The dying patient: A clinician's view

Considering the universality of death and its overwhelming personal significance, knowledge of how contemporary man relates to death is meager indeed. In the absence of systematic research gathered from dying individuals and others involved in the death setting, we have been obliged to rely heavily on the beliefs, observations and writings of philosophers and theologians, and artists and poets for interpreting and understanding death. As an oncologist, my experience affords me a different perspective. I encounter regularly the initial reactions of patients upon learning that they have a potentially fatal illness, the specific problems involved with their care in the hospital and some of the interactions among physician, patient and family as the disease progresses. It has been said that we are all moving toward death at a variable speed. One can conceive of life as a terminal illness from which only death can liberate us. Such a conception is excessively lugubrious and, for most of us, not workable. For practical and operational purposes, I will define the dying patient as one whose disease is expected by the physician, patient or family to result in death. The patient’s first response to the knowledge that he possesses a progressive terminal illness is highly variable, but most often it is one of disbelief, shock and denial. Dr. Kiibler-Ross, the psychiatrist, emphasized other stages: anger, bargaining, depression and acceptance. Anger occurs because the patient is sick but others are not, and because the patient will be unable to function whereas others will be well. Bargaining, most often with God, is a request for some extra time usually in exchange for something. “God, let me get to my daughter’s wedding and I will go to church/synagogue each week for the next year.” Depression follows, not only because of the inevitability of the illness, but also because of an awareness of all the things the patient will soon leave behind. Usually, acceptance of the over-all situation finally occurs. Of course, these are not precise stages, and at any one time all may be found together in any one individual. Throughout, hope persists for the human spirit always tends to endure. Let us further consider the first stage of denial, which I also call the “delusion of acceptance.” This is the major stage with which the physician and the outpatient are obliged to deal. Since the real fear of dying is not uppermost in the minds of most people, the patient is forced to accept his own finiteness despite the understandable wish to avoid it. Like soldiers in a fox hole, people view death as something that happens to others. Thus, in one study, more than 80 per cent of the individuals questioned thought it best to make some plans about death. Follow-up indicated that more than 70 per cent had had some form of life insurance, but only one of four reported making a will or having some kind of funeral arrangement. As Freud suggested, no one can contemplate his own death, to which I add, especially with equanimity. It is, indeed, difficult to acknowledge the physical aspects of death, particularly disfiguration and decay, and to consider the prospect of disappearance of self. The great majority simply avoid the issue by clothing themselves with a veil of denial, protecting themselves from the fact that they are severely ill. If they do accept the fact, then they deny the true seriousness of the disorder; thus the phrase “delusion of acceptance.” I have no quarrel with denial as long as it does not interfere with treatment or appropriate medical planning. No skilled, sensitive physician should strip the patient of needed defenses. I am reminded of a lady receiving chemotherapy for far-advanced lung cancer who insisted at each visit that I take her blood pressure. On the one occasion when I didn’t she became annoyed that I would forget such an important vital observation. I overlooked what she was trying to tell me. The fact that her blood pressure was always normal reminded her of one of the few remaining normal characteristics in her disease-ravaged body. Since most of mankind appears unwilling to accept