We don’t like to think of dying, but it is an eventual certainty for all of us. Most of us are not prepared to face the death of significant others, let alone our own demise. What can we do?
In the 1970s, working with terminally ill people, Elizabeth Kubler-Ross made us aware of what happens as death gets close. Once people can accept their eminent death, they need to make the most of the time left to them. They need to make closure with loved ones – to express buried feelings and try to heal wounds in relationships.
They also need social and psychological support in facing their death. However, fewer Americans are dying at home. They are more likely to spend their last days isolated, afraid and in pain in some impersonal institution. Now over 50% of Americans die in hospitals, and almost 20% die in nursing homes.
Psychologist Judy Maes Zarit has a geriatric practice in Pennsylvania. Although every dying person does not need a psychologist, she often consults with local nursing homes. She has found that, for most of those who have lived a full life, dying is not terrible.
However, Zarit finds that unexpected diagnoses may overwhelm people, especially when they progress quickly like cancer. These people are often overcome by grief and depression. They need help to review their lives and to complete any unfinished business. Before the opportunity is lost forever, some may need family therapy to resolve issues. Others may need help in facing their fate. Once the client’s matters have been resolved, if needed, she gives them permission to die.
Zarit does her best to reduce her clients’ anxieties. Her goal is to give them "a nice, calm death." This includes minimizing any pain. She ensures that her clients get adequate pain medication. With current legal liabilities, physicians are often afraid of having "their initials under a dose of morphine given 15 minutes before a patient dies." Still others have not shaken the "worry about patients getting addicted."
Zarit will ask the physician any questions that her clients dread to ask. She will talk with their families, arrange for visits from spiritual leaders, help them write a will or create a lasting power of attorney. In Zarit’s words, "I’ll do whatever I can do to get rid of practical anxieties."
Anyone’s death is difficult, but dying children pose special problems. The chief psychologist at Children’s Hospital in Boston, Gerald P. Koocher, indicates that the effect of help depends on the child’s developmental level. Younger children often don’t understand the permanence of death. They may be bothered by unresolved questions. "How will I find food in heaven?" "How can someone be buried and in heaven at the same time?"
In answering these questions, Koocher avoids adult metaphors. Likening death to "sleep" may make the child afraid of getting any rest. If a family has "lost" a member, the child may wonder why they don’t try to find that person.
If medical procedures need to be done, a child’s anxiety can be reduced by using dolls and actual medical equipment – syringes and IV lines. Koocher uses anatomically correct dolls with zippers down their bellies to reveal internal organs, so the children can better understand what is happening to them. The children are also encouraged to use the dolls to act out their fears and fantasies.
Dying teenagers present other problems. Typically, they want to be independent of their parents, while looking like everyone else and keeping up with their peers. These goals are interrupted when a teenager is dying. Rather than relating to adults, many dying teenagers seem to respond better to support groups of others their age.
Anybody who is dying needs open lines of communication. This is especially true for children. People often try to "protect" the dying by not talking about their condition. According to Koocher, this isolates those who are dying, when they need to communicate the most.
"There’s the child feeling weaker every day and knowing that things aren’t getting any better. He’s got no one to talk to, because he’s gotten the message that he has to keep quiet about this."
Many wonder how Koocher (and others who relate to dying people) can bear the sadness. As one strategy to guard against burnout, Koocher does not limit his practice to only dying clients. He also has the social support of colleagues. He focuses on the positive aspects of his work.
Many psychologists work with neurotic clients for long periods without seeing much improvement. In contrast, Koocher views his work differently.
"I work with families that are essentially normal but are facing a crisis. They’re so grateful and open to help that you can accomplish a lot in a very short period of time.
"Working with dying patients is tremendously anxiety-provoking at first. But it has also made me a vastly more empathetic, and successful, psychotherapist."
Hospice of Yuma (HOY)is a volunteer group dedicated to making the remaining time left to dying clients as meaningful and comfortable as possible. They work with clients who have less than six months to live and also help their families. They can help the terminally ill make the most of the time they have. There may be an added bonus. At 78 years of age, Koocher notes, "I know it’s also helped me decide how I would like to die."
* Adapted from Rebecca Clay’s "Helping dying patients let go of life in peace," The APA Monitor, April, 1997, page 42.
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