Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

 
Maybe instead of cryo-societies we should develop societies for dealing with the questions of death 
and dying, to encourage a dialogue on this topic and help people to live less fearfully until they die. 
 
A student wrote in a paper that the most amazing aspect of this seminar was perhaps that we talked 
so little about death itself. Was it Montaigne who said that death is just a moment when dying ends? 
We have learned that for the patient death itself is not the problem, but dying is feared because of 
the accompanying sense of hopelessness, helplessness, and isolation. Those who have attended the 
seminar and given thought to these things, expressed their feelings freely and experienced that 
something can be done, not only face their patients with less anxiety but also feel more comfortable 
about the possibility of their own death. 
 
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(P240) 
 
XII 
 
Therapy with the Terminally Ill 
 
Death belongs to life as birth does. 
The walk is in the raising of the foot 
as in the laying of it down. 
 
Tagore, from Stray Birds, CCLXVII 
 
From the foregoing it is evident that the terminally ill patient has very special needs which can be 
fulfilled if we take the time to sit and listen and find out what they are. The most important 
communication, perhaps, is the fact that we let him know that we are ready and willing to share 
some of his concerns. To work with the dying patient requires a certain maturity which only comes 
from experience. We have to take a good hard look at our own attitude toward death and dying 
before we can sit quietly and without anxiety next to a terminally ill patient. 
 
 The door-opening interview is a meeting of two people who can communicate without fear and 
anxiety. The therapist-doctor, chaplain, or whoever undertakes this role-will attempt to let the 
patient know in his own words or actions that he is not going to run a way if the word cancer or 
dying is mentioned. The patient will then pick up this cue and open up, or he may let the 
interviewer know that he appreciates the message though the time is not right. The patient will let 
such a person know when he is    ready to share his concerns, and the therapist will reassure him  
his return at an opportune time. Many of our patients have not had more than just such a door-
opening interview. They 
 
(P 241) 
 
were, at times, hanging onto life because of some unfinished business; they cared for a retarded 
sister and had found no one to take over in case of their death, or they had not been able to make 
arrangements for the care of some children and needed to share this worry with someone. Others 

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were guilt-ridden about some real or imagined "sins" and were greatly relieved when we offered 
them an opportunity to share them, especially in the presence of a chaplain. These patients all felt 
better after `confessions" or arrangements for the care of others and usually died soon after the 
unfinished business was taken care of. 
 
Rarely an unrealistic fear prevents a patient from dying, as earlier exemplified in the woman who 
was "too afraid to die" because she could not conceive of "being eaten up alive by the worms" 
(Chapter IX). She had a phobic fear of worms and at the same time was quite aware of the 
absurdity of it. Because it was so silly, as she herself called it, she was unable to share this with her 
family who had spent all their savings on her hospitalisations. After one interview this old lady was 
able to share her fears with us and her daughter helped her with arrangements for a cremation. This 
patient too died soon after she was allowed to ventilate her fears. 
 
We are always amazed how one session can relieve a patient of a tremendous burden and wonder 
why it is so difficult for staff and family to elicit their needs, since it often requires nothing more 
but an open question. 
 
Though Mr. E. was not terminally ill, we shall use his case as a typical example of a door-opening 
interview. It is relevant because Mr. E. presented himself as a dying man as a consequence of 
unresolved conflicts precipitated by the death of an ambivalent figure. 
 
Mr. E., an eighty-three-year-old Jewish man, was admitted to the medical service of a private 
hospital because of severe weight loss, anorexia, and constipation. He complained of unbearable 
abdominal pains and looked haggard and tired. His general mood was depressed and he wept easily. 
A thorough medical work-up was negative, and the resident finally asked for a psychiatric opinion. 
 
(P 242) 
 
He was interviewed in a diagnostic-therapeutic interview with several students present in the same 
room. He did not mind the company and felt relieved to talk about his personal problems. He 
related how he had been well until four months before admission when he suddenly became "an old, 
sick, and lonely man." Further questioning revealed that a few weeks before the onset of all his 
physical complaints he lost a daughter-in-law and two weeks before the onset of his pains his 
estranged wife died suddenly while he was on a vacation out of town. 
 
He was angry at his relatives for not coming to see him when he expected them. He complained 
about the nursing service and was generally displeased with the care he received from anybody. He 
was sure that his relatives would come immediately if he could promise them "a couple of thousand 
dollars when I die," and he elaborated at length about the housing project in which he lived with 
other old people and the vacation trip they all were invited to attend. It soon became evident that 
his anger was related to his being poor and that being poor meant that he had to take the trip when 
it was planned for his place of residence, i.e., he had no choice in the matter. On further questioning 
it became clear that he blamed himself for having been absent when his wife was hospitalized and 
tried to displace his guilt on the people who organized the vacation. 
 
When we asked him if he did not feel deserted by his wife and was just unable to admit his anger at 
her, an avalanche of bitter feelings poured out in which he shared with us his inability to understand 

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why she deserted him in favor of a brother (he called him a Nazi), how she raised their only son as 
a non-Jew, and finally how she left him alone now when he needed her the most! Since he felt 
extremely guilty and ashamed about his negative feeling towards the deceased, he displaced his 
feelings on the relatives and nursing staff. He was convinced that he had to be punished for all 
those bad thoughts and that he had to endure much pain and suffering to alleviate his guilt. 
 
 
We simply told him that we could share his mixed feelings, that they were very human and 
everybody had them. We also told him bluntly that we wondered if he could not acknowledge some 
anger at his former wife and express it in further brief visits with us. He answered to this, "If this 
pain does not 
 
(P 243) 
 
go away I will have to jump out of the window." Our answer was, "Your pain may be all those 
swallowed feelings of anger and frustration. Get them out of your system without being ashamed 
and your pains will probably go away." He left with obviously mixed feelings but did ask to be 
visited again. 
 
The resident who accompanied him back to his room was impressed with his slumped posture and 
took notice of it. He reinforced what we had said in the interview and reassured him that his 
reactions were very normal, after which he straightened up and returned in a more erect posture to 
his room. 
 
A visit the next day revealed that he had hardly been in his room. He had spent much of the day 
socializing, visiting the cafeteria, and enjoying his food. His constipation and his pain was gone. 
After two massive bowel movements the evening of the interview, he felt "better than ever" and 
made plans for his discharge and resumption of some of his former activities. 
 
On the day of discharge, he smiled and related some of the good days he had spent with his wife. 
He also told of the change in attitude towards the staff "whom I have given a hard time" and his 
relatives, especially his son whom he called to get acquainted a bit better, "since both of us may 
feel lonely for a while." 
 
We reassured him of our availability should he have more problems, physical or emotional, and he 
smilingly replied that he had learned a good lesson and might face his own dying with more 
equanimity. 
 
The example of Mr. E. shows how such interviews may be beneficial to people who are not 
actually ill themselves,  but-due to old age or simply due to their own inability to cope with the 
death of an ambivalent figure-suffer a great deal and regard their physical or emotional discomforts 
as a means of alleviating guilt feelings for suppressed hostile wishes toward dead persons. This old 
man was not so much afraid to die as he was worried about dying before lie had paid for his 
destructive wishes toward a person who had died without having given him a chance "to make up 
for it." He suffered agonizing pains as a means of reducing his fears of retribution and displaced 
much of his hostility and anger onto the nursing staff and relatives without being aware of the 
reasons for his resentment. It is surprising how a simple interview can reveal much of this data and 

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a few statements of explanation, as well as reassurance that these feelings of love and hate are 
human and understandable and do not require a gruesome price, can alleviate much of these 
somatic symptoms. 
 
(P244) 
 
For those patients who do not have a simple and single problem to solve, short-term therapy is 
helpful, which again does not necessarily require the help of a psychiatrist, but an understanding 
person, who has the time to sit and listen. I am thinking of patients like Sister I., who was visited on 
many occasions and who received her therapy as much from her fellow patients as she did from us. 
They are the patients who are fortunate enough to have time to work through some of their conflicts 
while they are sick and who can come to a deeper understanding and perhaps appreciation of the 
things they still have to enjoy. These therapy sessions, like the brief psychotherapy sessions with 
more terminally ill patients, are irregular in time and occurrence. They are individually arranged 
depending on the patient's physical condition and his ability and willingness to talk at a given time; 
they often include visits of just a few minutes to assure them of our presence even at times when 
they do not wish to talk. They continue even more frequently when the patient is in less comfort 
and more pain, and then take the form of silent companionship rather than a verbal communication. 
 
We have often wondered if group therapy with a selected group of terminally ill patients is 
indicated, since they often share the same loneliness and isolation. Those who work on wards with 
terminally ill patients are quite aware of the interactions that go on between the patients and the 
many helpful statements that are made from one very sick patient to another. We are always 
amazed how much of our experiences in the seminar are communicated from one dying patient to 
another; we even get "referrals" of one patient from another. We have noticed patients sitting 
together in the lobby of the hospital who have been interviewed in the seminar, and they have 
continued their informal sessions like members of a fraternity. So far we have left it up to the 
patients how much they choose to share with others, but we 
 
(P 245) 
 
are presently looking into their motivation for a more formal meeting, since this seems to be 
desired by at least a small group of our patients. They include those patients who have chronic 
illnesses and who require many re-hospitalizations. They have known each other for quite a while 
and not only share the same illness but they also have the same memories of past hospitalizations. 
We have been very impressed by their almost joyful reaction when one of their "buddies" dies, 
which is only a confirmation of their unconscious conviction that "it shall happen to thee but not to 
me." This may also be a contributing factor why so many patients and their family members, like 
Mrs. C. (Chapter VII), get some pleasure in visiting other perhaps more seriously ill patients. Sister 
I. used these visits as an expression of hostility, namely, to elicit patients' needs and to prove to the 
nursing staff that they were not efficient (Chapter IV). By helping them as a nurse, she could not 
only temporarily deny her own inability to function, but she could also express her anger at those 
who were well and unable to serve the sick more effectively. Having such patients in a group 
therapy set-up would help them understand their behavior and at the same time help the nursing 
staff by making them more accepting of their needs. 
 

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Mrs. F. was another woman to be remembered as she started informal group therapy between 
herself and some very sick young patients, all of whom were hospitalized with leukaemia or 
Hodgkin's disease, from which she had suffered for over twenty years. During the past few years 
she had an average of six hospitalizations a year, which finally resulted in her complete acceptance 
of her illness. One day a nineteen-year-old girl, Ann, was admitted, frightened of her illness and its 
outcome and unable to share this fear with anyone. Her parents had refused to talk about it, and Mrs. 
F. then became the unofficial counsellor for her. She told her of her sons, her husband, and the 
house she had taken care of for so many years in spite of the many hospitalizations, and finally 
enabled Ann to ventilate her concerns and ask questions relevant to her. When Ann was discharged, 
she sent another young patient to Mrs. F. and so a chain reaction of referrals began to take place, 
quite comparable to group therapy 
 
(P246) 
 
in which one patient replaces another. The group rarely consisted of more than two or three people 
and remained together as long as the individual members were in the hospital. 
 
The Silence that Goes Beyond Words 
 
There is a time in a patient's life when the pain ceases to be, when the mind slips off into a 
dreamless state, when the need for food becomes minimal and the awareness of the environment all 
but disappears into darkness. This is the time when the relatives walk up and down the hospital 
hallways, tormented by the waiting, not knowing if they should leave to attend the living or stay to 
be around for the moment of death. This is the time when it is too late for words, and yet the time 
when the relatives cry the loudest for help-with or without words. It is too late for medical 
interventions (and too cruel, though well meant, when they do occur), but it is also too early for a 
final separation from the dying. It is the hardest time for the next of kin as he either wishes to take 
off, to get it over with; or he desperately clings to something that he is in the process of losing 
forever. It is the time for the therapy of silence with the patient and availability for the relatives. 
 
The doctor, nurse, social worker, or chaplain can be of great help during these final moments if 
they can understand the family's conflicts at this time and help select the one person who feels most 
comfortable staying with the dying patient. This person then becomes in effect the patient's 
therapist. Those who feel too uncomfortable can be assisted by alleviating their guilt and by the 
reassurance that someone will stay with the dying until his death has occurred. They can then return 
home knowing that the patient did not die alone, yet not feeling ashamed or guilty for having 
avoided this moment which for many people is so difficult to face. 
 
Those who have the strength and the love to sit with a dying patient in the silence that goes beyond 
words will know that this moment is neither frightening nor painful, but a peaceful cessation of the 
functioning of the body. Watching a peaceful death of a human being reminds us of a falling star; 
one of a million lights in a vast sky that flares up for a brief moment only 
 
(P 247) 
 
to disappear into the endless night forever. To be a therapist to a dying patient makes us aware of 
the uniqueness of each individual in this vast sea of humanity. It makes us aware of our finiteness, 

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our limited lifespan. Few of us live beyond our three score and ten years and yet in that brief time 
most of us create and live a unique biography and weave ourselves into the fabric of human history. 
 
The water in a vessel is sparkling; 
the water in the sea is dark. 
 
The small truth has words that are clear; 
the great truth has great silence. 
 
Tagore, from Stray Birds, CLXXVI 
 
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End.