On Death and Dying

“If a patient is allowed to terminate his life in the familiar and beloved environment, it requires less adjustment for him.”

One of the principal anxieties about death is caused by the prospect of suffering and dying in a strange and uncomfortable place. The advent of modern medicine has allowed for great advancement and lifesaving technology while, at the same time, removing death from the home and the local community in which the rest of the individual’s life has been lived.

“The more we are making advancements in science, the more we seem to fear and deny the reality of death.”

Scientific advancements in modern times have cast the illusion that our greater ability to heal has given us the ability to cast off death, or to postpone it indefinitely. This is not the case, and thus the greater our ability to diagnose and heal, the greater our inability to conceive of death.

“If we cannot deny death we may attempt to master it.”

Our inability to push death away or ignore it causes us to try and gain victory over it. We believe that if science keeps advancing, then it could be possible to find a solution or remedy for death

“A look into the future shows us a society in which more and more people are ‘kept alive’ both with machines replacing vital organs and computers checking from time to time to see if some additional physiologic functionings have to be replaced by electronic equipment.”

As medicine advances and more powerful and invasive technologies are developed, the more likely it is that people will justify all kinds of unnatural and inhuman methods of sustaining life, even at the expense of quality of life. To avoid the finality of death, it is likely that we will defer to technology and machinery in more and more inconceivable ways.

“If all of us could make a start by contemplating the possibility of our own personal death, we may effect many things, most important of all the welfare of our patients, our families, and finally perhaps our nation.”

The ability to reflect on one’s own death is pivotal in the ability to process the death of others, especially the death of friends and family. Our ability to show compassion and empathy toward others, especially when they are at their most vulnerable, will increase. Communities will be more tightly knit, and the common good will benefit.

“[A]nger is displaced in all directions and projected onto the environment at times almost at random.”

When anger is felt toward an illness, it cannot actually find an object upon which to vent. It is often the people who are closest to the patient who end up bearing the brunt of the rage which pours out in response to a terminal diagnosis. When anger cannot find an appropriate target, any target will do.

“Rather than understanding the origin of her anger and resentment, people in the environment reacted to it personally and began to reject her even more in reality.”

Those on the receiving end of misplaced anger will react viscerally and defensively. It is natural to retreat from the source of the anger, in this case the terminal patient. Kübler-Ross talks about the ability to put aside personal feelings and realize that it isn’t personal; the anger will dissipate when the patient feels that they are being listened to.

“Psychologically, promises may be associated with quiet guilt, and it would therefore be helpful if such remarks by patients were not just brushed aside by the staff.”

In the bargaining stage, promises projected toward the universe or God are often the result of regret over what has been left undone, or over actions left for some now-impossible future. The guilt that patients feel needs to be assuaged by listening and receptivity. When patients are allowed to talk through their feelings their ability to move through the various stages of grief will be swifter.

“The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier, and he will be grateful to those who can sit with him during this stage of depression without constantly telling him not to be sad.”

It is unhelpful when a terminal patient’s loved ones tell them that it might not be too bad, or try to cheer them up through distraction or ignorance. The reality is that terminal illness is a tragedy, and the ability to accept that reality requires the ability to grieve, to feel sorrow.

“He will have mourned the impending loss of so many meaningful people and places and he will contemplate his coming end with a certain degree of quiet expectation.”

When acceptance is around the corner, it will come with quiet submission. Accepting the loss of a life well-lived, and of beloved family members and friends, is going to cause sorrow, but it can be accepted peacefully when the patient is allowed to work through their feelings of anger and grief. 

“Our presence may just confirm that we are going to be around until the end.”

In the last stages, especially in the transition from depression to acceptance (and in acceptance to death), what is often most appreciated are the presence of loved ones. Even in the absence of family members or friends, caring health care professionals or a chaplain can be an anchor in the final days leading up to death.

“The one thing that usually persists through all these stages is hope.”

While it might be thought that hope would abandon the patient, this is almost never the case. At every stage, even in deep depression and acceptance, hope remains, even if slight. The drive to live is so deep that hope for continued life is practically inextinguishable.

“This does not mean that doctors have to tell them a lie; it merely means that we share with them the hope that something unforeseen may happen, that they may have a remission, that they will live longer than is expected.”

Even in cases where death is absolutely certain, it is useful and preferable if doctors maintain hope for the patient. Even in the gravest and most certain of cases, the expectation of death cannot be predicted with 100% accuracy; human life is not a math equation. Hope is necessary even if only for the patient’s mental health.

“It might be helpful if more people would talk about death and dying as an intrinsic part of life just as they do not hesitate to mention when someone is expecting a new baby.”

The reality of death is hidden in funeral homes and hospice care centers. In previous generations death was a fact of life, even if just in the case of farm animals or in the hunting field. Now we can avoid death almost completely. Discussion about death needs to come back. Death needs to be treated as an inevitability.

“We cannot help the terminally ill patient in a really meaningful way if we do not include his family.”

It is absolutely necessary to include a terminally ill patient’s family in the decision-making process. The patient will only be at peace if their family is aware of the actions taking place. The patient will know that when they die there will be at least some semblance of normality or planned action.

“Just as we have to breathe in and breathe out, people have to ‘recharge their batteries’ outside the sickroom at times, live a normal life from time to time; we cannot function efficiently in the constant awareness of the illness.”

It is impossible to be consumed by the dying process at all hours of the day for weeks or months on end. The circle surrounding the terminal patient needs to be reminded that it is both okay and necessary to spend time doing normal things.

“The dying patient’s problems come to an end, but the family’s problems go on.”

In a certain sense, the patient is better off during the death process. Their problems end with death, while the problems of the family continue. The family will suffer the loss of their loved one and experience the hole of their absence. Preparing them needs to be taken seriously.

“Guilt is perhaps the most painful companion of death.”

The guilt that accompanies death can be paralyzing and cause illness. It is necessary to treat and assuage guilt as early in the death process as possible. Therapy and ways of managing guilt need to be explored in the days and weeks following the death of the patient.

“Arrangements should be made increasingly to facilitate accommodations for members of the family of patients in such treatment units.”

Hospitals are designed for the most efficient care possible and for the convenience of health care professionals. Very little attention is often paid to making the space convenient for visitors. More care should be given, as the presence of loved ones is vital to the wellbeing of terminally ill patients.

“The most heartbreaking time, perhaps, for the family is the final phase, when the patient is slowly detaching himself from his world including his family.”

In the end, the patient will even have to let their families go. This can be painful for those left behind, as they may feel abandoned and unappreciated. However, it is the natural, final stage in the dying process as the patient prepares to take the final step toward death.

“When we lose someone, especially when we have had little if any time to prepare ourselves, we are enraged, angry, in despair; we should be allowed to express these feelings.

The emotions that follow in the wake of a loved one’s death can be unexpected and uncontrollable. This is not a sign of immaturity, but the natural reaction to the tragedy and crisis of death. Emotions need to flow through the individual and be fully felt, not repressed.

“The most meaningful help that we can give any relative, child or adult, is to share his feelings before the event of death and to allow him to work through his feelings, whether they are rational or irrational.”

The patient should be assured that their emotions are being listened to and accepted. Anger and sorrow are natural, even if they appear to be irrational or manifest in illogical ways. Patients must feel listened to if they are to work through their time of crisis.

“[T]he more training a physician had, the less he was ready to become involved in this type of work.”

A high degree of training was associated with a doctor’s inability to see the emotional and human side of a terminally ill patient’s circumstance. Formal education can make doctors more attuned to empirically verifiable facts versus a patient’s emotional needs.