Based on the responses of the participants, three main thematic areas emerged: (1) changes following the death education intervention, (2) the usefulness of the death education intervention in terms of the elaboration of traumatic grief in the community, and (3) motivations to reintroduce the death education intervention..
Thematic area 1: Changes following the death education intervention
Some participants reported that the theme of death was not novel, as the traumatic grief that surrounding a student’s suicide had previously forced the community to ask questions about the issue of youth suicide. Caterina, one of the teachers, stated that “It was like seeing a person disappear overnight, not being able to convince oneself that everything was over. We feel that the person will return and that he/she has gone away only for a moment.”
The experience of reflecting upon the meaning of dying enabled an exploration of ontological representations of death, as elaborated upon by Andrea, one of the hospice nurses:
The course of death education allowed me, in the first place, to examine the ontological representations I had concerning death and, while reflecting upon them, to modify the most distressing ones. Initially, I saw death as something to avoid, something I preferred not to think about, that I preferred to cast aside, and now, instead, I am able to face the idea of death in a calmer way, I am able to speak about it, to mention it; I am able to accept death as, indeed, the conclusion of a path that is part of life. This allows me to act as a support for the patients’ relatives in the hospice and also as a support for my own relatives and friends.
For many of the hospice staff, understanding the meaning of the term passage and being able to question it was important, as Andrea emphasised:
I reconsidered my ideas of death, and now I do not consider death as the end of something but rather as a passage. The more I felt that death represented a crossing, the stronger I felt and the more my view concerning life changed too: the idea of life as a succession of experiences that were preserved after death also became stronger.
Lucio, one of the nurses, stressed:
My personal approach to the little things in everyday life has radically changed: I felt more enriched, just waking up in the morning and going to bed in the evening. I was definitely more aware of the fact that all the little things in life should be appreciated. As regards my approach to life, I certainly learned to transform my fear of dying into a desire to live.
According to Giancarlo, one of the teachers, the intervention gave him:
Participation in the project confirmed that death does not paralyze life, quite the opposite. I could explain this through this metaphor: there is a room, and there are two doors, or better, a revolving door, and life is exactly at the border of these two dimensions. So, I could say that the effect was that I became more aware of my own way of seeing life and death rather than actually changing the way I relate to life.
Some teachers reported that they perceived a change in their students concerning their way of seeing life: Michela, one of the teachers, affirmed:
The students understood that each moment and simple things like a hug or a smile to a person who was suffering, that is, being there, present, was beyond words. I could see that the kids had grown up: the narratives of other experiences made them feel much closer to one another and part of the great mystery of life.
The teachers reported that they experienced feelings they had not prior to their participation in the intervention. Giulio, another teacher, stated that he experienced a paradox:
Talking about the meaning of death, which is the last experience in human life before eternal life, has contributed to make more meaningful and truer my everyday life. In this way, I certainly learned to grasp nuances in life that perhaps I took for granted before. Because of this, I learned to value life itself even more.
There was a shift in how the community viewed the hospice (end-of-life care) and hospice staff after the death education project. Prior to the project, the hospice and hospice staff were surrounded by an aura of mystery and fear because of prejudice on the part of the community (i.e., social censorship). Giulio affirmed:
The general fear was of entering a sort of “factory of death.” When I proposed to visit the hospice, the students were full of prejudices that certainly came from what we, as adults, communicate to them, from the way in our society we talk about the hospice.
All the teachers stressed the usefulness of the intervention in overthrowing these prejudices, as Caterina affirmed:
The intervention has served to break down barriers, various prejudices concerning the hospice, and I must say I keep talking about it fondly; the idea of dying at the hospice, with all the people I love close to me, has made me rethink and revaluate the concept of this place, and now I see it as a place full of dignity. Before this experience, I knew nothing about the work of end-of-life professionals, I did not have any kind of experience in this field. I have often worked in close contact with people suffering and marginalized in the past, but I did not know there were personnel qualified in end-of-life care. And I must say I found this particularly impressive.
Giancarlo (teacher) affirmed:
The students had faith in this course and in the end, they changed their opinion, and they also talked about this experience at home and with their friends. Thanks to the themes addressed during this path, their fears and anguish declined. This allowed the students to delve deep into themselves and better understand their emotions.
Thematic area 2: Usefulness of death education for the elaboration of traumatic grief in the community
In relation to the elaboration of traumatic grief, almost all the hospice staff and the professors expressed the concept in very positive terms. Valeria, a psychologist at the hospice, affirmed:
There is a huge difference between being silent, as often happens after a suicide, and being able to talk about it, considering death as something natural. In the latter case, the elaboration of grief helps people draw on resources they need to face the situation and the distress, without isolating themselves, but on the contrary talking about grief at the community level offers support to all.
Fabio, a doctor, declared:
Talking about death can make us reflect upon the fact that death is part of life and that therefore it is not something obscene but rather something that is natural. It is important to intervene with a philosophical reflection concerning life, considering it a good that is not endless, but on the contrary available for a limited amount of time.
Many of the teachers also had a very positive view of the death education intervention. Rosaria stated:
A student of mine had suffered a great loss but, thanks to this intervention, he could go on with his life, elaborating on his grief, and this allowed him to get through it peacefully and calmly. This intervention was fundamental because it allowed us to understand that life, which ends with death, is made of steps that are very satisfying but also of other steps that are made of intense suffering. So, a life without suffering is not possible, but it is not necessary either; by eliminating loneliness and involving people in social relationships within the community, suicide can be prevented.
Matteo, a doctor in the hospice, expressed the following sentiments:
The course of death education could be reintroduced because from the palliative doctor’s point of view or from the point of view of the end-of-life care staff who are striving to create a network between themselves and the community, I think this is one of the most important and fundamental ways to change our culture concerning end-of-life care. It would be a Copernican revolution if we could improve the life quality and well-being of people and of community. This would certainly result in a more mature approach to death.
Among the nurses Lucio said:
Death education is useful because it means going back to our origins; in the past, indeed, when there wasn’t a very sophisticated health network, these paths to accompany people facing death were conducted at home, and therefore there was much more solidarity. A communitarian path would help rediscover what we already have inside of us, that is, the importance of accompanying a person right until his/her last instant of life. Thanks to these death education paths, there is a more welcoming atmosphere in the hospice, and the sense of responsibility towards the patients and their families increased, because we now operate in a cultural environment that needs to seriously deepen the themes of death.
The teachers’ declarations on the usefulness of death education at the community level appeared to be just as positive as those of the hospice staff. In some cases, they favoured a proactive approach, with some putting forward innovative proposals to facilitate death education in schools, parishes, and city squares. Antonio one of the teachers, affirmed:
It would be useful especially because of the psychological help the patients’ relatives could receive, but also because it would promote human growth: everyone could become aware of the fact that every one of us will one day live the experience of death.
Thematic area 3: Motivations to reintroduce the death education intervention
The psychologist Valeria declared that “The educational, pedagogical, and formative power inherent in this intervention might help people understand that sooner or later they will have to handle separation, loss, and illness.” According to Catia, who was the family liaison officer, a similar intervention should be proposed again:
From a professional’s point of view, it would help those who are part of the palliative care team, like us, to reformulate and reconsider our knowledge and competencies, as well as what we think we have learned, which can be questioned precisely thanks to the discussion with the students.
According to Rosaria (teacher):
On a personal level, I believe that an intervention like this one has a lot to offer because it allows the teacher to enter into a relation with other teachers, and it allows us to break through barriers with the students, so that we do not rigidly distinguish between the teacher and the student, and this is very worthwhile. I think it is a way to grow up together.
Both the teachers and hospice personnel reported that they believed that the students would welcome the reintroduction of the intervention. Catia stressed:
For the students, this is certainly an experience to repeat, especially at this age when it is important to start reflecting upon and facing the theme of life and death. Reintroducing this project in schools would also be helpful to us as professionals and as parents of adolescent children. I am really frightened by the idea that my children might not be prepared to face death-related events, which may be expected, sudden, or long and painful, like those often associated with a terminal illness.
Luisa, one of the teachers, affirmed:
It would be useful to repeat this experience because we have new students every year, and the intervention could create a cycle of events, with important outcomes. The students had an opportunity to experience something that few, if any, students have today in schools that is, the possibility deal in a serious way with these themes and to be able to approach them both as individuals and as a community.
Catia expressed the main strengths that should be maintained in a future intervention:
One of the main strengths was the multidisciplinary approach, which allowed that students to meet all the hospice staff, even those who might have marginal roles, such as administrative staff. Another strength was the possibility to engage with the students, to take the time to talk to them, and to allow their fears to emerge, together with their anxieties concerning the themes of death and dying. Not even the teamwork should be underestimated: everyone, with his/her own competence, tried to offer the best contribution possible.
According to the cleric Luigi:
The most meaningful part of the intervention was that the students had the opportunity to visit the hospice, which in the eyes of the community represents a place of death and therefore a place to avoid: this experience had a major emotional impact on the students; another important aspect was the interaction between students and different professional figures. In this way, a sort of osmosis occurred. Finally, another meaningful aspect was the contact with the young generation concerning a thematic area that is rarely directly explored.
According to Caterina (teacher), it was important that the intervention will be reintroduced:
The encounters with the psychologist were very important: the students, at first, found it difficult to open up, but then, thanks to the psychologist’s help, they managed to do so, and certain bad situations between students changed. What impressed me the most is that many of the kids chose me to talk about certain problems they had, or even to talk about their parents’ or grandparents’ relationship with death and suffering; what surprised me also was that we talked about death in class, whereas they usually asked me to talk about it outside of class time. Seeing kids who normally hang around in small groups all coming together was amazing.
Along the same lines, Giulio, a teacher, stated “Another positive aspect emerged concerning the capability to resolve certain critical situations that were present in the classes, like arguments and discussions, and it was possible to build more empathy among the students.”
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Finally, with respect the last confirmability phase, the results of all the analyses were submitted again to the participants, asking them whether they confirmed the findings. The answers were all positive and some of them suggested to add some considerations, as for example priest Luigi, who further emphasized this aspect: “The tests are going great. I confirm that the project has paved the way in the work of the hospice team for a new look of understanding palliative care and spiritual accompaniment.” Among the nurses, Maria affirmed: “Yes, all well and good, but I would like to stress more that here in hospice we were all amazed at the maturity shown by the students. They discussed with us and showed great depth of thought, despite their young age, and this was even more important, because it means that they really think about death even though no one seriously talks to them about it, and this course permitted them to reflect on this issue in a more profound way.” The teacher Giovanni said: “Yes, I absolutely agree, but I want to make some additions. It is very important to affirm that all the schools should realize death education courses, inserting them into the educational system in a structural and interdisciplinary way. In fact, I do not believe that only the spiritual dimension can help to manage death. Indeed, there are texts of great importance, but also theatrical, musical, pictorial works. Art also helps to manage anguish. We all need good and beautiful readings that enrich our language and the ability to give word to experiences of loss and mortality”. The teacher Francesco wanted to add: “I agree with everything, but now that I have the chance, I feel I still have something to express. The project has highlighted the relationship between love and death. Yes, love is what allows us to live but it is also what allows us to face the passage of death. Without love, death is unbearable. The project has therefore enhanced love and this aspect must be highlighted. I believe that the students understood first of all that those who do not love are already dead, those who love do not die. This is the synthesis of what we all understood together.”