Microsoft Word Elisabeth Kubler-Ross On Death And Dying doc

the clock back." It was unacceptable to him to lose his wife. He could not comprehend that she did 
not have the need to be with him any longer. Her need to detach herself, to make dying easier, 
 
was interpreted by him as a rejection which was beyond his comprehension. There was no one 
there to explain to him that this was a natural process, a progress indeed, a sign perhaps that a dying 
person has found his peace and is preparing himself to face it alone. 
 
The team decided to operate on the patient the following week. As soon as she was informed of the 
plans she weakened rapidly. Almost overnight she required double the dose of medication for her 
pains. She often asked for drugs the moment she was given an injection. She became restless and 
anxious, often calling for help. She was hardly the patient of a few days before; the dignified lady 
who could not go to the bathroom because she was not wearing slippers! 
 
Such behavioral changes should make us alert. They are communications of our patients who try to 
tell us something. It is not always possible for a patient to openly reject a life prolonging operation, 
in the face of a pleading, desperate husband and children who hope to have mother home once 
more. Last but not least, we should not underestimate the patient's own glimpse of hope for a cure 
in the face of impending death. As outlined earlier, it is not in human nature to accept the finality of 
death without leaving a door open for some hope. It is therefore not enough to listen only to the 
overt verbal communications of our patients. 
 
Mrs. W. had clearly indicated that she wished to be left in peace. She was in much more pain and 
discomfort after the announcement of the planned surgery. Her anxiety increased as the day of the 
operation approached. It was not in our authority to cancel the operation. We merely communicated 
our strong reservations and felt sure that the patient would not tolerate the operation. 
 
Mrs. W. did not have the strength to refuse the operation nor did she die before or during the 
procedure. She became grossly psychotic in the operating room, expressed ideas of persecution, 
screamed and carried on until she was returned to her room minutes before the planned surgery was 
to take place. 
 
She was clearly delusional, had visual hallucinations and paranoid ideas. She looked frightened and 
bewildered and made no sense in her communications to the staff. Yet, in all this psychotic 
behavior, there was a degree of awareness and logic that remained impressive. As she was returned 
to her room, she asked to see me. When I entered the room the following day, she looked at her 
bewildered husband and then 
 
(P104) 
 
said, "Talk to this man and make him understand." She then turned her back to us, clearly 
indicating her need to be left alone. I had my first meeting with her husband, who was at a loss for 
words. He could not understand the "crazy" behavior of his wife who had always been such a 
dignified lady. It was hard for him to cope with her rapidly deteriorating physical illness, but 
incomprehensible what our "crazy dialogue was all about. 
 
Her husband said with tears in his eyes that he was totally puzzled by this unexpected change. He 
described his marriage as an extremely happy one and his wife's terminal illness as totally 

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unacceptable. He had hopes that the operation would allow them once more to be "as close together 
as they had been" for the many happy years of their marriage. He was disturbed by his wife's 
detachment and even more so by her psychotic behavior. 
 
When I asked him about the patient's needs, rather than his own, he sat in silence. He slowly began 
to realize that he never listened to her needs but took it for granted that they were the same. He 
could not comprehend that a patient reaches a point when death comes as a great relief, and that 
patients die easier if they are allowed and helped to detach themselves slowly from all the 
meaningful relationships in their life. 
 
We had a long session together. As we talked, things slowly began to clear and came into focus. He 
gave much anecdotal material to confirm that she had tried to communicate her needs to him, but 
that he could not hear it because they were opposing his needs. Mr. W. felt obviously relieved when 
he left and rejected an offer to return with him to the patient's room. He felt more capable of talking 
with his wife frankly about the outcome of her illness and was almost glad that the operation had to 
be canceled because of her "resistance" as he called it. His reaction to her psychosis was, "My God, 
maybe she is stronger than all of us. She sure fooled us. She made it clear she did not want the 
operation. Maybe the psychosis was the only way out of it without dying before she was ready." 
 
Mrs. W. confirmed a few days later that she was not able to die until she knew that her husband 
was willing to let go. She wanted him to share some of her feelings rather than "always pretend that 
I am going to be all right." Her husband did make an attempt to let her talk about it, though it came 
hard and he "regressed" many times. Once he clung to the hope for radiation, at another time he 
tried to put pressure on her to come home, promising to hire a private nurse for her care. 
 
During the following two weeks he often came to talk about his wife and his hopes but also about 
her eventual death. Finally he came to accept the fact that she would become weaker and less able 
to share the many things that had been so meaningful in their life. 
 
She recovered from her psychotic episode as soon as the operation was permanently canceled and 
her husband acknowledged the impending death and shared this with her. She had less pain and 
resumed her role of the dignified lady who continued to do as many things as her physical 
condition allowed. The medical staff became increasingly sensitive to the subtle expressions to 
which they responded tactfully, always keeping in mind her most important need: to live to the end 
with dignity. 
 
Mrs. W. was representative of most of our dying patients, though she was the only one I have seen 
to resort to such an acute psychotic episode. I am sure that this was a defense, a desperate attempt 
to prevent a life-prolonging intervention which came too late. 
 
As stated earlier, we have found that those patients do best who have been encouraged to express 
their rage, to cry in preparatory grief, and to express their fears and fantasies to someone who can 
quietly sit and listen. We should be aware of the monumental task which is required to achieve this 
stage of acceptance, leading towards a gradual separation (decathexis) where there is no longer a 
two-way communication. 
 

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