Dealing With Death Taboo: Discussion of Do-Not-Resuscitate Directives With Chinese Patients With Noncancer Life-Limiting Illnesses

BACKGROUND

Noncancer patients with life-limiting diseases often receive more intensive level of care in their final days of life, with more cardiopulmonary resuscitation performed and less do-not-resuscitate (DNR) orders in place. Nevertheless, death is still often a taboo across Chinese culture, and ethnic disparities could negatively affect DNR directives completion rates.

OBJECTIVES

We aim to explore whether Chinese noncancer patients are willing to sign their own DNR directives in a palliative specialist clinic, under a multidisciplinary team approach.

DESIGN

Retrospective chart review of all noncancer patients with life-limiting diseases referred to palliative specialist clinic at a tertiary hospital in Hong Kong over a 4-year period.

RESULTS

Over the study period, a total of 566 noncancer patients were seen, 119 of them completed their own DNR directives. Patients had a mean age of 74.9. Top 3 diagnoses were chronic renal failure (37%), congestive heart failure (16%), and motor neuron disease (11%). Forty-two percent of patients signed their DNR directives at first clinic attendance. Most Chinese patients (76.5%) invited family caregivers at DNR decision-making, especially for female gender (84.4% vs 69.1%; P = .047) and older (age >75) age group (86.2% vs 66.7%; P = .012). Of the 40 deceased patients, median time from signed directives to death was 5 months. Vast majority (95%) had their DNR directives being honored.

CONCLUSION

Health-care workers should be sensitive toward the cultural influence during advance care planning. Role of family for ethnic Chinese remains crucial and professionals should respect this family oriented decision-making.

Upstreaming and Normalizing Advance Care Planning Conversations-A Public Health Approach

As a society, we simply don’t talk about this universal experience called dying and death; in fact, we ignore it until we have to face it. Thus, it is often in a crisis experience when we have to make decisions while we are laden with uncertainty and intense emotions. Sixty percent of people say making sure their family is not burdened by tough decisions is extremely important, yet 56% of them have not held a conversation about its context. Instead of waiting to make end-of-life decisions, let us begin to think about what matters most while we are living, what we value most, and how we translate these values into conversations about what is important. As a public health concern, if we can upstream the advance care planning discussion into usual health promotion activities, perhaps, as a society, we can begin to normalize and reshape how we make decisions about the last chapters of our lives.

"Before I die I want to …": An experience of death education among university students of social service and psychology

The censorship of death and dying has removed the "memento mori" practices, and in order to reintroduce this practice, some "Before I die" projects have been increasingly implemented. Running in parallel, in the syllabi of social service and psychology students, some experiences of death education has commenced. This study illustrates the results of a qualitative research conducted on the "Before I die I want to …" Polaroid^® Project (BIDIWT), which is divided into two phases. The first phase entails an analysis of the wishes collected from the United States, Japan, India, and Italy. The second phase refers to the analysis of the captions of the BIDIWT realized from two groups of undergraduates, with regard to the effect of such experience on their religiosity, representation of death, and fear of death.

Psychodrama and Moviemaking in a Death Education Course to Work Through a Case of Suicide Among High School Students in Italy

This study describes the psychological effects of an experience of death education (DE) used to explore a case of suicide in an Italian high school. DE activities included philosophical and religious perspectives of the relationships between death and the meaning of life, a visit to a local hospice, and psychodrama activities, which culminated in the production of short movies. The intervention involved 268 high school students (138 in the experimental group). Pre-test and post-test measures assessed ontological representations of death, death anxiety, alexithymia, and meaning in life. Results confirmed that, in the experimental group, death anxiety was significantly reduced as much as the representation of death as annihilation and alexithymia, while a sense of spirituality and the meaning of life were more enhanced, compared to the No DE group. These improvements in the positive meaning of life and the reduction of anxiety confirmed that it is possible to manage trauma and grief at school with death education interventions that include religious discussion, psychodrama and movie making activities.

Let's Start With the End: Bibliodrama in an Italian Death Education Course on Managing Fear of Death, Fantasy-Proneness, and Alexithymia With a Mixed-Method Analysis

This article presents the results of an experience of death education (DE) course with bibliodrama in Italian high schools, which focused on emotions and existential themes. The research analyzed the inability to recognize or describe one's own emotions (alexithymia), fantasy-proneness, and attitudes toward death in two different groups of students: one who took a course on DE (with 113 students) and another who did not participate in it (with 114 students). The use of a mixed method allowed this study to explore the quantitative results that the students indicated in the questionnaire and the qualitative open answers to the final question about how they had profited from this DE course. The results showed that the course had a positive effect, as the DE group significantly decreased alexithymia and negative attitudes toward death, particularly in fear and avoidance of death, making their representation of death less traumatic.

End-of-life and palliative care education in US pharmacy schools

The objective of this endeavor was to ascertain the current status of end-of-life and palliative care within the curriculum of US pharmacy schools and compare to a similar 1986 study. Additionally, responses to recent professional guidelines for pharmacy schools regarding end-of-life issues can be addressed. A fixed-choice survey was mailed to the 125 US pharmacy schools with a 49% response rate. Results revealed that the lecture format of teaching on end-of-life issues continues to be used today with an increase in offerings and greater participation by students than in 1986. Recently established guidelines and standards regarding end-of-life issues for pharmacy schools are being addressed, thus today's pharmacists should be better prepared to relate to patients with terminal illnesses and their families than in 1986.

Beyond the Wall: Death Education at Middle School as Suicide Prevention

This study investigates the psychological effects of participation in Death Education (DeEd) by middle school children in two towns in northeast Italy in which suicides occur to a greater extent than in the rest of the region. The aims of the project "Beyond the Wall" were inherent to the prevention of suicide, address existential issues and enhance the meaning of life through positive intentions for the future and reflection on mortality. It involved eight classes (150 students in four classes in the experimental group; 81 in four classes in the control group) engaging with films, workgroup activities, photovoice and psychodrama. The constructs of resilience, emotional competency and psychological well-being were monitored with the Resilience Scale for Adolescents, the Hopelessness Scale for Children, the Alexithymia Questionnaire for Children and the Stirling Children's Well-being Scale. The DeEd intervention was found to be significantly related to some of the variables investigated, improving the students' ability to recognise emotions and communicate them verbally while maintaining stable initial characteristics, such as psychological well-being and positive expectations for the future.

Development of death education training content for adult cancer patients: A mixed methods study

AIMS AND OBJECTIVES

The aim of this mixed methods study was to develop science-based content for a systematic death education training system based on the needs of adult cancer patients. The study contained two parts: survey development and Delphi survey. First, a small sample test was conducted to check the reliability and validity of the questionnaire. Next, this questionnaire was applied to investigate adult cancer patients' needs for death education. Then, we invited experts in the fields of nursing management, clinical medicine, clinical nursing and psychological care to carry out two rounds of Delphi consultations to revise the training content.

BACKGROUND

Death education is often combined with hospice care, which is based on a clear 6-month survival period. However, the survival of adult cancer patients has improved with improved cancer diagnoses and treatments, and death education should be initiated before the dying stage. At the same time, patients' needs for medical information become increasingly important in daily clinical practice. Therefore, a death education programme based on adult cancer patients' needs was developed to help these patients reflect on the meanings of life and death.

DESIGN

A mixed methods study.

METHODS

During the survey development period (from April 2017-September 2017), a small sample test (n = 150) was conducted to verify the reliability and validity of the questionnaire on death education needs of adult cancer patients. This questionnaire was developed based on a literature review and discussion among the study group. Next, 324 adults with cancer, recruited from a three-level cancer hospital in Tianjin, China, were surveyed to analyse their needs for death education, using the questionnaire that had been tested in the pretest period. Finally, a Delphi survey was conducted from October 2017-January 2018. A panel of experts (n = 23) recruited from major hospitals, nursing schools and universities in China in the fields of clinical nursing, nursing management, clinical medicine and psychological care took part in the study to revise the training contents based on the investigation results.

RESULTS

The reliability and validity of results based on the small sample test revealed that the Cronbach's alpha coefficient and the half-degree of reliability of the questionnaire were 0.924 and 0.951, respectively. This demonstrated that the questionnaire had high reliability. The KMO was 0.756 and the Bartlett Test of Sphericity showed p < 0.001, indicating that the factor analysis was justified in the sample. Eight components with eigenvalues greater than one were retained by the factor analysis. The investigation of the patients' needs for death education showed that the overall score of patients' needs was 3.60 ± 0.709 points (needs were measured on a scale from 1-5, where 5 indicates high needs), and there were high demands for education regarding "cancer patient life reviews," "death-related ethical issues" and "to leave peacefully." Data from expert panel members were collected in two rounds over a 4-month period, and consensus was achieved in the second Delphi round. The final death education contents of adult cancer patients contained four sections: cancer, death, psychology and practice. These were divided into 54 teaching topics to be included in 14 courses.

CONCLUSIONS

The adult cancer patient death education training content devised in this study is science-based, practical and can be used as a guide for clinical nurses to provide high-quality care to adult cancer patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses could become more involved in providing death education to adult cancer patients and their families. Further research is needed to explore the applicability of the training content and to develop the content according to changing times and patients' needs.

Voices We Forget-Danish Students Experience of Returning to School Following Parental Bereavement

This study explores how Danish students experience returning to school following parental bereavement. Eighteen focus group interviews with 39 participants aged 9 to 17 years were conducted. All participants had experienced the loss of a primary caregiver. Data collection was divided into two phases. In Phase I, 22 participants from four grief groups were interviewed 4 times over the course of a year. During Phase II, confirmatory focus groups were undertaken with the 17 participants. This article explores findings related to the four themes of initial school response, long-term support, challenges within the class, and academic challenges. The study found that (a) students struggle to reconnect with classmates following the return to school and often feel alone, (b) schools fail to have guidelines in place for what they are allowed to do if becoming sad the class, and (c) schools seem to forget their loss as time passes.

Enhancing Existential Thinking through Death Education: A Qualitative Study among High School Students

The censorship of death-related issues is widespread in contemporary Western culture because the boundary between death and life is substantially managed in medical areas. In the context of Italian educational initiatives, to remove this limitation, 215 high school students in Southern Italy were educated on death through conventional and informal lessons. The students answered a questionnaire with open questions to survey their emotional and reflective experiences. Their answers were qualitatively, thematically analysed to explore how the representation of death can follow a death education course, and if this experience can be managed without harmful effects. The students’ answers narrated how the course reduced their anxiety linked to these themes, on the one hand improving communication between peers by making it more authentic and empathic and, on the other, providing alternative perspectives on life. Indeed, the project offered an opportunity to discuss something strongly heartfelt but rarely faced, and the survey confirmed that the research objectives were fully achieved.

Community-based death preparation and education: A scoping review

The COVID-19 pandemic revealed a need for people and communities for death preparation. Few studies have examined community-level interventions for death preparation and education. This scoping review scrutinized the relevant literature following PRISMA 2018 guidelines. Six databases were searched for articles published between 2010 and 2020. We found that cultural, socioeconomic, and individual values affected death preparation and that online courses and life-death education were effective preparation methods. Additional research is needed to identify the population-specific effectiveness of interventions. To fully investigate death preparation and education at the community level, theory-based studies employing quantitative and qualitative methods are also needed.

Engaging College Undergraduates in Advance Care Planning

Advance care planning (ACP) is a critical part of long-term health-care planning, as no one knows when the ability to make personal medical decisions may be impaired. Many assume ACP is only necessary for older adults or those with life-threatening health conditions; however, there are growing discussions about healthy, young adults also engaging in ACP, as they too suffer from unexpected medical events that limit their ability to make medical decisions. The current study examined the reactions of college students following the completion of their advance care plans and then sharing these plans with friends and family. The students reported that while completing their advance care plans created many emotions, they found the experience to be valuable and facilitated conversations with family and friends about end-of-life care that may not have occurred otherwise.

The effectiveness of 8A model death education on the reduction of death depression: A preliminary study

Aim

Death education using the 8A model can reduce death distress and promote mental health. The aim of the present study was to investigate the effectiveness of the 8A model death education programme for reducing death depression among nurses. The hypothesis was that participating in the 8A model death education programme would reduce death depression.

Design

A pre-test-post-test intervention.

Methods

Ten nurses were selected randomly from the intensive care units and critical care units wards of the Khatom-Al-Anbia General Hospital in Tehran, Iran. They completed the Death Depression Scale before and after intervention. The 8A model was conducted in six workshops weekly, each of 6 hr, for a total of 36 hr.

Results

There was a significant difference between pre-test and post-test on the Death Depression Scale scores.

Discussion

The 8A model appears to be useful for the reduction of death depression and the promotion of mental health in the sample. However, the model should be tested on larger samples and with a control group before concluding that the model is effective in reducing death distress.

Transforming Students' Attitudes and Anxieties Toward Death and Loss: The Role of Prior Death Experiences

This study examines the impact of a death and dying course on 39 undergraduate students' attitudes and anxieties about death. Authors outline key aspects of the curriculum used in the course and discuss how the approach lends itself to a transformative learning experience related to death and loss, preparing students who will face clients with a variety of needs in these areas across practice settings. The majority of students ( n = 34) experienced a decrease in death avoidance, fear of death, and overall death anxiety. Students with a history of multiple violent, traumatic, or unexpected deaths ( n = 5) did not experience any significant changes but demonstrated increased scores of death anxiety suggesting that they may be in need of greater support while engaging in death education.

"Imagine You Have ALS": Death Education to Prepare for Advance Treatment Directives

The study presents the results of qualitative research carried out within a death education project dedicated to advance treatment directives (ATDs) in which it was proposed to participants to empathize with people who had received a diagnosis of Amyotrophic Lateral Sclerosis (ALS). The study involved 104 people who discussed and reflected on issues related to the knowledge of having to die, palliative care and ATDs, investigating what choices they would have made if they had received such a diagnosis. Finally, they were asked to write a paper describing their impressions and hypothetical choices. Qualitative analysis has elucidated among fundamental themes. Four thematic areas emerged from the data analysis: (1) ATDs and the family; (2) the importance of reducing pain and suffering; (3) emotions and considerations regarding death, illness and spirituality; and (4) opinions on the DeEd course. It has emerged that some people are unfamiliar with palliative care or the right to self-determination and that addressing these issues helps manage the thought of the future with less terror. The experience of death education has therefore proven to be very positive in dealing with complex and often censored issues, allowing thinking about death in a less distressing way.

Introducing the Study of Life and Death Education to Support the Importance of Positive Psychology: An Integrated Model of Philosophical Beliefs, Religious Faith, and Spirituality

Life education, also known as life and death education, is an important subject in Taiwan with institutions (e.g., high school) offering degree programs and courses that focus on quality learning and implementation of life education. What is interesting from the perspective of Taiwanese education is that the teaching of life education also incorporates a number of Eastern-derived and conceptualized tenets, for example, Buddhist teaching and the importance of spiritual wisdom. This premise contends then that life education in Taiwan, in general, is concerned with the promotion, fulfillment, and cherishing of quality life experiences (e.g., personal contentment, happiness). One example of life education, which resonates with other spiritual beliefs and religious faiths (e.g., Hinduism), is related to spiritual cultivation and the enlightenment of life wisdom. Our own teaching of the subject, likewise, places emphasis on the goal of teaching students to seek meaningful understanding of and appreciation for three major, interrelated components of life education: life wisdom, life practice, and life care. It has been acknowledged, to a certain degree, that life education has made meaningful contributions, such as the creation and facilitation of a civil, vibrant society, and that many Taiwanese individuals show dignity, respect for elders, and reverence for spiritual and religious faiths. For example, aside from high-quality hospice care, many Taiwanese engage in different types of benevolent acts (e.g., providing spiritual advice to someone who is dying), where possible. Life education is a beneficial subject for teaching and learning as its theoretical understanding may help individuals cope with pathologies and negative conditions and life experiences. One negative life experience, in this case, is the ultimate fate of humankind: death. Approaching death and/or the onset of grief is something that we all have to experience. How does one approach death? It is not easy feat, and of course, grief for a loved one is personal, and some of us struggle with this. We contend that spiritual cultivation and enlightenment, arising from life education, may assist us with the topic of death (e.g., the possibility of transcendence beyond the realm of life). More importantly however, from our own teaching experiences and research development, we strongly believe and rationalize that the subject of life education could, indeed, coincide with and support the paradigm of positive psychology (Seligman, 1999, 2010; Seligman and Csíkszentmihályi, 2000). Forming the premise of the present conceptual analysis article, we propose that a person's "spiritual and enlightened self," reflecting the convergence of three major aspects of life education (i.e., philosophical reflection, enrichment of personal well-being, and spiritual cultivation), would result in the initiation and creation of a number of virtues and positive characteristics, for example, having a positive outlook in life, having a perceived sense of spirituality, showing compassion, forgiveness, etc. These virtues and quality characteristics, from our philosophical reasoning, are equivalent to those qualities that the paradigm of positive psychology advocates for. In summary, we conceptualize that the subject of life education, from the perspective of Taiwanese education, may intertwine with the paradigm of positive psychology. A person's spiritual and enlightened self, or his/her "holistic self," from our rationalization, is the ultimate optimal life experience that he/she may have, enabling him/her to address the gamut of life conditions and experiences. The distinctive nature of life education in this case, as a point of summary, is that it incorporates spiritual beliefs and religious faiths (e.g., Buddhist faith), encouraging a person to seek nature and divine-human relationships, as well as to contemplate and to explore the complex nature of his/her inner self. The notion of Buddhist samsâra, for example, as "evidence" of spirituality, entailing the endless cycle of birth, rebirth, and redeath, may provide a person with hope into the afterlife. Such esoteric discourse, we contend, is positive and optimistic, allowing individuals to discard the dividing line between life and death.

Death Attitudes and Death Anxiety Among Medical Interns After the 2020 Outbreak of the Novel Coronavirus

This study investigates the status quo and influencing factors of death attitudes and death anxiety among medical interns in China as measured by the Death Attitude Scale and Death Anxiety Scale following the outbreak of “Novel Coronavirus Pneumonia” in China in early 2020. Results of this study show that under the influence of COVID-19, in terms of death attitude, medical interns scored the highest in neutral acceptance and the lowest in escape acceptance. There were significant differences in death attitude and anxiety among the groups with different backgrounds, including their families’ approaches to discussions of death, the number of funeral experiences, and other factors. There were two additional factors affecting attitudes that were related to the epidemic situation: whether the individual had participated in work to treat COVID-19 and whether their close friends or relatives (“cherished persons”) had been diagnosed with COVID-19. The study reveals the ways that the epidemic had an impact on death attitude and death anxiety.

"Mourning With the Morning Bell": An Examination of Secondary Educators' Attitudes and Experiences in Managing the Discourse of Death in the Classroom

A plethora of research exists about death and dying, particularly with regard to the prescriptive strategy on how teachers should address death in their classrooms. However, there is a gap in the literature about teachers' perceived preparedness to discuss a student's death in their classrooms. The following qualitative study used focus groups to explore teachers' experiences with and beliefs about death, dying, coping, student death, and preparedness to address student death in the classroom. Data were transcribed and thematically analyzed. Themes and subthemes for all research questions are presented and explained; some themes explored include teachers' views of death, death versus dying, initial and long-term coping, difficulties in addressing student death, the teachers' role after a student's death, feelings of being prepared versus unprepared to address student death in the classroom.

The Hospice as a Learning Environment: A Follow-Up Study with a Palliative Care Team

In Western society, the topic of death has been removed from everyday life and replaced with medical language. Such censorship does not reduce individuals’ fear of death, but rather limits their ability to elaborate their experiences of death, thus generating negative effects. The objective of this follow-up qualitative study was to detect how and if death education can help to improve individuals’ relationship with death and enhance care environments like hospices. Semi-structured interviews were conducted with palliative care professionals and teachers who had taken part in a death education initiative three years earlier. The results confirmed the initiative’s positive effect on both palliative care professionals and teachers. The participants reported that the education initiative helped them to positively modify their perspective on death, end-of-life care, and their own relationship to life, as well as their perception of community attitudes towards the hospice, which seemed to become less discriminatory. This study confirmed that school education initiatives can usefully create continuity between hospices and local communities. This project provided an educational space wherein it was possible for participants to elaborate their experiences in relation to death and to re-evaluate and appreciate hospices.

Psychology Students' Perceptions of COVID-19 in a Death Education Course

The systematic removal of death from social life in the West has exposed people living in areas affected by COVID-19 to the risk of being unable to adequately manage the anxiety caused by mortality salience. Death education is a type of intervention that helps people manage their fear of death by offering them effective strategies to deal with loss and anxiety. To that end, a path of death education has been carried out with University students of psychology. The main purpose of the research is to understand how students who participated in the death education course perceive the lockdown experience in light of course teachings. The research was carried out at a University in northern Italy in an area severely affected by COVID-19, during the first year of the pandemic. The group of participants included 38 students, 30 women and 8 men, with an average age of 25.45 years (SD = 7). At the end of the course, the students could respond on an optional basis to the request to comment on the training experience according to what they experienced during the pandemic. A thematic analysis was subsequently carried out on the texts, which made it possible to identify the most relevant thematic areas for the students. The qualitative analyses permitted recognition of three main forms of discovery: the removal of death in contemporary culture; the importance of community, ritual and funeral, and spirituality; and the significance of death education for future health professionals. The texts have highlighted how the removal of these issues exposes people to the risk of being unable to handle extremely painful events such as those related to dying. The results show the positivity of death education pathways conducted at the University level to help students reflect on these issues and manage the related anguish.

A Challenge for Palliative Psychology: Freedom of Choice at the End of Life among the Attitudes of Physicians and Nurses

This article considers a particular aspect of palliative psychology that is inherent to the needs in the area of attitudes concerning Advance Healthcare Directives (AHDs) among Italian physicians and nurses after the promulgation of Law No. 219/2017 on AHDs and informed consent in 2018. The study utilized a mixed-method approach. The group of participants was composed of 102 healthcare professionals (63 females and 39 males). The quantitative part utilized the following scales: Attitudes toward Euthanasia, the Religious Orientation Scale, the Balanced Inventory of Desirable Responding, and the Testoni Death Representation Scale. The results were mostly in line with the current literature, especially concerning a positive correlation between religiosity and the participants’ rejection of the idea of euthanasia. However, the qualitative results showed both positive and negative attitudes towards AHDs, with four main thematic areas: “Positive aspects of the new law and of AHDs”, “Negative aspects of the new law and of AHDs”, “Changes that occurred in the professional context and critical incidents”, and “Attitudes towards euthanasia requests.” It emerged that there is not any polarization between Catholics or religious people and secularists: Their positions are substantially similar with respect to all aspects, including with regard to euthanasia. The general result is that the law is not sufficiently understood, and so a quarter of the participants associate AHDs with euthanasia. Discussions on the opportunity for palliative psychologists to help health professionals to better manage these issues through death education courses are presented.

A Systematic Review of Barriers and Facilitators to Implementing Assisted Dying: A Qualitative Evidence Synthesis of Professionals' Perspectives

Assisted dying is a divisive topic and draws both lamenting and approving commentary from political, medical, legal, and philosophical domains. This systematic review and qualitative evidence synthesis aims to identify the factors that healthcare professionals experience when working within assisted dying frameworks. PRISMA guidelines for systematic reviews were followed. Search results yielded 15,426 papers with 39 papers meeting inclusion criteria for this review. Remaining papers were subjected to critical appraisal and a thematic synthesis. Eight themes fell under the domain of 'barrier' and represented different personal and professional factors that hinder professionals from delivering assisted dying healthcare. Five themes came under the domain of 'facilitators' and represent factors that contribute to the smooth implementation and delivery of assisted dying services. Health professionals experience a range of factors that both impede and propel delivery of assisted dying frameworks.

Do men and women with intellectual disabilities understand death?

BACKGROUND

Individuals with ID are often withheld information about the death of their loved ones as it has often been thought that they do not understand death or cannot grieve. This grief exacerbates the stress of individuals with ID as they often encounter secondary losses such as transitioning to a care facility. The aim of this study is to investigate men and women with ID understanding death concepts and to what extent.

METHOD

Adopting a stratified random sampling method, 156 Chinese people with ID were invited to join the study. One hundred and ten participants were interviewed using simple death related vignettes expanding upon and replicating a published study carried out in Ireland. The understanding of the five death concepts: causality, irreversibility, nonfunctionality, universality and inevitability was examined. The correlates of demographics, bereavement experiences and comprehension were explored.

RESULTS

The majority of the participants did understand concepts such as death is irreversible and that the deceased no longer function. One third of the participants understood causality and the universality of death. One fifth understood the inevitability of death. Previous bereavement experiences were correlated with higher understanding. Communication and community skills were correlated with all concepts of death except universality.

CONCLUSION

The results indicate that individuals with ID do have a partial to full understanding of the concepts of death. The culture of Hong Kong is one that considers death to be a taboo or unlucky subject. Therefore, the results mirror the the lack of understanding of universality and inevitability concepts as it is forbidden to speak of these concepts. An open and honest environment is encouraged to educate individuals with ID about death and bereavement.

Using Zoom and Card Game to Conduct Advance Care Planning Classes: An Innovative Practice

BACKGROUND

This article demonstrates the innovative practice of using a card game to teach participants about Advance Care Planning (ACP) and palliative care in Thailand via Zoom during the COVID-19 pandemic.

AIMS

To assess the feasibility of using online workshops to conduct sensitive topics of palliative care and death and dying.

METHODS

The interactive online workshops were conducted after imposition of the COVID-19 restriction and national lockdown in Thailand between March and September 2020. The sessions were conducted via Zoom meetings and Facebook secret group. Trained facilitators plus one IT team member hosted each workshop. Participants were given an anonymous post-course evaluation with open-ended written feedback form. Content analysed was used.

RESULTS

Eleven sessions were conducted. 103 participants joined the online classes. Participants gave an overwhelmingly positive of the workshops, emphasising on: (i) convenient; (ii) social connectedness during the lockdown; (iii) bichronous element of the activities.

My Future: Psychodrama and Meditation to Improve Well-Being Through the Elaboration of Traumatic Loss Among Italian High School Students

This study was designed as an action research aimed to help students to elaborate their feelings of traumatic grief, due to a car accident and a suicide of two of their classmates, in an Italian high school. A death education project was realized in order to prevent the Werther effect. The intervention was based on psychodramatic techniques and meditation with Tibetan bells to encourage reflection on the suffering of traumatic loss, the sense of life, and their future. A total of 89 students from four classes (46 in the experimental group: two classes, 43 in the control groups: two classes) participated in the study, among which 82 (45 in the experimental group, 37 in the control group) completed the pre- and post-test survey. The intervention consisted of eight 2-h meetings, during which the themes of death and loss were dealt with through theoretical discussions, dramatization, and meditation. Two other classes which participated in the assessment as a control group did not attend the activities. The following instruments were used: Death Attitude Profile-Revised, which measures individual attitudes toward death; Psychological Well-being Scale, which measures a person’s psychological well-being; Resilience Scale for Adolescents, which measures the construct of resilience in adolescents; Self-Transcendence Scale, which measures self-transcendence; and Testoni Death Representation Scale, which measures the ontological representations of death. The results demonstrated that in the experimental group, there was a reduction in the fear of death and its avoidance, and that the students normalized the representation of death as something natural, thus improving their well-being. It is consequently possible to say that well-being is not simply the absence of suffering and worries, but rather, is rooted in the possibility of thinking of creative solutions to the trauma.