Death and dying

Death and dying

Death and dying

Death is an integral part of medicine, but doctors and othermedical staff often feel confused by the psychological andethical questions it poses. Should a terminally ill patient bekept alive as long as possible, or allowed to die in peace?Should every patient with a fatal illness be told of his diagnosis,and if so how should they be told? Can a dyingpatient be helped to come to terms with death, and howcan this happen? What are the psychological reactions inthe relatives of dying patients, and what support do theyneed?These questions are problematic not only because of alack of training and technique, but also because death is anintrinsically difficult subject which all but the exceptionally compassionate find hard to face. Patients and doctors alikedeny the reality of death in order to carry on with life.

REACTIONS IN THE PATIENTThe response of the patient to the knowledge that he hasa terminal illness can be compared to a bereavement reaction.The patient enters a state of grief for the loss of hisown life. The initial reaction is usually one of numbnessand shock, a struggle between denial and acceptance. Thepatient attempts to fight off what is happening and cannotbelieve it is true, that it is happening to him. This is oftenfollowed by a period of severe anxiety, in which the patientbecomes dependent on visitors, family and medical staff,and finds it very hard to be alone. A period of sadness andweeping is inevitable. Anger is also a normal feature of thisphase, and the patient may become difficult, complaining,ungrateful and demanding. With time, however, the patientgradually becomes calmer, and during this phase theopportunity to talk may be very helpful. This series ofreactions may be compressed into a few hours or spreadover months, and, as with bereavement, does not follow aneat, orderly course.

TALKING TO DYING PATIENTS Breaking bad news and talking to dying patients is an art that can be learned through watching others, and through discussion of the feelings and difficulties it arouses. Thepatient can often be helped if staff and family recognizethe subsequent reactions for what they are and then let the patient talk about his anger, panic and sadness. When thishas happened the patient may feel better.The issue of 'to tell or not' is a false alternative. Some patients want to know their diagnosis in great detail; others would rather not know. It is unnecessary and inappropriateto confront all patients with the stark reality of theirillness. On the other hand, far more patients than areofficially 'told' want to know their diagnosis or know italready. The patient needs space and time in which todiscuss his feelings and ask questions. Gentle probingmay be needed to help the patient make use of thisopportunity.

REACTIONS IN THE FAMILY Like the patient, families also go through an anticipatorygrief reaction when a loved one is dying. The death of achild or adolescent is especially painful and unsupportable.Spouses of dying patients are particularly vulnerable. Theymay, for example, feel angry with their husband or wife forbeing ill, and feel very guilty about having such unvoicedthoughts. The stress of death may lead to tense and angry out bursts, either within the family or outside it at medical staff. Doctors and nurses should be prepared for this.Family counselling can help with these grief reactions and help to make death and bereavement, when they come,more bearable.

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