Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

down, you would have fallen out of bed and cracked your head open." If we look at this incident 
again in an attempt to understand the reactions rather than to judge them, we must realize that this 
nurse also used avoidance by sitting in a corner reading paperbacks and "at all costs" tried to keep 
the patient quiet. She was deeply uncomfortable in taking care of a terminally ill patient and never 
faced him voluntarily or attempted to have a dialogue with him. She did her "duty" by sitting in the 
same room, but emotionally she was as far detached from him as possible. This was the only way 
this woman was able to do this job. 
 
She wished him dead ("crack your head open") and made explicit demands on him to lie still and 
quiet on his back (as if he were already in a casket). She was indignant when he asked to be moved, 
which for him was a sign of still being alive and which she wanted to deny. She was obviously so 
terrified by the closeness of death that she had to defend herself against it with avoidance and 
isolation. Her wish to have him quiet and not move only reinforced the patient's fear of immobility 
and death. He was deprived of communication, lonely and isolated as well as utterly helpless in his 
agony and increasing anger. When his last demand was met with an initially increased restriction 
(the symbolic locking him up with the Side rails raised), his previously unexpressed rage gave way 
to this unfortunate incident. If the nurse had not felt so guilty about her own destructive wishes, she 
probably would have been less defensive and argumentative, thus preventing the incident from 
happening in the first place and allowing the patient to express his feelings and to die a bit more 
comfortably a few hours later. 
 
(P48) 
 
I use these examples to emphasize the importance of our tolerance of the patient's rational or 
irrational anger. Needless to say, we can do this only if we are not afraid and therefore not so 
defensive. We have to learn to listen to our patients and at times even to accept some irrational 
anger, knowing that the relief in expressing it will help them toward a better acceptance of the final 
hours. We can do this only when we have faced our own fears of death, our own destructive wishes, 
and have become aware of our own defenses which may interfere with our patient care. 
 
Another problem patient is the man who has been in control all his life and who reacts with rage 
and anger when he is forced to give up these controls. I am reminded of Mr. O. who was 
hospitalized with Hodgkin's disease which, he claimed, was caused by his poor eating habits. He 
was a rich and successful businessman who had never had any problems in eating, and had never 
been obliged to diet to lose weight. His account was totally unrealistic, yet he insisted that he, and 
only he, caused "this weakness." This denial was maintained in spite of the radiotherapy and his 
superior knowledge and intelligence. He claimed that it was in his hands to get up and walk out of 
the hospital the moment he made up his mind to eat more. 
 
His wife came one day to my office with tears in her eyes. It was hard for her to bear it any longer, 
she said. He had always been a tyrant and kept strict control over his business and his home life. 
Now that he was in the hospital, he refused to let anybody know what business transactions had to 
take place. He was angry with her when she visited and overreacted when she asked questions of 
him or tried to give him any, advice. Mrs. O. asked for help in the management of a domineering, 
demanding, controlling man, who was unable to accept his limits and unwilling to communicate 
some of the realities that had to be shared. 
 

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We showed her-in the example of his need to blame himself for "his weakness"-that he had to be in 
control of all situations and wondered if she could give him more of a feeling of being in control, at 
a time when he had lost control of so much of his environment. She did that by continuing her daily 
visits but she 
 
telephoned him first, asking him each rime for the most convenient time and duration of the visit. 
As soon as it was up to him to set the time and length of the visits, they became brief but pleasant 
encounters. Also, she stopped giving him advice as to what to eat and how often to get up, but 
rather rephrased it into statements like, "I bet only you can decide when to start eating this and 
that." He was able to eat again, but only after all staff and relatives stopped telling him what to do. 
 
The nursing staff used the same approach by allowing him to control certain times for infusions, 
changing bed sheets, etc., and-not surprising perhaps-he chose approximately the same times for 
these procedures as they had been previously done, with no anger and struggles involved. His wife 
and daughter enjoyed their visits more and also felt less angry and guilty about their own reactions 
to this very sick husband and father, who had been difficult to live with when he was well, but who 
became almost unbearable when he was in the process of losing his controlling grasp on his 
environment. 
 
For a counselor, psychiatrist, chaplain, or other staff member, s-ach patients are especially difficult 
as our time is usually limited and our workload great. When we finally have a free moment to visit 
patients like Mr. O., we are told, "Not now, come later." It is very easy then to forget such patients, 
to just leave them out; after all, they did it to themselves. They had their chance and our time is 
limited. It is the patient like Mr. E.)., however, who is the most lonely, not only because he is hard 
°$f take but because he rejects first and can only accept when it is on his terms. In that respect, the 
rich and successful, the controlling vip is perhaps the poorest under these circumstances, :a he is to 
lose the very things that made life so comfortable for ,rim. In the end, we are all the same, but the 
Mr. O's cannot admit that. They fight it to the end and often miss an opportunity for reaching a 
humble acceptance of death as a final outcome. They provoke rejection and anger, and are yet the 
most desperate of them all. 
 
The following interview gives an example of the dying patient's anger. Sister I. was a young nun 
who was re-hospitalized with Hodgkin's disease. It is a verbal transcript of a discussion by the 
 
(P50) 
 
a chaplain, the patient, and me during her eleventh hospitalization. Sister I. was an angry, 
demanding patient who was resented by many within and outside the hospital because of her 
behavior. The more incapacitated she became, the more she became a management problem 
especially for the nursing staff. She made it a habit while hospitalized to go from room to room, 
visiting especially sick patients and eliciting their needs. She would then stand in front of the 
nurses' desk and demand attention for these patients, which the nurses resented as interference and 
inappropriate behavior. Since she was quite sick herself, they did not confront her with her 
unacceptable behavior, but expressed their resentment by making shorter visits to her room, by 
avoiding contact, and by the briefness of their encounters. 
 

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