Awareness of Death in Open and Closed Contexts

In 1965, Barney G. Glaser and Anselm L. Strauss's study of the different awareness contexts of dying was the result of an extensive field study of how dying and death were treated in a number of American hospitals in the early 1960s. The four different awareness contexts portrayed by this study were to lay the foundation for an awareness of dying and death that resulted in a new paradigm.

In the first, closed awareness, dying patients do not know of or recognize their impending death because this information is withheld from the patients. Five structural conditions contribute to closed awareness: (1) the patients' lacking the experience to recognize signs of death, (2) physicians' not informing the patient that death is imminent, (3) the lack of discussion of death among family members, (4) the medical organization's not providing adequate information to the patient, and (5) the patients' lacking allies who would reveal the truth.

The second awareness is suspicion awareness.The patient does not know he or she is dying, but suspects death is close and also suspects the professionals are withholding information that would confirm this suspicion. Several structural conditions are supposed to account for this suspicion: (a) bodily changes in the patient, (b) changes in or termination of treatment, (c) cues from professionals or next of kin, and (d) the patient's being alarmed by the name of the care unit (i.e., the intensive care unit or oncology department).

The third awareness context is the ritual drama of mutual pretense. That is, the patient, professionals, and the next of kin know that the patient is about to die but pretend they do not know and hence act as if this were not the case. The structural conditions of open awareness are present here, but one of the parties expresses a desire to pretend that death is not impending and the other party (or parties) decides to play along in this drama. Two rationales for agreeing to mutual pretense on behalf of the professionals are found: (1) the patient wishes to pretend, and (2) the patient is easier to handle if the matter of death and dying is not openly discussed.

When both patient and professionals know the patient is dying and acknowledge this, there is an open awareness, the fourth context. Here different degrees of openness are found to occur. This includes whether death is expected, when it is expected, and how it will come about.

Further Contexts of Awareness

This fourfold analysis does not fully entail the complexity of awareness contexts, and further research has found elaborated versions of awareness. If a person acquires knowledge about impending death, but this knowledge is effectively blocked out, this results in suspended awareness. If the dying person oscillates between periods of open and closed awareness, this results in conditional awareness, in which the oscillation is triggered by different external or internal factors. Awareness of dying in the conditional sense can also be contrasted with the awareness of being mortal, an awareness that it is sometimes claimed we should have throughout life, that is, the idea about memento mori.

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