On Death and Dying

Once denial has been dealt with, and at least some partial acceptance has taken root, the “next question becomes: ‘Why me?’” (63). The anger that follows this questioning “is displaced in all directions and projected onto the environment at times almost at random” (64). Too often those upon whom the patient’s anger is vented don’t stop to ask why it is occurring, or what they would do in the same situation; rather, they feel resentful and angry themselves. A patient “who is respected and understood, who is given attention and a little time, will soon lower his voice and reduce his angry demands. He will know that he is a valuable human being, cared for” and will almost without exception become more amenable (65).

The author relates a case where a nurse did everything she could to avoid contact with her patient. The nurse’s lack of compassion stemmed from her own fear of suffering and death. Her behavior made the patient’s outbursts and disagreeableness unbearable. In another case, a patient who had been the controlling type all his life only became mollified when allowed to have some semblance of control, even in regard to the most trivial things: “He was able to eat again, but only after all staff and relatives stopped telling him what to do” (68).

The most complex case is illustrated by an interview with “an angry, demanding patient” known as Sister I., who took out her anger on the hospital staff (69). Those who had charge of her took it personally: “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” (90). Once her situation and motivations were considered, those around her acted with far more empathy, leading to a complete change of the patient’s attitude.

The stage of bargaining is often very brief, if seen at all. The patient believes they can negotiate; after all, there have been other times in life when deals have been struck and good behavior rewarded. According to Kübler-Ross: “The bargaining is really an attempt to postpone; it has to include a prize offered ‘for good behavior,’ it also sets a self-imposed ‘deadline’ […] and it includes an implicit promise that the patient will not ask for more if this one postponement is granted” (96). Those caring for patients should understand that “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” (96).

Once denial is no longer a possibility and numbness has worn off, “anger and rage [are] replaced with a sense of great loss” (97). In addition to the reality of a terminal illness are financial burdens and perhaps unemployment. Two different types of depression arrive, “reactive” and “preparatory” (98). Reactive depression is a response to the various things that are no longer in one’s control. This is easier to deal with: “An understanding person will have no difficulty in eliciting the cause of the depression and in alleviating some of the unrealistic guilt or shame which often accompanies the depression” (98).

Preparatory depression sets in as the patient prepares to face the reality of death. Here, reassurances are not helpful; neither is a false sense of comfort. What is really necessary is the ability and space to reckon with the fact of death. If the patient is allowed to express their 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” (99).

Kübler-Ross gives the case of Mr. H., whose depression was exacerbated by “the lack of awareness and understanding of this patient’s needs on part of those in his environment, especially his immediate family. […] His depression paralleled his increasing weakness and inability to function as a man and provider” (100). In his interview with the seminar, he showed that he was in fact very open and honest even though the hospital staff had judged him to be uncommunicative. His hopelessness was due to his inability to grieve, in part because he had never properly grieved the deaths of his own parents and child. He wasn’t unaware of his own illness or unable to come to terms with it. Rather, “he was reviewing the meaning of his life and searching for ways to share this with the most significant person—his wife” (120).

When the terminal patient has had sufficient time for reflection, acceptance can take hold: “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” (123-24). While one should not confuse acceptance with happiness or contentment, acceptance brings with it peace or calm, a desire to move into the final stage of illness and the passage from life to death. In these final moments, the patient often needs the presence of those they love: “We may just let him know that it is all right to say nothing when the important things are taken care of and it is only a question of time until he can close his eyes forever” (124).

In one example given by the author, a woman—Mrs. W.—suffered a psychotic break when her husband refused to accept her impending death: “She was angry at him for not facing it and for so desperately clinging on to something that she was willing and ready to give up” (127). She could not die in peace until her husband had come around to the reality of the situation.