the act of grieving whose emotional depth allows an individual to go through the process of expressing a range of feelings (e.g., denial and anger), especially during the period of bereavement.As a result, it allows a healthy emotional release rather hoarding all the feelings within the bereaved.
4. Inspires legacy building: By commemorating someone who has passed on, death awareness can inspire the bereaved to create legacies left behind by a loved one.This can be achieved by preserving memories (e.g., to hold a death anniversary in fond memories of the deceased), setting a charity foundation under the deceased's name (e.g., to contribute to a meaningful cause to the departed), or continuing the family traditions observed during special occasions celebrated by the departed when he or she was still alive.5. Encourages personal growth: Personal growth can be promoted positively through self-reflection when confronting mortality.Given time to grieve, the bereaved or mourners can also reassess their goals, priorities and values in life, or they may want to search for new meaningful directions and insights that can advance their personal life development.
6. Strengthens connection with others: Being aware of one's mortality can help to enhance one's compassion and empathy for others.Through sharing of one's experience of loss, this opportunity promotes bonding with others and also establish a supportive network for those are still grieving.It also makes one more compassionately receptive to the sufferings and misfortunes of others.7. Facilitates spiritual exploration: For some, death awareness sparks a search for spiritual or existential understanding.Exploring one's beliefs and finding solace in spiritual practices can provide a framework for coping with loss and finding a sense of peace.

Importance of Knowing & Understanding Death Awareness for an Educational Therapist
As a board-certified educational therapist, this author firmly believes that it is important to know and understand the death awareness when working with children and adolescents with special needs, especially those who face inevitable life termination due to incurable diseases, such as amyotrophic lateral sclerosis (ALS), Huntington's disease, stage IV childhood leukemia (especially, acute lymphoblastic leukemia), AIDS-related illnesses, and motor neuron disease.The author wants to reiterate that it is not the sole responsibility of the educational therapist alone to work with terminally ill clients, but involves an interdisciplinary collaboration with professionals, such as palliative care physicians, counselors, allied therapists and psychologists, too.The author of this paper has listed five reasons what educational therapists should take note when working with terminally ill clients: 1. Emotional support and coping strategies: Understanding death awareness is crucial for an educational therapist working with children with special needs, who are also facing incurable diseases, because these children often grapple with complex emotions associated with mortality.In order to engage terminally ill clients, activities used in educational therapy should offer socio-emotional support as well as to attain a sense of achievement -a crucial objective set to create a small legacy by the clients facing end-of-life challenges to be passed to their caregivers once they are gone.An awareness of death or mortality allows the educational therapist to provide appropriate emotional support, helping these terminally ill children and their families develop coping strategies to navigate the psychological challenges associated with the impending end of life.
2. Tailoring educational approaches: Knowledge of death awareness enables an educational therapist to tailor his/her approaches and interventions to meet the unique needs of each child.Not forgetting that educational therapy can help preserve cognitive function and stimulate the brain, which can be important for maintaining quality of life, even in the face of a terminal illness.However, not every child may benefit from an affective-focused educational plan.There are always others who need a specially designed program that can help to address their existential questions and/or to facilitate their legacy-building activities while time is still available to them.Understanding death awareness allows the educational therapist to design appropriate educational strategies that align with the child's emotional and cognitive state.
3. Communication and honesty: Open and honest communication is essential when working with children facing incurable diseases.An educational therapist, who is aware of death-related issues, can work with a palliative counselor or psychologist, to approach discussions about the client's condition with sensitivity, age-appropriate language, and honesty.This can foster trust between the educational therapist (together with other palliative professionals), the child, and the family, creating an environment where difficult conversations can take place more comfortably.
4. Facilitating life review and legacy building: Death awareness is closely tied to the concept of life review and legacy building.It is good if educational therapists can assist terminally ill children and adolescents with special needs by guiding them to take pride in their small achievements attained (e.g., explaining in their own words the little knowledge that they have learnt, sharing their memorable experiences, or a skill that they have just acquired), and also to reflect on their lives with curiosity that makes learning as well as interacting with others "such a dynamic experience" (Notbohm, 2022, p. 101).In this way, the educational therapists can help to establish a sense of proper closure with meaning and purpose as they allow the terminally ill child to leave a lasting legacy for their caregivers.Hence, by understanding death awareness and journeying with someone terminally ill right to the end-of-life can empower an educational therapist to know how to guide such activities in a supportive and purposeful way should they be called upon again to help another such client.5. Supporting families and caregivers: A collaborative approach to work with terminally ill children and adolescents with special needs often involves an interdisciplinary team, which should always include the parents, caregivers, and other close family members and/or friends.It is important for an educational therapist working with such a case to be well-versed in mortality awareness, palliative care or counseling.This also includes assisting family members to navigate their own emotions, helping them to communicate sensitively to the client's siblings (if any), and also providing any end-of-life planning resources so much needed during that time.More importantly, it is also the educational therapist's role to maintain a sense of normalcy and routine for the client and the caregivers during the most difficult moments.Alternatively, working mutually with a palliative counselor or medical doctor can also provide invaluable support to the terminally ill client's entire family unit.Finally, what is most crucial is for everyone involved in this end-of-life case is to enhance the overall well-being of the client facing an untreatable devastating condition.In essence, for an educational therapist working with chronically ill clients with life-threatening conditions, especially children and adolescents with special needs, it can be a heart-wrenching or agonizing experience.Nevertheless, death awareness remains indispensible for educational therapists if they continue to provide compassionate support for terminally ill children and adolescents with special needs.A comprehensive knowledge, understanding and related experience working on such cases can enable the educational therapists to express compassion and empathy, encourage more transparent dialogue, customize their intervention plans to promote purposeful experiences, and provide support for the terminally ill client and the caregivers as they share the challenging journey together.

Conclusion and Recommendation
Having briefy explored the different perspectives and definitions of death awareness, with each offers its own unique insights into the nature of mortality, death is defined differently depending on which perspective one chooses to adopt.From the scientific view of point, death is the cessation of all biological or neurobiological functions.The philosophical viewpoint marks death as the end of one's conscious experience, while the psychosocial standpoint, being influenced very much by varied beliefs and socio-cultural backgrounds, regards death as a state that encompasses emotional and socio-cultural dimensions.Throughout different parts of the world, different cultures have fostered diverse rites and rituals as well as mourning practices to negotiate the challenging issues of mortality.
In the context of several psychosocial theories related to dying and death, the author of this paper has chosen to focus on death awareness from an Eriksonian psychosocial perspective with an emphasis on the profound psychological and emotional implications on individuals.His proposed developmental awareness of mortality theory (DAMT) underscores the prominence of death awareness at various psychosocial developmental stages of life.In the end, death holds an intense and diverse subject of interest, prompting us to scrutinize the nature of mortality as well as to come face to face with life's mysterious and inevitable conclusion.
It is crucial for us to take an interdisciplinary approach in exploring death and dying by integrating all varied persepctives (e.g., scientific, philosophical and psychosocial) in order to establish a comprehensive understanding of mortality.This means interdisciplinary studies are certainly needed to create academic intersections among three key domains, i.e., (i) biological processes of death, (ii) philosophical concepts of consciousness and identitiy, and (iii) psychosocial factors including socio-cultural beliefs and coping mechnaisms.More importantly, there is a need for the professionals from different disciplines to know and understand its implications in their respective works, and to come together to share a common professional platform for discussion on latest developments in the field of thanatology, end-of-life (palliative) care, counseling and bereavement support services, mental and emotional wellness.Besides, there is also a need to include approaches on death awareness from diverse cultures and societies in order to establish a deeper understanding of the universality of death and diversity of experiences related to mortality.
Finally, more longitudinal studies are needed, especially to examine individuals' changing perceptions and attitudes towards dying and death over time, how the awareness of death has evolved through the decades, and how the overall well-bing and quality of life can be impacted by mortality.Findings from such studies can inform and enrich the educational therapists' indepth knowledge and understanding of mortality with its implications for their services as they engage with their terminally ill clientele".

Figure 1 .
Figure 1.The Seven Factors of Developmental Awareness of Mortality Theory.

7.
Late Adulthood (61-75 years) -Reflection and acceptance of mortality: Generally, sexagenarians (aged 60s) and the early septuagenarians (aged 70 to 75 years) often reflect on their life and they are quite receptive (or perhaps, more resigned to) to their mortality being a natural part of their human life cycle.It is also noted that these individuals also show a greater sense of peace and solace, more so if they have led a fulfilling life.8. Old Age (76-90 years) -Preparation and closure: For the septuagenarians (aged 70s) and octogenarians (aged 80s) in this phase, they begin to make their preparations for the end of life (e.g., creating wills and