Category: Fear of Death

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Cancer patients often want ‘one more round.’

— Should doctors say no?

Studies show that when cancer returns, patients are often quite willing to receive toxic treatments that offer minimal potential benefit.

By by Mikkael A. Sekeres, MD

My patient was in his early 30s and his leukemia had returned again following yet another round of treatment.

He was a poster child for the recently reported rise in cancer rates in the young, and had just asked me what chemotherapy cocktail I could devise for him next, to try to rid him of his cancer.

I hesitated before answering. Oncologists are notorious for always being willing to recommend to our patients one more course of treatment, even when the chances of success are negligible.

One grim joke even poses the question, “Why are coffins nailed shut?” The answer: “To keep oncologists from giving another round of chemotherapy.”

This unflattering stereotype is unfortunately backed by data. In one analysis of patients with a cancer diagnosis treated at one of 280 cancer clinics in the United States between 2011 and 2020, 39 percent received cancer therapy within 30 days of death, and 17 percent within two weeks of dying, with no decrease in those rates from 2015 to 2019.

My patient had received his leukemia diagnosis five years earlier, and initially, following chemotherapy, his cancer had entered a remission. He and his parents were farmers from Latin America and relocated at the time to the United States to focus on his treatment. When the leukemia returned after a year, he underwent a bone-marrow transplant, and that seemed to do the trick, at least for a while.

But then it reared its ugly head a couple of years later, and we worked to slay it with yet more chemotherapy and another transplant.

That victory was short-lived, though, and multiple rounds of unsuccessful treatment later, here we were. The last course had decimated his blood counts, landing him in the hospital with an infection, a bad one that he had barely survived.

Does it help patients live longer or better?

Giving chemotherapy toward the end of life would be justifiable if we benefited our patients by enabling them to live longer, or live better. While that’s our hope, it often isn’t the case.

Other studies have shown that patients with cancer who receive treatment at the end of life are more likely to be admitted to the hospital and even the intensive care unit, less likely to have meaningful goals-of-care discussions with their health-care team, and have worse quality and duration of life.

Recognizing this, the Centers for Medicare & Medicaid Services has identified giving chemotherapy within two weeks of death as a poor-quality indicator that may adversely affect payments to hospitals. As a consequence, cancer doctors are discouraged from offering treatment to patients at the end of life, and can get in trouble with hospital administrators for doing so.

Despite the CMS measure, though, over the past three years the percentage of patients treated at the end of life hasn’t changed much, with one recent study actually showing an increase in patients treated.

Why do we do it? Perhaps optimism is part of our nature, and what draws us to a career in oncology. I focus on the positive, and that may actually help my patients. Other studies have shown that optimism in people with cancer is associated with better quality of life, and even longer survival.

And perhaps the data on giving chemotherapy close to a person’s last days on Earth, and the CMS quality metric, are unfair, and insensitive to the realities of how doctors and patients make decisions.

I stared back into the eyes of my young patient and then into those of his father, who was about my age. He looked kindly, with a thick, bushy white mustache, a red tattersall shirt, and work jeans. This man adored his son, accompanying him to every appointment, and always warmly clasped my right hand with both of his in thanks for our medical care — a gesture I felt unworthy to receive, given my inability to eradicate his son’s leukemia.

If our roles were reversed, how would I react if my son’s cancer doctor told me that the option for more chemotherapy was off the table, as CMS recommends, given the less than 10 percent chance that it would work, and the much higher likelihood that it could harm?

Wouldn’t I demand that the doctor pursue any and all means necessary to save my son’s life? Patients often do, and studies have shown that patients with cancer that has returned are quite willing to receive toxic cancer treatments that promise minimal potential benefit.

We discussed giving another round of chemotherapy, though I told my patient and his family that I was reluctant to administer it given the vanishingly slim chance that it would help. We also talked about my patient enrolling in a clinical trial of an experimental drug. And finally, we talked about palliative care and hospice, my preferred path forward.

“You’ve given us a lot to think about,” my patient told me as he and his family got up to leave, even smiling a bit at the understatement. His father came over to me and clasped my hand warmly, as usual.

But a couple of days later, despite how well he looked in clinic, my patient developed an infection that landed him in the intensive care unit. If I had given him chemotherapy, we would have blamed the treatment for the hospitalization.

But the cause actually lay with his underlying cancer, which had compromised his immune system, making him more vulnerable to infections. This time, my patient became sick enough that he decided enough was enough, and he accepted palliative care.

For many of my patients at the end of life who doggedly pursue that “one more round” of chemotherapy, a hospitalization becomes the sentinel event convincing them that the side effects of treatment just aren’t worth it anymore. It’s then no wonder people die so soon after their final treatment and time in the hospital.

It isn’t justifiable to give people with cancer chemotherapy when it is futile, just to be able to say “we tried something.” That’s what the CMS quality metric is trying to prevent. But in doing so, it shouldn’t interfere with a patient’s opportunity to come to that decision themselves.

Complete Article ↪HERE↩!

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3 Things to Do If You’re Terrified of Your Parent Dying

— If watching them age is causing dark-thought spirals, here’s what a psychologist recommends.

By Cathryne Keller

My deepest fears love to show up right as I’m trying to drift off to sleep—anxious brains are fun like that—and lately, a recurring theme in my after-dark intrusive thoughts is my mom dying. I’ve been straight-up terrified of losing her since I was a little girl (for a bunch of sad, childhood-trauma-related reasons I won’t hit you with here, this topic is dark enough already). But I haven’t been this anxious about it in years, and I know why it’s haunting me again: I’m watching her age.

She’s in her 70s now, and while she’s relatively healthy, active, and sharp (shout-out to my Wordle buddy), there’s no getting around the fact that her body is getting older, and she’s not going to be around forever. In other words, my formerly irrational fear of suddenly losing her isn’t all that far-fetched. And I know—from talking to other friends with older parents, listening to mental health podcasts like it’s my job, and using common sense—that my experience isn’t unique.

Parents are typically the first adults we attach to as babies and who we first rely on for survival, so of course the thought of them dying is going to bring up bone-deep, primal terror for a lot of us. And while an occasional “My parent is going to die!” freak-out might feel manageable, if that fear is regularly causing you to spiral (or, like me, lose sleep), it’s worth finding ways to manage it.

That’s why I asked Beverly Ibeh, PsyD, a therapist at Thrive Psychology Group who specializes in anxiety and grief, for her best advice on what to do if you’re overcome with anxiety and existential dread at the thought of losing your aging parent(s)—both so you (and I) can feel a bit better now and in the future.

Examine your underlying fears—and then fact-check them.

Often, our biggest fears stem from imagining the worst-case scenario instead of the likely one. “Feelings are usually never logical, so make sure to understand where your worries stem from, and then look into how based in reality they are,” Dr. Ibeh says. Yes, your parent(s) will die at some point, as we all will, but your anxiety about that fact likely comes from what you imagine will happen after they pass away, she explains—and fact-checking this fictional future can make it look less bleak.

If I question the root of my mom-death fear, I can see that it’s not just about the fact that I won’t be able to call, hug, or do crossword puzzles with her, but that, without her on the planet—the only person who accepts me fully, 100% of the time—I won’t be okay. The thing is, I don’t know that, because she’s still here. But I do have plenty of evidence to the contrary: I know that people have been losing their parents and surviving the grief since the beginning of time—and that I’ve gotten through other very dark, seemingly hopeless periods.

If you, too, are terrified you won’t be able to cope, take some time to think about (or write down) other losses you’ve survived in the past or personal strengths that make you resilient to prove yourself wrong, Dr. Ibeh recommends. Or maybe your underlying fear is more about losing emotional support. You can challenge that too: Think of other people in your life who you know you can lean on, and remember that you can talk to a therapist for help if you need it, she adds. Again, the idea here is to ask yourself what you’re really scared of, and then “follow the thread of anxiety-fueled what-ifs and answer them with logic and reasoning, using real-life solutions,” Dr. Ibeh says.

Focus on what’s within your control.

Once you get curious about your anxiety, you may also find that you’re worried about specific things you’ll miss about your parent (see: crosswords and hugs above) or logistical stuff, like their end-of-life wishes. That’s why, Dr. Ibeh says, it can also be helpful to ask yourself: “What meaning are you attaching to the loss of your parents as it pertains to how your life will change, and what is within your control now?”

Are you devastated by the idea of never hearing their voice or enjoying your favorite home-cooked meal that only they know how to make? Dr. Ibeh suggests starting to hold onto those special moments in the present, so you can rely on them in the future when you’re grieving. Maybe you can download some of their sweet voicemails or take more videos of them when you’re hanging out, for example, or ask them to teach you how to make their impossibly tender dumplings. There’s no way to replicate hugs, of course, but you can be mindful of savoring them now, so you can seek comfort in those memories when you miss your parent dearly, she says.

As for more practical matters, like what’ll happen to their possessions when they’re gone or their medical care and burial preferences, tackling them head-on is the best way to calm your fear, according to Dr. Ibeh. Ask them if they have a will, for example, or if they have strong feelings about leaving certain belongings to specific family members. If they don’t have an end-of-life plan, you can help them make one—the National Institute on Aging’s free Get Your Affairs In Order Checklist is a great place to start. (They can also consider buying a “Departure File” for $100 from Good to Go, which will help them document everything from what they want on their tombstone to the passwords for their social media accounts.) Having a game plan can ease your uncertainty and, therefore, your anxiety, Dr. Ibeh says.

Connect with them while you can.

“Anxiety takes us away from our present lives and keeps us ruminating about our future to the point that we may miss core memories that will help us keep the spirit of our loved ones alive in our minds and hearts,” Dr. Ibeh says. So when you start dwelling on losing a parent, it can help to think about how you’ll feel when they’re gone: Will you be glad you spent so much time obsessing about their death when they were still here? Or as Dr. Ibeh wisely puts it: “Is there a chance you’re missing out on the life in front of you by focusing on the life you’re afraid you will have in the future?”

If the answer is yes, she recommends “creating new memories with your parent that will outlast their physical presence”—maybe you plan a weekend getaway at a cozy cabin in the mountains if you both love to hike, or schedule a monthly call where you catch up and ask them about things you’ve always wanted to know, like what their college experience was like or how they got through their first big heartbreak. “You can also practice gratitude for the things you love about your parents and the relationship you share,” she adds.

Even if you’re not exactly close with them, focusing on the present is still the best move. If the relationship isn’t so great, you may want to think about how you can improve it (or come to accept it) now, so you’re not left with the weight of unresolved conflict when they’re gone, Dr. Ibeh says. That might mean setting boundaries so you can enjoy your time together while protecting your mental health or talking to them—and/or a therapist, if you don’t get anywhere—about your feelings so you can be more at peace.

I interviewed Dr. Ibeh two months ago and have been implementing some of her advice ever since. No, I can’t say that my mom’s eventual death never haunts me at night, or that my heart rate no longer kicks up when I think about it. But by challenging my fears with facts, trying my best to savor the best parts of our relationship (and accept the hard ones), and working on my anxiety in therapy (let’s be real), I now feel an underlying sense of peace that wasn’t there before. When that awful day comes, I probably won’t be okay initially, but I will eventually, because the things I’m most scared of losing (my memories, our connection, my sense of her) can never leave me.

Complete Article ↪HERE↩!

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Illness and death are facts of life

– Buddhism teaches us to be mindful but not fearful of it

‘It doesn’t take a deep understanding of Buddhism to acknowledge that sickness, old age, and death are inevitable facts of life.’

The art of developing a healthy relationship with our own mortality lies in neither avoiding the reality of suffering nor obsessing over it

By Nadine Levy

Over the last year, I have spent a lot of time eating pre-packaged sandwiches in hospital cafeterias. I often joke that those of us who are lucky enough to hit 35 will have at least one, if not multiple, serious health scares every year. At some point, however, we will face much more than a simple scare – serious illness can impact anyone, any time, with little notice.

As well as being a source of stress, pain and discomfort, unwanted health diagnoses have the radical potential to upend our lives and ignite burning questions relating to impermanence and human suffering which we may not have considered in the past. We may come face-to-face with our shared vulnerability for the first time – which was present all along – as well as the indisputable fact that we are all but one breath away from a health crisis or poor prognosis.

Working with our mortality in a meaningful way can be challenging. For one, we live in a death-averse culture in which comforting and life-affirming ways of thinking and talking about illness and death are rare. Further, the unprecedented nature of Covid-19, as well as an increase in self-diagnosis via the internet (“cyberchondria”), has been associated with an overall rise in health anxiety.

In the founding story of Buddhism, the historical Buddha, a sheltered 29-year-old prince, ventures out of his palace and for the first time encounters sickness, ageing, and death on the streets of what is now Nepal. These sights impact him in such a visceral and immediate way that he is compelled to relinquish his wealth and material comforts to enter a life of asceticism, contemplation, and reflection.

It doesn’t take a deep understanding of Buddhism to acknowledge that sickness, old age, and death are inevitable facts of life. Many of us know this intimately. However, we may not realise that the more we deny this truth and cling to a fantasy of perpetual health and youthfulness, the more we suffer.

This is not to dismiss our attempts at living a healthy lifestyle that prevents ill health. Indeed, moderation and cultivating physical and mental wellbeing are at the heart of Buddhist practice. Still, we face the cruel irony that even our best efforts to address risk factors through diet, exercise, and supplementation, often fall short. Mark Twain once said, “I take my only exercise acting as a pallbearer at the funerals of my friends who exercise regularly.”

On my first overseas trip as a child, I witnessed individuals with debilitating and treatable illnesses in plain sight. One afternoon, I went to a cafe for lunch and couldn’t swallow my sandwich. As hard as I tried, I could not force the muscles in my throat to perform their job. There was a lump in my throat that persisted. The sharp edges of the human condition had suddenly shifted from theory to reality.

I encountered Buddhism a few years later and I was relieved to find an approach that did not look away from what was true: the body deteriorates, decays, and changes. It is made up of the elements and is of the nature to sicken, age, and die. While death is certain, the time of death is uncertain. Do not turn away from your mortality.

Later, I downloaded an app that reminded me daily I was going to die, though I’m not sure I needed the reminder.

Was this a type of exposure therapy that would liberate me from my worst fears, or was it simply making my anxiety worse?

Years later, I confided in a Buddhist teacher about my ongoing health anxiety, and he said something that changed the way I now view the Buddhist practice of death contemplation: the art is not to be anxiously fixated on death but simply mindful of it. The invitation was to extend a gentle and curious gaze to our fear of death itself. This seems a subtle point, but one that has enormous significance.

First, it invites us to bring awareness to how we relate to and perceive our impermanence. What is it that scares us exactly? The psychotherapist, Irvin Yalom talks about death and health anxiety being a placeholder for a range of natural existential concerns – from fear of pain, loss, and separation from loved ones to terror of our ultimate annihilation. At times, it correlates with deep disappointment that our life has lacked meaning or purpose.

Once we become familiar with what “health” or “death” represent in our unique psyche, we can bring attention to when and how these fears present themselves. Do particular sensations, memories, or emotions trigger these fears? Are they felt predominantly in the body or in a mind that races and tries to fix and control? Do you find yourself reaching for your phone? Instead, can you remain in the here and now, with a racing heart, lump in your throat, images of a poor prognosis, or your final breath? Can you stay put and allow the fears to arise, change, and dissipate? The practice is to avoid the extremes of obsessing about the finitude of our life on the one hand and avoiding our mortality on the other. Acceptance and wisdom lie in the place in between.

You and I will die. Can we stay steady in our seat knowing this with certainty, while remaining open to a broader indescribable mystery which may well outperform our wildest expectations?

Complete Article ↪HERE↩!

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Thanatophobia

— Or the Fear of Dying, May Prevent You From Actually Living

BY Mara Santilli

Despite the best efforts of the death positivity movement, most people do not have a good time going to wakes or memorial services, and that’s completely normal. But for others, the thought of death—whether it’s a loved one dying or themselves—sparks intense fear and panic. “Fear is a natural and important human emotion,” says Mitchell L. Schare, PhD, ABPP, director of the Hofstra University Phobia and Trauma Clinic. But sometimes that fear of dying can be taken to extremes. “When it becomes inhibitory to living life, it becomes a phobia,” says Dr. Schare. Specifically, that phobia is known as thanatophobia, or the intense fear of death and dying.

“Fear is a natural and important human emotion. When it becomes inhibitory to living life, it becomes a phobia.” —Mitchell L. Schare, PhD, ABPP, director of the Hofstra University Phobia and Trauma Clinic

Thanatophobia (also called “death anxiety”) can be considered the “master fear,” says Dr. Schare, since so many other phobias—from fearing spiders to airplanes to illness—can be traced to a fear of death. But as with any kind of phobia, thanatophobia is more serious than just a distaste for thinking about death. It can cause avoidance of anything that might theoretically lead to death or situations in which family members or friends are dying.

There’s so much to unpack when it comes to thanatophobia. Here’s what you need to know about the fear of death, where it comes from, and how someone can cope with thanatophobia.

Is thanatophobia a mental illness?

Like other specific phobias, thanatophobia is considered a type of anxiety disorder1. According to the DSM-5-TR (aka the Diagnostic and Statistical Manual of Mental Disorders, the tool mental health professionals use to make diagnoses), a phobia is a “marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).” For people with phobias (like thanatophobia), their fear or anxiety is way greater than the actual danger they face from their phobia, they go to great lengths to avoid it, and it cannot be explained by another mental health disorder.

Because thanatophobia is a type of anxiety disorder, mental health professionals will apply some of the same techniques used to treat anxiety disorders, such as cognitive behavioral therapy (CBT). (More on that in a bit!)

How common is thanatophobia?

There’s not a ton of data available on the general population, but an estimated 3 to 10 percent of people experience thanatophobia, according to the Cleveland Clinic.

Interestingly, research suggests that the prevalence of death anxiety changes with age in unexpected ways. One 2007 paper published in the journal Death Studies found that death anxiety spikes in young adults in their early ‘20s2, and then dips off. It also found that in women (but not men), death anxiety surges again in their ‘50s. While you might assume that older adults might have more fear of death (because they’re, you know, closer to the natural end of their lives), other research suggests that elderly patients have lower levels of death anxiety3 than their children.

What are the symptoms of thanatophobia?

“Thanatophobia [symptoms] can vary in prevalence depending on cultural, personal, and situational factors,” explains clinical psychologist Alexander Alvarado, PsyD, phobia specialist at Thriving Center of Psychology. Here are some of the common emotional and behavioral symptoms of thanatophobia:

  • Obsessive thoughts, including checking things constantly about your health and well-being (or that of your loved ones)
  • Avoidance behaviors around death or potentially dangerous situations (like refusing to drive or fly in airplanes, for example, out of fear of fatal accidents)
  • Severe anxiety (like feelings of dread, panic, etc.) when thinking about death. This might manifest as physical symptoms of anxiety in the form of heart palpitations, dizziness, chills, nausea, shortness of breath, etc.

This might seem a bit confusing initially; isn’t everyone afraid of dying, at least a little bit? “Having some degree of a fear of death can be functional—it might make you drive more carefully, or take extra care of yourself when you’re sick, so you can live a better quality of life,” says Dr. Schare.

But the tipping point into death anxiety can be how the anxiety manifests. Being so afraid of being in any situation that could involve death (no matter how remote the possibility) that you isolate yourself and never go out is likely closer to thanatophobia, Dr. Schare says as an example.

What causes thanatophobia?

As with any type of anxiety disorder, thanatophobia doesn’t always have a clear-cut cause. But experts believe there are some risk factors or potential triggers worth knowing.

A history of trauma or mental illness

“There isn’t a clear medical cause of thanatophobia, but it’s believed to be related to existential concerns and possibly a history of trauma,” says Dr. Alvarado. The trauma history could be related to significant life changes, such as a personal illness or near-death experience. (This could explain, for example, why nurses and emergency-services personnel had very high levels of death anxiety4 during the early years of the COVID-19 pandemic.) It’s also more likely to be prevalent in people who have a history of anxiety disorders.

Loved ones dying early

People who have experienced the death of a loved one, especially if they did not have a thorough understanding of death at that time, could be susceptible to developing thanatophobia, says clinical psychologist Tirrell De Gannes, PsyD, anxiety disorder specialist at Thriving Center of Psychology. It might be more pronounced for people who have an over-reliance on loved ones, he adds, and therefore fear what could happen if that person were to die.

Religious, spiritual, or philosophical beliefs

People have different religious, spiritual, and philosophical outlooks on death and what the aftermath of that process might look like, says Dr. Schare, whether that’s a spiritual “better place” that someone believes in, or a rebirth. Those beliefs might moderate the fear in some respects, he adds.

Other times, people believe in none of the above, and that doesn’t mean that they automatically have thanatophobia. It’s just that the fear of dying could be more pronounced if people emphasize the “unknown” aspect of what happens after death.

Interestingly, a 2017 meta-analysis published in the journal Religion, Brain & Behavior found the people who were least likely to have death anxiety were the atheists and the extremely religious5. “It may well be that atheism also provides comfort from death, or that people who are just not afraid of death aren’t compelled to seek religion,” said the researchers in a press release.

How is thanatophobia diagnosed?

If a mental health professional suspects you could have thanatophobia, or any phobia, the diagnosis involves clinical interviews. The therapist will ask you questions to assess how your fear (and its symptoms) impact your life, Dr. Alvarado says. They will take notes on how much death is a focus, adds Dr. De Gannes, whether or not the person has any sense of relief, and whether or not it affects their behaviors, such as isolating from other people or not participating in activities that could be a risk of injury or illness.

How is thanatophobia treated?

As with other specific phobias, thanatophobia is often treated with CBT. This research-backed practice will help patients challenge and change their negative thought patterns around death, says Dr. Alvarado.

Exposure and response prevention therapy (ERP) is a specific type of CBT that is commonly used with phobias. The goal is to help someone learn to manage their phobia by getting exposed to it gradually in a safe, controlled setting. “The goal is to reduce avoidance behaviors, and potentially introduce mindfulness practices to help cope with existential concerns,” adds Dr. Alvarado. No, this doesn’t involve seeing a dead body in therapy or something. Dr. De Gannes says a therapist might try the following exposures instead: talking about the topic of death, practicing having an end-of-life conversation with a loved one, and/or imagining consequences after the death of a relative.

ERP has varying intensities and styles, says Dr. Schare. It can be very literal, done in real-world environments. Think: a therapist taking someone who is afraid of bridges on a walk over a bridge, and speaking with them afterward to recap what happened and help the person understand that they are safe, he explains. Exposure therapy can also be done in virtual reality or imaginary environments, where the person, guided by a mental health professional, enters a scenario in which they could have a near-death experience, allowing them to confront that anxiety around it head-on.

Coping with thanatophobia

It is possible that the fear of life gets more pronounced with age, as people start to have more prominent health issues and start to become closer to death, says Dr. Schare. But the bottom line is that phobias and anxiety disorders can be cured, he says. The cognizance that you and your loved ones will die at some point does not go away, but people can become better equipped to cope with it.

Some coping strategies can include daily mindfulness, meditation, and journaling to help you stay present and focused on the here and now, as well as to process the fears, suggest Dr. Alvarado. You also might find relief and some additional coping skills from talking to other people in support groups about phobias, and of course from individual therapy.

Avoiding death and anything to do with it is not the most helpful way to cope with thanatophobia. “Shying away from the topic of death only increases the mystery and fear of it,” says Dr. De Gannes. He emphasizes that it’s important to normalize the concept of death in conversations to demystify the fear and help you continue to live your life.

Complete Article ↪HERE↩!

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Terror Management Theory

— How Humans Cope With the Awareness of Their Own Death

By Cynthia Vinney, PhD

Terror Management Theory (TMT) suggests that human beings are uniquely capable of recognizing their own deaths and therefore they must manage the existential anxiety and fear that comes with knowing their time on Earth is limited.

The theory was developed by psychological researchers Jeff Greenberg, Sheldon Solomon, and Tom Pyszczynski, who published the first TMT article in 1986.1 They based TMT on the writings of Ernest Becker, who spoke of the need to protect against the universality of the terror of death.

In this article, we’ll review key concepts of TMT, look at empirical evidence in support of TMT, explore real-life examples of TMT, and discuss how it is used across different fields.

Key Concepts and Principles of Terror Management Theory

Terror Management Theory explains that people protect themselves against mortality salience, or awareness of one’s own death, based on whether their fears are conscious or unconscious.

If they’re conscious, people combat them through proximal defenses by eliminating the threat from their conscious awareness. If they’re unconscious, distal defenses, such as a sense of meaning, like cultural worldviews, or value, like self-esteem, diminish unconscious concerns about death.2

Cultural worldviews and self-esteem are key concepts of TMT. They are both central to protection against mortality salience. David Tzall, PsyD, a licensed psychologist in New York, notes, “TMT suggests that individuals gravitate towards and defend their cultural worldviews more strongly when confronted with thoughts of mortality.”

Through cultural worldviews, people can achieve literal or symbolic immortality. Literal immortality, the idea that we will continue to exist after our death, is usually the domain of religious cultural worldviews. Symbolic immortality is the idea that something greater than oneself continues to exist after their death, such as families, monuments, books, paintings, or anything else that continues to exist after they’re gone.

TMT suggests that individuals gravitate towards and defend their cultural worldviews more strongly when confronted with thoughts of mortality.

Self-esteem plays a significant role in TMT too. “When faced with the awareness of death,” Tzall says, “people often engage in activities or behaviors that boost their self-esteem as a way to manage the anxiety associated with mortality.” In so doing, they provide the sense that they are a valuable participant  in a meaningful universe.3

These have led to two important hypotheses in TMT. First, the mortality salience hypothesis says we have negative reactions to individuals from a different group, called “outgroupers,” who present a threat to our group, and have positive reactions to those who represent our cultural values, referred to as “ingroupers.” Second, the anxiety-buffer hypothesis says strengthening our anxiety-buffer by, for example, boosting self-esteem, should reduce the individual’s anxiety about death.4

Review of Empirical Evidence Supporting Terror Management Theory

There are over 500 studies conducted in countries around the world supporting TMT. For example, one study found that raising self-esteem reduces anxiety in response to images of death.5 Similarly, increasing self-esteem reduces the effects of mortality salience on the defense of one’s worldview. When the researchers provided positive personality feedback instead of neutral feedback, their preference for a US-based author was equivalent to that of the control group, whereas participants who received neutral feedback far exceeded the control group in preference for the author.6

Another study found that worldview threats increase accessibility of death thoughts. When Canadians were exposed to a website that either derogated Canadian values or Australian values, they had far more thoughts about death when they encountered the anti-Canadian information.7

Real-Life Examples Illustrating the Application of Terror Management Theory

There are many ways that terror management theory can be applied to real life. Tzall provides some examples, such as “religion where religious beliefs and practices offer explanations for life’s meaning, purpose, and what happens after death. People will turn to religion to alleviate existential anxiety and find solace in the idea of an afterlife.”

Believing in religion may provide a chance at literal immortality, but beyond that, it can provide a cultural worldview that brings meaning and purpose to life and can alleviate mortality salience.

Likewise, Tzall gives the example of belonging to a nation that “provides a sense of identity and belonging, which can help individuals feel connected to something enduring. People may strive to achieve success, create meaningful relationships, or contribute to society in ways that leave a lasting impact.” There are all sorts of ways that people can find meaning and achieve symbolic immortality, including being part of a nation that will go on after their death.

In addition to feeling like a part of the nation, people will want to put their own stamp on the nation whether through success in industry, meaningful relationships that have a lasting impact, or other options like volunteering, having a family, or writing a book.

Implications of Terror Management Theory across Different Fields

Different fields can use TMT in different ways. For example, the most obvious may be the field of therapy and counseling. As Tzall explains, “TMT sheds light on how individuals’ psychological well-being, self-esteem, and behavior are influenced by thoughts of mortality.” Tzall continues, this “can help therapists understand existential anxiety and develop strategies to address it.”

The theory can similarly be used in marketing and advertising, but the emphasis is different. “TMT can inform advertising strategies that tap into consumers’ desires for symbolic immortality,” Tzall says. In this conception, marketers and advertisers advertise goods or services in a way that communicates their desire for symbolic immortality can be met.

Similarly, political science “can help explain the polarization of political ideologies,” explains Tzall, “and the ways in which leaders appeal to their followers’ existential concerns to gain support.” Through cultural worldviews that appreciate others like them but reject others that are not like them, leaders can exploit their followers and even lead them to rise up against others that do not agree with them, in wars, conflicts, or events like January 6th, where a small group of like-minded citizens stormed Congress.

Significance of Terror Management Theory in Understanding Human Behavior and Beliefs

Though some studies about TMT have failed to be replicated, Terror Management Theory has continued to resonate with many people. And researchers still use it to describe various events.

For example, a group of researchers used TMT to detail the COVID-19 pandemic during its height, explaining that regardless of how deadly the virus is, the risk of dying was highly salient.8 As a result, in response to the pandemic, people responded to the constant fear of death in both proximal and distal ways.

In proximal ways: drinking and eating in excess to arguing that the virus isn’t nearly as lethal as health experts claim. And in distal ways: affirming an individual’s cultural worldview to maximizing one’s self-esteem, in line with the TMT literature. As threats that remind us of our own deaths continue and expand, TMT will continue to be a leading source of understanding human behavior and beliefs.

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Deadass Podcast’s host Bryan Perry on mission with Nicholas Smithson to talk about death openly

Deadass Podcast host Bryan Perry (left) talks with Nicholas Smithson openly about death.

By Jasmine Hines

When Nicholas ‘Nicko’ Smithson was diagnosed with stage 4 cancer, he would lie awake at night terrified of dying.

The tradesman spent years labouring in the sun and was diagnosed with melanoma when he was 38 years old.

He was given just six months to live.

“I was quite petrified of whether there was life after death,” Mr Smithson said.

“They didn’t catch it (the cancer) in time … it spread throughout my entire body, my bones, my liver, everything like that.”

Mr Smithson, who lives in Rockhampton in central Queensland, underwent intense immunotherapy and two years later is in remission.

A man with brown hair, a mustache and arm tattoos lies in a hospital bed
Nicholas Smithson at a hospital in Brisbane.

He has teamed up with his best friend, Bryan Perry, who owns a crematorium business to help demystify and start the conversation about death through their Deadass Podcast.

In denial about death

Leading palliative care researcher Adjunct Professor Elizabeth Lobb said Australians live in a “death-denying society”.

A close up headshot of a woman with short brown hair smiling
Elizabeth Lobb says it is important for people to talk about their feelings after a diagnosis.

She has spent 28 years of her life dedicated to the psychological impact of oncology, palliative care and grief.

She said people avoid the topic because it is confronting and people fear the unknown.

“It’s not something that we talk about, [but] certainly when someone receives a diagnosis of cancer, it’s one of the first things that comes into their mind,” Dr Lobb said.

She said when you did not know how to respond or help those with life-limiting diagnoses, the first step was to give people a chance to talk about their feelings.

“I often say to family members that sometimes words aren’t needed, it’s just important to listen, we can’t solve this,” Dr Lobb said.

“People who are facing a life-limiting illness can become very isolated and it can be lonely because no one wants to talk about it.”

Sharing eulogies

Mr Smithson, now 40, works for the podcast creating digital content and has been featured in episodes to share his life story, or “eulogy”.

He has been warned by health professionals that his cancer could return, and he has decided he will not seek further treatment because of the harsh impact on his body.

a man with brown hair, a mustache and blue eyes is in front of a microphone
Mr Smithson has shared his story with the podcast.

Mr Smithson said the double doses of immunotherapy led to ulcerative colitis, and his colon had to be removed.

He said working on the podcast has helped him come to terms with death.

“It’s kind of shed a bit of light and helped ease the anxiety a little bit of, if it does end up happening, I’d be OK with that,” he said.

Mr Perry, who hosts the show, said he wanted a platform to share his mate’s story, as well as other people’s eulogies before it was too late.

“We were contemplating his own mortality and discussing some of the things we’ve done together over the years and taking the opportunity to record those memories,” Mr Perry said.

“The intentions were to either keep those or to share them and even potentially have his own funeral.”

A man with facial hair and tattoos smiling bending down and posing with his medium sized white dog
Mr Perry spends so much time with death, he even named his dog Rigor Mortis.

Preparing for death

Mr Perry, who has worked in the funeral industry for more than 20 years, said people were hesitant to think about death.

He urged more people to think about it practically.

“Jot down what you want, put down what sort of songs you want, where you want to have it,” he said.

“It’s just peace of mind for the people that you’re leaving behind so that when your time does come, the family knows exactly what you want and it just lessens the burden for them.”

A man with facial hair and tattoos looks at a casket. There are stacks of caskets in the background
Mr Perry says he wants to capture more people’s eulogies while they’re still living.

Dr Lobb said not everyone was able to communicate their final wishes but she recommended those who could to consider their financial affairs and where they want palliative care to take place, whether it be at home or in a hospital.

“There’s no right or wrong and it’s very individual,” she said.

“Yes, it is devastating, it’s overwhelming, but not necessarily as fearful as [it’s] perhaps being portrayed.”

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Psychedelics gave terminal patients relief from their intense anxiety

— End-of-life cancer patients in a therapy group in Canada used psilocybin to reduce their fears. It helped some find peace.

Valorie Masuda, left, Gail Peekeekoot, center, and Barb Fehlau participate in a grounding ceremony for staff members at Roots to Thrive, a wellness center in Nanaimo, British Columbia, in August.

By Meryl Davids Landau

When Brian Meyer received a Stage 4 prostate cancer diagnosis three years ago at age 62, he was determined to make the most of his remaining years. He immediately retired from a decades-long career in the grocery business and took every opportunity to hike, camp and — his all-time favorite — fish for salmon. Brian and his wife, Cheryl, regularly visited their two grown children and three grandsons and spent time with their many friends.

But it was sometimes hard to keep his mind off his pain and the reality that life was nearing an end. “It tugs at the heart all the time,” Meyer, from Vancouver Island, British Columbia, said in August. A calm person by nature, he found his anxiety skyrocketing.

By November, though, despite a new, highly aggressive liver cancer that shrank his prognosis to months or weeks, Meyer felt calm much of the time. The prime reason: a 25-milligram dose of the psychedelic drug psilocybin he had taken several months earlier, due to a Canadian program being watched elsewhere for the emotional benefits it may offer people nearing death.

In mid-August, Meyer and nine other people with terminal cancers had gathered in two rooms, and there, lying on plush floor mats with blankets covering their bodies, their eyes covered by sleeping masks and music piped in over headphones, they swallowed the psilocybin capsules. The consciousness-altering drug, administered by the nonprofit Vancouver Island wellness center Roots to Thrive, set Meyer and the others on a six-hour journey of fantastical images and thoughts. The hope was that this “trip” would lead to lasting improvements in mood and lessen their angst around death. It was accompanied by weeks of Zoom group therapy sessions before and after, along with an in-person gathering the evening before for a medical clearance and the opportunity for participants and their spouses to meet in person.

Canadian health-care providers have been able to offer this otherwise illegal drug since 2022 when the country’s national health-care system began a special access program for certain patients with serious or life-threatening diseases. To date, 168 Canadians have been authorized to receive the drug under the program. Similar access is not available in the United States, because a terminal patient’s right to try experimental therapies excludes psychedelics, which are banned by the Controlled Substances Act. Oregon and Colorado are in the early stages of allowing psilocybin-assisted psychotherapy due to ballot initiatives passed in the states, but people who receive the drug there could be charged with a crime under the federal law.

Clinical trials assessing psychedelics for various mental health concerns tend to administer them to patients individually. But Roots to Thrive prefers to do it in groups. “The group process in psychedelic-assisted therapy allows for a shared experience that helps people realize they are not alone in experiencing difficult emotions, symptoms or challenging life circumstances,” said Pam Kryskow, the center’s medical director.

By the time Meyer swallowed the psilocybin capsule, he felt comfortable with his cohort. Some, like Christine “Cat” Parlee, 53, who has Stage 4 melanoma that has spread to her lungs and throat, had become friends. At a restaurant where Parlee, her husband, Cory, and Cheryl gathered before the in-person meeting, Brian and Cat shared their hope that the drug experience would be joyful and that it would subsequently enhance their peace of mind.

The day after taking the psychedelic, however, sprawled on a couch in the resort room Brian and Cheryl had rented for the week, Meyer couldn’t conceal his disappointment. Although he didn’t have a negative trip, two of the other participants were overwhelmed by the drug’s intense effects and spent the hours yelling for it to stop. This repeatedly pulled Meyer away from the intriguing images filling his mind, including sword-fighting in a medieval castle yard and cooking elaborate meals of lobster and lamb in a massive industrial kitchen.

His mental journey was also interrupted by having to urinate regularly, a symptom of his prostate cancer, although he was struck by the intense spiritual connection he felt with one of the facilitators, registered nurse Gail Peekeekoot, as she touched his hands to guide him to the restroom. “It was like she was me, I was her. We were one together,” he marveled.

Psychedelic journeys don’t always proceed as people anticipate, leaving some feeling dissatisfied immediately after, said Barb Fehlau, a palliative care practitioner on Vancouver Island and the medical facilitator in the room, who herself has pancreatic cancer. Regardless of the experience while the drug is active, though, psychological healing often follows, she said.

That was the case for Meyer. In addition to his enhanced calmness, he remarked in November that taking the drug seemed to have deepened the connection he felt toward the friends and family who had streamed into his and Cheryl’s home following his worsened prognosis. “I have a way more sensitive outlook. I feel more love toward people,” Brian relayed at the time. Three weeks later, in a hospital surrounded by more than a dozen family members, Brian died. “He remained calm, peaceful and joyful” to the end, Cheryl said.

Should psychedelics ever be legalized as medicine — the first, methylenedioxy-methamphetamine, or MDMA, to treat post-traumatic stress disorder was submitted to the U.S. Food and Drug Administration in December by the MAPS Public Benefit Corporation (now called Lykos Therapeutics) — people who might benefit most are those who have a terminal diagnosis, said Anthony Bossis, a clinical assistant professor of psychiatry at New York University.

Psychedelics do not alter the course of the person’s disease, but they can help make the remaining time more meaningful, Bossis said. He is co-author of a 2016 study of 29 cancer patients that found that a single dose of psilocybin significantly reduced depression and anxiety and “led to decreases in cancer-related demoralization and hopelessness, improved spiritual wellbeing, and increased quality of life,” the study reported.

Feeling a sense of connection to something larger than themselves, akin to what Meyer experienced with Peekeekoot, may be especially important, the study found. “After this experience, people often say, ‘I realized I’m not just my cancer. I’m not just this body. I’m something more enduring.’ This is a real gift,” Bossis said.

How psychedelics might change a person’s outlook is under investigation. One study with mice this past summer by Johns Hopkins University researchers found that the drugs reopen “critical learning periods” in the brain for months after their use. Mice studies don’t translate exactly to humans, but this finding suggests that psychedelics may cause people to be especially receptive to new ideas and ways of being.

Still, the research on psilocybin for those at the end of their lives is in the early stage, and whether the drug might prove harmful for some isn’t yet known. Roots to Thrive’s unpublished research surveying 20 people from its prior three psilocybin group sessions found many felt more positive, peaceful, lighter and less stressed. But four felt little to no change.

Cat Parlee, who participated with Meyer in the August session, had taken psilocybin two prior times at Roots to Thrive in the previous 18 months. While some people experience lasting transformation after taking the drug once, Parlee found that after six months her fears and anxiety would return.

Reclining on a comfortable hammock chair on their home’s back patio the day after Parlee’s August session, her husband, Cory, says the two have come to view the psyche as if it were a cookie with pieces bitten off around the edges. “The psychedelics help Cat find the missing pieces that make her more whole,” Cory reflected. “Psychedelics help you answer questions you may not know or give yourself permission to ask.”

Cat Parlee agreed. “Every time I’ve walked out of psychedelic medicine session, I feel like I’ve left weight behind — weight I’ve consciously decided I’m not going to carry anymore,” she said. This included the negative emotions she had felt toward her deceased mother and the people who badgered her to try the cancer “cures” they read about online. “A lot of energy was wasted on a lot of anger, a lot of sadness and a lot of guilt. I realized I don’t have time to waste on that anymore,” she said.

While many people might benefit from addressing psychological issues that impede their lives, the urge to confront such demons often intensifies when a person is given a few months or years to live, according to Shannon Dames, the founder of Roots to Thrive. Most of us operate under the illusion that we have time to change these things, Dames said. “When you’re at a place when you don’t have that perception of time, there’s a calling that’s really potent.”

About a month before his death, Meyer credited the psychedelic with reducing the discomfort he felt about dying. “I don’t want to say I’m excited, but I am very curious now,” he said. He realized the mushrooms had taken him to an unknown, altered world; death would do the same.

In Parlee’s case, her fear “was that there is nothing — just emptiness — after you’re dead.” During her second psilocybin trip, she watched herself swim in brightly lit, vivid waters amid an intense feeling of love. She was soothed by the sense that experience may be similar to the afterlife.

Since her August session, Parlee has also increasingly found pleasure in standing up for her needs, rather than always worrying about other people as she had previously done. “There’s one thing I want to do before I leave this world: It’s to know that I spent my last few years happy. One thing I can say right now is I don’t have any real regrets,” she said.

Then she took a deep breath and smiled. “I don’t know if I would have ever gotten to that place without this psilocybin journey.”

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