33 (2).indd Anthropology & Aging Quarterly 2012: 33 (2) 44 Feature aging & anthropology in east asia probleM and purpoSe Notification that an illness is terminal evokes myriad feelings and desires, facing the reality of one’s mortality. Academic studies from philosophy, psychology, psychiatry and anthropology have addressed the ways patients and families deal with death. Freud’s (1917) research on the grieving process of the bereaved focused on severing of the bonds between bereaved family members and their departed loved ones. In recent years, Freud’s assertion of the importance of severing such bonds has been seriously challenged. More recent research has asserted that there is value in maintaining bonds with those who have passed (e.g., Klass, 1996; Neimeyer, 2002, 2004). A R T I C L E S A Japanese Terminal Patient’s Hopes for Connections Transcending Time Megumi Kondo-Arita, PhD Tenri Health Care University, Japan What is the meaning or value of the bonds between those approaching death and the ones they leave behind? Previous studies have asserted that the prospect of mortality induces anxiety-avoidance behaviors such as seeking a religious connection with God or emphasizing a prospective reunion with loved ones who have already died. (e.g., Shneidman, 1973; Kashiwagi, 1985; Kawashima, 2011). Yet little of this prior research has elucidated issues concerning the bonds between the dying person and those who will go on living. This article explores the spiritual questions some Japanese people pose, through the example of one terminally ill female patient. With the spread of the hospice movement in the 1970’s, “deathwatch” in medical facilities became a topic of Abstract Terminal cancer patients face not only issues unique to their diseases, but also issues rooted in their previous life experiences, including physical, social, psychological, and spiritual pain. This study focuses on the hopes of a terminal patient for “Continuing Bonds.” Much current research emphasizes the importance of “continuing bonds” for the health of bereaved families, but little has looked at the meaning of “continuing bonds” for dying patients themselves. I attended an elderly terminal cancer patient in a Japanese hospital, observing and conversing with her as she went through the process of examining her life and faith. The patient granted permission to record and share these observations to shed light on Japanese views of “death” and “life.” This research shows that Japanese face death not merely as personal issues, but in the broader perspective of continuing family bonds. Keywords: death, dying, bonds, self-esteem, transcendence Anthropology & Aging Quarterly 2012: 33 (2) 45 Megumi Kondo Japanese Terminal Patient’s Hope thanatology. Figures influential in this clinical practice included Saunders and Kübler-Ross (1969), who conducted research on dying patients in modern hospices and hospital wards. More recent research explored patients’ spiritual questions immediately before death (e.g. Tomer, 1994; Vickio, 1999). Spirituality has become an important concern in American and European palliative care. The word “spiritual” calls up a plethora of meanings and associations--but the English word “spiritual” does not have a direct translation in Japanese. The term is often translated into Japanese words such as “seishinteki” or “reiteki” reminiscent of the Greek “ethos” or “pneuma.” Spiritual questions are ultimate, fundamental, and existential questions connected to the passage of time and to interpersonal relationships (Murata, 1999a,b). Spiritual questions may be painful, threatening the meaning of, the purpose of, or hopes for life. Such spiritual problems cannot be readily remedied through mere association with a religion. How can caregivers or family help dying people resolve such questions, especially in modern secular culture? The concept of spirituality covers multiple meanings and interpretations. Kashiwagi’s Palliative Care Manual (1992) suggested that three types of spiritual questions for terminal patients include (1) self-esteem, (2) chronological existence, and (3) relational existence. The first type of spiritual question for terminal patients regards self-esteem. Patients’ physical conditions influence how they see their own existence. The progression of illness limits the patients’ Activities of Daily Living (ADL). Unable to function as they used to, their self-confidence and self-esteem decline. They may say, “My body has deteriorated so much; I can do so little now. There is no point in my continuing in this condition. I am just a useless burden.” As a result, they are forced to adjust their perception of themselves. The second type of spiritual question for terminal patients involves the passage of time. Nishihira (1993) applied Erikson’s developmental theories in his examination of children with muscular dystrophy, noting, “human development is an effort to live a life despite the awareness that people grow up only to die.” Similarly, terminal cancer patients cherish each moment. They look forward to the next moment, even though the passage of time means getting closer to death. Questions about “life” and “death” are intertwined in such people’s lives. Patients may say, “I know I am going to die anyway, so I want to die quickly. If everything is going to end anyway, there is no meaning to life any more. I am just wasting time waiting to die.” They become aware that they cannot avoid death. And this death awareness leads to a fear of disappearance, a loss of meaning, a feeling of emptiness. Their questions about the meaning of their remaining time impacts them psychologically. A third type of spiritual question concerns their relational existence. Some lose social roles when they resign work due to illness. Others lose social connections due to their hospitalization. They may say, “No one needs me. I can do nothing for anyone. Nothing will remain when I die.” They question their own worth in society and relationships. They become unable to see their self-worth in social contexts. Abundant research on the bonds between the deceased and their bereaved families has focused largely on how the bereaved families fare after losing someone. Klass (1996) introduced the idea of “continuing bonds,” refuting Freud’s (1917) theories of grief that had encouraged disconnection from the deceased. Klass emphasized the importance of the family members’ bonds with the deceased; he derived his idea of “continuing bonds” in part from his observations of traditional Japanese culture. In Japanese traditional arts such as Kabuki, the conferring of familial names on actors as they mature emphasizes the importance of blood relationships. Such relationships often provide hints for the spirituality of the dying and bereaved (Hattori, 2002; Furuido, 2008). Recent research (Stroebe, 2010) has substantially advanced our understanding of continuing bonds for the bereaved, and increasing emphasis can be seen on qualitative studies in this area (Asai, 2010; Wilson, 2011). However, these studies focus on the bereaved who are left behind, rather than on the role of continuing bonds for the dying patient oneself. Of course, these questions vary from individual to individual. People pose different questions depending on their previous environments and interpersonal relationships (Shneidman, 1980). For Japanese, spiritual questions are often understood to have multiple meanings about the meaning and future of their existence, not limited to their existence as individual entities, but also including interpersonal relationships with family, friends, and significant others. Japanese people tend to prioritize groups (e.g., family) over individuals (Watsuji, 1979; Hiroi, 1997, 2001), so their lives as patients, including disclosure of diagnosis, determining the treatment, and decision-making around death, are largely influenced by their notions of interdependence (Inoue, 1980; Ishizaka, 2006). Many Japanese studies report instances of terminally ill patients posing existential and spiritual questions (Kashiwagi, 1985; Kishimoto, 1996; Arita, 2006). The most Anthropology & Aging Quarterly 2012: 33 (2) 46 Megumi Kondo A Japanese Terminal Patient’s Hope frequent questions pertained to “existence after death,” which includes both social and spiritual connections with their family after their own death (Kondo, 2010). Questions associated with family bonds were more prevalent among Japanese than existential questions. Among many questions regarding death, people often wonder about existence after death, asking, “Where do we go after death?” and “What happens after death?” Some people with terminal illness have concerns about afterlife, often associated with religion and spirituality (cf. Kübler-Ross, 1988). This fear of death is not only about physical pain before death but also the existence or nature of the afterlife. How do people overcome this fear? Interpersonal relationships may suggest answers to life after death, to doubts about religion, and concern about an unfamiliar afterlife. In a Japanese social context, not only the possibility of a soul being reborn in heaven, but the possibility of being remembered or even reborn and again and loved on this level pose alternative hopes for post-mortem self-existence. This article shows the role of social interconnections and continuing bonds, focusing on a dying patient and her relationships with family and fellow patients. reSearch MethodS Interview methodology Many professional thanatologists learn about their lives of dying patients by spending time with and sharing feelings with their patients. Kübler-Ross became internationally known for her conversations with terminally ill cancer patients, while Glaser and Strauss (1965, 1988) became authorities of qualitative research methods by establishing the Grounded Theory approach. Participant observation and dialogue methods are commonly employed to study people during their terminal stages (e.g., Carverhill, 2002; Wright & Flemons, 2002). Participant observation in qualitative studies focuses on the dynamics of a dialogue between a participant and a researcher. The researcher inter-subjectively perceives the participant’s internal “thoughts” and “emotions” during the dialogue. Kujiraoka proposed that conscientious self-reflection on inner processes of the dialogue could enable the researcher to overcome merely subjective understanding of the participant’s world (Kujiraoka, 1998, 1999). Along the same lines, I have argued elsewhere that the primary requirement of qualitative research is to expose the researcher’s subjective experience along with the phenomenon presented by the participant. Researchers need to grasp the feelings and nuances that are “non-verbally expressed” (Kondo, 2010). Context and method In the early months of 2005, I did research at a palliative care unit of a general hospital in the Nagoya area of Japan. The palliative care unit had 19 beds in single rooms, and actively collaborated with other departments of the hospital to meet the needs of the patients and their families. I conducted many 90-minute interviews with terminal patients. While I accompanied a primary physician on his morning rounds, I met all the patients in the palliative care unit. The primary care physician introduced me as a graduate psychology student who was researching to improve psychological care at the palliative care unit. The primary care physician explained that I would ask questions as a part of her study; and that our conversations would be voluntary and not a part of their treatment. Then I asked each patient individually whether they would agree to participate in this research. I made scrupulous notes after each interview with cooperating patients, and later attempted to reinterpret them conscientiously based on Kujiraoka’s principles. I analyzed our dialogues, making observations on our interpersonal relationships, and on my own subjective experiences that illuminated my interactions with the participant (Kondo, 2010). I encouraged the patient/participant to share her thoughts about “daily life” and “recent thoughts,” rather than using a structured interview script. This method was modeled after Shneidman’s (1980) research on a dialogue with a terminally ill patient. I employed an unstructured interview in order to explore the participant’s psychological conditions that varied daily. I transcribed the conversation after the interview with the permission of the participant. The primary care physician, the primary nurse, the participant’s family, and the participant herself all reported on her physical and psychological conditions. The participant’s discussion of “self-existence” was extracted and analyzed using an “interactive-observational” interview. The context of the conversation was also considered. Ethical considerations The hospital Institutional Review Board (IRB) approved this research study. I cleared all interview protocols and procedures with the primary care physicians and nurses, as well as the hospital IRB. Each patient was given detailed verbal and written explanations of the purpose of the study, the use of the interview materials, and waiving of confidentiality. Patients who agreed to Anthropology & Aging Quarterly 2012: 33 (2) 47 Megumi Kondo A Japanese Terminal Patient’s Hope participate signed the consent forms allowing the sharing of all their interviews. I discussed the patients’ conditions with their primary care physician and nurses immediately before each session, so each session was conducted with consideration to the patient’s reported conditions. With the patient’s permission, the transcribed contents of these sessions were also shared with the physician and nurses, in order to further improve their care. Background of the case study The case study presented here involved 14 interviews with a 69-year-old patient whom I shall call “Kikyo,” dying of rectal cancer which had metastasized to her lungs. Kikyo had already lost her parents and husband, but had a married son and two married daughters. Her elder daughter was a nurse who served as her key caregiver during her hospitalization. Kikyo had undergone an operation for rectal cancer in July of 2000, followed by removal of the inferior lobe of her right lung in July of 2001. In December of 2004, she was hospitalized for chemotherapy, but she was already aware that she was terminal. A friend at her previous hospital had told her about this palliative care unit, so in Japanese style, Kikyo requested her previous physician to write a letter of recommendation to be transferred to this palliative care unit. At Christmastime of 2004, she was admitted to the PCU where she remained until her death on February 26, 2005. She was glad to be admitted, but sad to acknowledge that her life was almost over. Her active decision-making in requesting placement to the PCU was atypical of Japanese who tend to be less proactive or self- assertive. I conducted 14 90-minute interviews during the last seven weeks of Kikyo’s hospitalization in the PCU. I encouraged Kikyo to share her “recent thoughts” about “daily life.” Rather than using a structured interview script, I employed unstructured interviews to explore Kikyo’s varying psychological condition. The content of these interviews, while overlapping, can be loosely divided into (1) Spiritual Issues, (2) Physical Issues, and (3) Psychological Issues, which are introduced in the order in which she confronted them below. Each of these issues is totally permeated by a social consciousness which cannot be separated from them. dialogueS with KiKyo (1) Spiritual iSSueS: reincarnation within the FaMily Kikyo had resided in the PCU for two weeks when I first met her, accompanying her primary physician on his morning rounds. Kikyo had so much fluid in her abdomen that she looked pregnant, but other than her abdomen and swollen legs, she was emaciated. At their first meeting, Kikyo was quiet, answering the physician’s questions calmly, displaying none of the physical or emotional pain that many patients do. She neither welcomed nor rejected the doctor’s inquiry about participating in my research study. Three days after our first meeting, I asked Kikyo if she wouldn’t mind participating in some interviews. When she agreed, I made an appointment to see her again, precisely a week after their first meeting. Each time prior to seeing Kikyo, I consulted Kikyo’s nurse to ensure the interview would not be too stressful for Kikyo. When I entered Kikyo’s room on the day of their appointment, Kikyo was massaging her feet with an electronic massaging machine, as she often did in the afternoon. She welcomed the author, offering her a chair the moment she entered the room. When I asked, “Does massaging your legs help?” Kikyo smiled for the first time and answered, “Not really. But my physician recommend this machine, so I use it.” The tone of her greeting and their small talk during the first week made me feel that some rapport was developing. Since her grown children worked full time or were busy as homemakers, Kikyo was almost totally alone in the hospital, rarely having visitors. I started to spend time working on daily tasks with Kikyo in her hospital room. Little by little, Kikyo had shared some of her family history. Kikyo explained that her biological father had died of stomach cancer, while her husband died after fighting cerebral hemorrhages for five years. She herself contracted cancer while she was taking care of her husband. Kikyo had shown very reserved emotion during the first week, but after our first week of contact, she smiled at me and welcomed me. Whereas at first she had been close-lipped around me, Kikyo was completely different at the outset of these visits; she warmed to the conversation, readily sharing stories about her family. Kikyo welcomed my interest, and started to talk about events that occurred on the nights before my visits. She often talked about her dreams. For example, she had told her medical staff that she often dreamed of her deceased husband and her mother. She told me that she often woke up in the middle of the night, and she continued remembering the same dream after awakening for a while. In subsequent conversations, she spoke of her father, children, siblings, and mother-in-law. Kikyo talked about her family tree and her husband’s family tree, and visibly brightened when I took out a piece of paper to sketch them out in clearer detail. Kikyo asked me to obtain a copy of her family register in order to chart a more precise family tree. When she was discussing her father’s cancer, Kikyo started to talk about reincarnation within her family. I had no idea of the significance of this concept at that time, but I was happy to learn more about Kikyo’s past. Anthropology & Aging Quarterly 2012: 33 (2) 48 Megumi Kondo A Japanese Terminal Patient’s Hope Dialogue 1: Reincarnation within the family (February 2) Kikyo: Do you remember what I was talking about the other day (yesterday)? I was thinking that one family member’s death is connected to another family member’s birth. Could you draw a diagram for me? Author: Yeah, you suggested that when someone dies, someone else is born at the same time within your family. It is mysterious. Kikyo: Yes, mysterious. Author: Maybe we could trace those interconnections. Why don’t we diagram it some time? Kikyo: Yeah. I have been thinking about doing so. Observation Kikyo believed in a particular sect of Buddhism that respected family ancestors. Perhaps fearing that medical professionals would condemn her religiosity, Kikyo was somewhat hesitant to speak of “reincarnation” in the hospital setting (see Long, this issue). Nonetheless, Kikyo apparently pondered and explored this idea daily. It was clear that she cherished the notion of reincarnation within the family. This concept of reincarnation within her family was important for Kikyo as she pondered her own living and dying. Her concern with this idea led to her asking a relative to obtain a copy of her family register so that I could sketch her family tree. Kikyo was not a demanding person, rarely complaining of frustration or expressing fear of death. However, she was virtually obsessed with the concept of reincarnation within her family. Kikyo insisted that she wanted me to make a family tree of her family members’ “reincarnations.” She asked her daughter to obtain a copy of her family register instead of relying on her memory to create a kinship diagram. Using the kinship diagram, she was able to document that quite frequently, when one family member died, a baby was born to another family member within a few days. When Kikyo looked at the family register and discussed its details, it seemed she was seeking to affirm some ■ ● （Died on March 13, 1928） ● ■ ● （ Died on January 16, 1956） ●（Died on October 6, 1999） ■ ● KIKYO ■ （Born on June, 1928） （Died on February 26, 1994） □ ○ ○ □ ○ （ Bornh on January 16, 1956） □ ○ （Born on February 28, 1994） （Born on November 11, 1999） Note: ◌Female (alive) ●Female (deceased) □Male (alive) ■Male (deceased) Figure 1. Reincarnation within the family ■ ● （Died on March 13, 1928） ● ■ ● （ Died on January 16, 1956） ●（Died on October 6, 1999） ■ ● KIKYO ■ （Born on June, 1928） （Died on February 26, 1994） □ ○ ○ □ ○ （ Bornh on January 16, 1956） □ ○ （Born on February 28, 1994） （Born on November 11, 1999） Note: ◌Female (alive) ●Female (deceased) □Male (alive) ■Male (deceased) Figure 1. Reincarnation within the family Kikyo's "Family Tree," showing dates of births immediately following deaths Anthropology & Aging Quarterly 2012: 33 (2) 49 Megumi Kondo A Japanese Terminal Patient’s Hope primordial faith in the myth of eternal return, and in her ongoing existence within her family. Her kinship diagram remained unfinished when she passed away, but is shown in Fig 1 (below). Kikyo’s belief in reincarnation had two functions for her. One function was to estimate the approximate date of her own coming death. Since she expected to be reborn within her extended family, she thought she might predict the date of her own death by finding the date that some relative expected to deliver a baby. But Kikyo was unable to find someone pregnant in her extended family. Even failing to predict the date of her own death and rebirth, the kinship diagram fulfilled a second function of reaffirming her connections to her absent family. The process of creating a kinship diagram functioned to document her interconnections following the path of her ancestors. The kinship diagram confirmed “the fact that life cycled from generation to generation”. Kikyo had lived a life that came from her ancestors and that would be passed on to her offspring. This process assured her of a “place,” an identity and a significance which went beyond time and space. (2) phySical iSSueS: coMparing her own bodily condition to otherS’ Kikyo was quiet each time her physician came to examine her. She rarely complained of her suffering from fluid in abdomen, though this condition had been conspicuous even before her admission to the palliative care unit. Kikyo had learned her diagnosis of rectal cancer on her own. She had stoically undergone outpatient cancer treatment even while she was caring for her husband with a cerebral hemorrhage. Kikyo often displayed a surprising objectivity and ability to joke about her illness with me. When she had earlier undergone surgery for her lung cancer, Kikyo had shared a hospital room with another lung cancer patient. Kikyo repeated to me the conversations she had had with her fellow patient, acting out the role of the other as though she herself were really in pain, imitating her labored breathing. Her acting was so realistic--as if she were re-living the suffering of her fellow patient--that it was difficult for me to refrain from intervening. The fluid in her abdomen often caused Kikyo to suffer the same labored breathing that her former roommate experienced, sometimes more troublesome than the pain of her cancer. When her stomach rumbled during our conversations, she joked with her abdomen (e.g., “What’s bothering you?”) Dialogue 2: Dealing with another patient’s death (February 2) Kikyo: At the previous hospital, I shared a room with three other patients. A lady with terminal lung cancer had the bed by the window. She said, “You are lucky, Kikyo. You can go home as soon as you are able to eat.” I responded, “You will go home soon, too.” But she said, “I don’t think I’ll make it.” When I woke up at night, I saw her sitting up in bed hugging her legs in a fetal position. (Kikyo acted like the patient and tried to hug her legs.) Author: Like this? (I mimicked Kikyo.) Kikyo: I cannot really do it because my stomach is so swollen. (Kikyo looked at her abdomen full of fluid, faking the labored breathing of the deceased patient). Author: Kikyo, are you all right? Kikyo: That lady breathed like this. When I asked her “Is it painful?” she said, “yeah.” I was discharged soon after. I tried to visit her when I returned for an outpatient checkup a couple days later, but she had already passed away. Her words came back to me; looking back on it, I saw that she knew she was dying. Observation Ever since she was first diagnosed, Kikyo had received periodic treatment for her cancer. Because such treatments seemed to work, even if temporarily, she had not considered her cancer life threatening. At the same time, however, she worried that her cancer might become terminal for her as it had been for her father. Kikyo did not talk much about her own suffering or pain, but she frequently mentioned her father’s terminal cancer. Kikyo had some idea of the metastasis of her cancer, because she had watched her father undergo the same process. She appeared to have wished a greater connection with her family; she wished to share her feelings with her father now that she suffered from the same cancer. Kikyo rarely complained of her pain or suffering. This was partly an emulation of her father, who also held back from sharing his suffering or pain. She also refrained from voicing her pain because she had had such a hard time constantly listening to her husband complaining of his pain. In emulating her father’s stoicism, she was also trying to spare those around her from hearing her complaints. I pondered why Kikyo did not actively pursue information on the prognosis of her illness. It appeared that Kikyo Anthropology & Aging Quarterly 2012: 33 (2) 50 Megumi Kondo A Japanese Terminal Patient’s Hope was trying to estimate her condition by paying attention to her own body, and comparing it to the experiences of those she had previously watched die. Her imitation of labored breathing may have been grounded in genuinely labored breathing during the nights when she was alone. As she reenacted her former fellow patient’s departure, she was at the same time preparing herself for her own departure. And throughout the process, she was carefully conscious of the effects of her own words and actions on those around her. (3) pSychological iSSueS: huMor towardS and inFerenceS FroM otherS Kikyo and I developed some familiar routines. In every session, I would typically sit across from Kikyo, moving a chair close to her bed that paralleled the window. Once I moved the chair to that location and sat down, Kikyo would initiate our conversation. We shared a number of small but memorable occasions. For instance, one day on his morning rounds, the doctor suddenly decided that he would drain her abdominal fluid. Both of our stomachs growled as we skipped lunch while we conversed, waiting for the procedure to finish. On another instance, I accompanied Kikyo when her pharmacist and nurse discussed her medications with her. This accumulation of small daily conversations led Kikyo to open up to me and to voluntarily share her thoughts without prompting. One Monday, Kikyo was massaging her legs, and I was relieved to see some healthy color on her smiling face. I was already aware of Kikyo’s deterioration because she had been struggling with her physical condition in our previous session, and her chart indicated that she had been delirious over the weekend. I asked Kikyo to describe her weekend. Kikyo smiled wryly as she recounted an episode of the previous Friday: witnessing Kikyo’s delirium and decline, the hospital staff had asked her family to visit her. The hospital staff explained her condition to her family in front of Kikyo. Kikyo knew that her family would not initiate visits on their own; their visit and the staff’s explanation was so unusual that Kikyo inferred she was about to die. Kikyo grew delirious again on the following day, rarely responding to me. The last moment we shared together was listening to her favorite song on a portable tape- recorder. Then Kikyo went unconscious. I held her hand as her breathing grew labored, her shoulders heaving with each breath. She was pronounced dead during the next weekend, when I was not present at the unit. Observation Constantly seeking cues about their conditions and prognoses from the brief interactions that they are allowed with medical staff, palliative care unit patients often become very sensitive to the conversations and behaviors of their staff and families. It was unusual for Kikyo to have many family members visit at the same time. She spent most of the time alone at the hospital. Aware of her deteriorating physical condition, Kikyo surmised that her death was imminent because the hospital staff had asked her family to come to the hospital. Another reason that Kikyo thought her death impending was because of her decreased appetite. When she was first admitted to the palliative care unit, she was ecstatic that she was still able to eat and enjoyed her food with a good appetite. Though on one level she was emotionally ready to accept death, her dwindling appetite also made Kikyo realize that her death was imminent. Kikyo often joked about her own death. Perhaps she was trying to gradually accept the difficult reality of her own death by joking about it with others. Unsure of her true motives, I tried to support Kikyo by laughing with her as she joked about the progression of her illness and coming death. I was not merely laughing, but attempting to accept the reality that Kikyo faced. concluding diScuSSion: tangible and intangible connectionS beyond the extant FaMily Kikyo smiled and asserted that she was ready to die on the very first day I met her. She was quiet and rarely complained of her physical condition. However, our dialogues revealed that she always reflected upon spirituality and the nature of her post-mortem existence. Kikyo had decided to be transferred to the palliative care unit after learning about her poor prognosis. Her time at the palliative care unit was the time she chose to face her death. Instead of complaining of her pain, exhaustion, or labored breathing, she talked about her dying journey and her internal “dialogues” with those who had died. Kikyo’s behavior was largely influenced by her care- giving experiences in the past. She projected others’ dying process onto her own dying process. She used to be a caregiver, and was always the one “left behind”; here at the palliative care unit she was no longer a caregiver “left behind,” but instead she was the dying one. Her conversations with the dead, and her reviewing such conversations with me, helped Kikyo to confirm her connection with those living and dead. Remembering and empathizing with people whom she had watched dying Anthropology & Aging Quarterly 2012: 33 (2) 51 Megumi Kondo A Japanese Terminal Patient’s Hope helped Kikyo to face her own death. Kikyo was unable to empathize totally with such people who died of cancer, but she re-lived the experience of “dying” by having internal conversations with these dead people. Corr (1993) suggested that dying individuals face four types of tasks, viz.: (1) physical, (2) psychological, (3) social, and (4) spiritual. Non-spiritual problems include dealing with physical decline (compromised Activities of Daily Living, changes in body image); psychological challenges (accepting one’s own death, anxiety, attitude toward death); and social issues (financial problems due to illness, loneliness or alienation due to weak community ties). Conversely, spiritual tasks derive from worldview values, cultural background and lifetimes of experience. Indeed, Kikyo too confronted each of these issues in her own way. However, the order in which she expressed them was somewhat reversed: first she faced spiritual issues in a Japanese manner, only later facing psychological and physical issues. Significantly, her social concerns were not a separate set of issues, but inextricably interwoven throughout all of her other concerns--although perhaps particularly prominent in her spiritual concerns about survival. Aside from the history of her own illness, Kikyo primarily focused her discussions on reincarnation within her family. Kikyo did not simply contemplate afterlife or heaven; she pursued “connections” with her beloved family; “connections with others” not only prompted questions regarding her hereafter, but also provided her answers to them. Her pursuit of connections is not explicable simply through existential theories. Kikyo questioned whether and how she would exist in this world beyond the time of her death: she sought assurance through dialogue and through shared time with those left behind. She talked about reincarnation within the family as an underlying theme of “connection with others.” Importantly, her definition of “connection with others” comprised both (1) a connection with her extended family and (2) a connection with former deceased cancer patients. It may be improper to generalize from a detailed study of a single patient, but this study suggests that a Japanese approach to spirituality, as well as to physical and psychological self-definition, is more involved with this-worldly social interconnections than with existential or other-worldly issues. Future studies may find ways that this cultural tendency can be better understood and utilized in caring for terminal patients. In concluding, I should like to express my gratitude to Kikyo for helping me explore the most fundamental questions of human life; she guided me like a forerunner on the road from life to death. 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