Exploring the psychological support that we might be able to offer a dying person.

Hiker on mountain top 

When adversity arises as a life-threatening illness…it is a heroic journey that is not respected as such, any more than the potentially life-threatening and always life-altering experience of pregnancy, labour and delivery…. In both circumstances, people find fortitude, courage the ability to endure pain, and strengths they never dreamed they had.’ (1)

 

To understand the range of feelings your dying friend or relative might be experiencing, see Emotional Changes.

What follows is the psychological support that we might be able to offer the dying patient. To understand how a meditative approach can help, regardless of the emotional state, please see Managing emotions with meditation.

Below are some pointers about how you might be most helpful when the other is experiencing specific emotions. If you feel out of your depth, seek the advice of a psychotherapist.

 

What to do/not do when the other is experiencing….

Whatever the issue, respond as you judge appropriate for the person and in the particular context

 

Shock: While the person is stunned, trying to comprehend the news that they are dying, resist the temptation to chatter, to fill in the silence. Your comments or questions can interrupt their processing and they may just want you to sit by them. Simply knowing you are there may be tremendously helpful.

‘Normalise’ their reaction, for example saying ‘I can imagine that this is a huge shock; it’s understandable if you feel numb… if you can’t quite compute this.’

If you know them enough to feel it would be welcome, physical reassurance – such as taking hold of their hand – can be helpful. Touch brings us into an awareness of our body, especially helpful when we are in this state and perhaps have some degree of disassociation from our bodies. Physical warmth can also be helpful – a warm blanket or a cup of hot tea – and the maintaining of a routine. Complementary therapies, such as colour puncture, aura soma, reiki, and rescue remedy can be effective.

Denial: Do be mindful that denial is not a conscious effort to avoid reality; it’s the only way one can handle the enormity of such a situation. An aggressive approach, such as telling the person to ‘get real and face facts ‘is likely to be counter-productive. As with shock, normalise what the other is experiencing.  A possible ‘in’ could take the form of ‘I hear what you are saying – that the doctor is wrong; you are not dying. And at the same time I wonder how it might feel if it were true, as of course it will be for all of us one day or another.’

Anger: When the person is expressing anger – in asking, for example, what they have done to deserve such a fate – they may just be needing to let off steam. Anger can also be triggered by the re-opening of old grievances and grudges or may be a camouflage for guilt and blame. Be a good listener. Not all questions need answers. Your presence, just your willingness to be there, can be very supportive. Be aware too, however, that because of your availability you can be the target for anger.

Dr Buckland points out that ‘When somebody… is facing a serious illness and death, the anger that they feel may really be directed at the illness; but it comes out directed at you because you are the only person around.

‘If you are aware of the fact that the anger isn’t meant for you personally, then you might be able to respond in a different way [than you otherwise would.] If you are able to respond differently, then you might allow the patient to defuse her anger and talk about it instead of simply boiling with it.’  (2)

For example, your ill friend says, ‘Everything hurts, and now you’ve gone and made my pillows really uncomfortable. You know how I like them.’

You might instantly fire back: ’I’m doing my best but you are so fussy!’ Or, ‘You liked them that way yesterday. I’m not a mind-reader!’ This unthinking, automatic riposte tends to create a vicious circle and sets off the other person, who – also in reaction – says something that triggers your reaction, and so it goes on.

When we respond (a behaviour that comes from a place of centring and calmness) rather than react (an automatic and defensive behaviour), we become part of the solution. By staying open and not rising to the bait we’re giving the person a chance to say more about what’s really going on.

On the other hand, if our own hurt pride gets in the way of our trying to understand the other, and we make an unthinking retort, we may become part of the problem.

Some books suggest that now is not the time to open up old wounds or family feuds. However, this can be the very time when blocked, hurt energy that has hindered relationships can be cleared, so that there is space for understanding and forgiveness.  Clearly, you need to gauge when the emotional climate is right – that is, when those involved are mindful to ‘own’ their feelings and appreciate that a dialogue can be helpful not only to the patient but also to them.  [See also Unfinished business]

Letting off steam can be done consciously and in such a way that nobody gets hurt. Alternatively, when anger has simmered down, it’s possibly to just observe it from inside, as simply another passing emotion. [See Managing emotions with meditation]

Fear and anxiety:  People may be ashamed of their fears and anxieties and so are unwilling to discuss them. As well, not everyone is happy to listen to such talk; sensing this, the dying person may keep his fears bottled up inside. Anxious, the other is in emergency mode, so it is important that, in their confiding in you about their anxieties, they feel safe. They need to be able to look at their fears from a sense of sanctuary. Knowing the place of calmness inside and/or knowing how to connect with their inner centring provides that. [See Managing emotions with meditation]. With this resource in place they can start to look at their fear. Through that conscious encounter fears can begin to dissolve.

Encourage the other to articulate their fears – practical, psychological and spiritual. As appropriate, encourage the dying person to explore their options. For example, if they are afraid that they will be forgotten, help them look at what they could do to keep memories alive – such as creating a ‘Memory box,’ making an audio or videotape of themselves or bequeathing money to a cause they support.

Fear of pain is common and, for most people, the pain will be controllable. Ask their doctor to address this worry; he or she can explain how medication can be titrated and the degree of comfort they can expect in their particular case. Familiarise yourself with the variety of meditative methods that can be used. [See Meditations for Pain Management]

Fears about how they will manage in the last moments can be addressed by bringing the other back to the present. For example, you can ask, ‘And as you tell me about that, how are you feeling right now?’ This brings the other back to the present, to their body, and there is the realisation that in the present moment there isn’t a problem.

Avoid giving assurance or making promises that you may not be able to honour – such as saying, ‘There’s nothing to fear – I will be with you.’ The doctor may also be able to realistically allay fears about what the actual moments of dying will be like.

Concerns about an afterlife and the meaning the person attaches to these can be explored together. For example, if they ask, ‘Jesus will be there, waiting for me, at the gates of heaven, won’t he?’ – a question no one can respond to with certainty – you might ask: ‘What does that mean to you – his being there?’ or ‘How do you feel when you imagine that?’

The use of touch can be very reassuring, for example, holding the person’s hand as they talk to you. Similarly, massage, aromatherapy and reflexology can have a very calming effect.

Hope and Despair. Avoid endorsing what might be unrealistic hopes – something that, encouraged by the patient, loved ones, the nursing and the medical staff are often tempted to do because it is uncomfortable to be with someone who is sunk in despair: the natural urge is to relieve the pain. However, if you try to do that by giving them false hopes, you may alleviate the pain momentarily, but when those hopes are dashed the patient may be left feeling even worse.

On the other hand, doctors don’t always get it right, so who is to say what might be an ‘unrealistic hope’?  And also to be considered: There’s a price to pay for determining to explore every possible avenue and miracle cure – that is, the loss of money and of time to enjoy being with those you love and other those facets of everyday life.

If you or the patient are in doubt about the prognosis, a second opinion can be sought. If that backs up the first and you still feel driven to seek another, ask yourself what are you unable to hear? According to Dr Buckman, ‘constant shopping around is a sign of denial… a sign that the patient or you (or both) are not ready to accept what’s happening.

‘Despite the “How can you give up on him?” cries from well-meaning friends and advisors (who may be unable to accept the patient’s death themselves), acceptance of the inevitable and preparation for death is not cowardly or treacherous.’ (3)

Bargaining  In helping the other to work through this strategy, bear in mind that it is what they need to do in order to reach a stage of acceptance. Rather than endorsing the probability of their ‘deal’ coming to pass or not, support the other with your non-judgementalness and openness.

 

Grief As with the all responses to their dying, the other needs loving, non-judgemental understanding, and the chance to express – through words, through silence, through tears and rage – what they are feeling. We can best respect the other by allowing them their experience rather than – out of our own discomfort or mistaken ideas of helping – trying to console them or reason away why they shouldn’t feel as they do.

‘Normalise’ their feelings – that is, assuring the other that it is understandable that they feel as they do. Listen, love, encourage their talking and crying, and be ready to simply be with them in their silence – if that is what they want and you are comfortable with that.

 

Ambivalence: The patient may continue to be ambivalent, moving from one emotion and then to its polar opposite, right up to the time of their dying. As a carer, if you understand this and can stay flexible – supporting the other regardless of what they are feeling – you don’t run the risk of becoming exasperated by the constant change in the patient’s emotions (and perhaps your own!).

From the spiritual perspective it is helpful for the person dying to reach a place of acceptance.

 

Guilt, shame, unlovability: Self-acceptance is key to the resolution of these feelings. Loving, non-judgmental listening – which go a long way towards letting the other know that they are acceptable as they are – can allow the other to unburden themselves through words and expressing their feelings, perhaps through crying or anger, and to arrive at a new appreciation of themselves.

 

Blame: If a particular person is a target for blame – such as the doctor – avoid taking sides. Remain aware of the patient’s need to let off steam and give voice to many of the feelings that they are experiencing to someone by whom they do not feel judged.

Depression:  The most useful question to ask the patient is if they are depressed and then to enquire and gauge the severity and any feelings of suicide. Dr Heyse-Moore notes that ‘Talking with depressed people can be difficult because of their lack of response. Questions are answered briefly or not at all. They may look away and seem uninterested. It feels as if there is a wall between you which, in psychological terms, there is.’

It can be helpful to have a psychotherapist talk with the patient. If the reaction is severe and ongoing best to consult the doctor. Typically antidepressants are prescribed for major depression.

Dr Susan Block points out that not only should depression – and anxiety – be treated because of the risk of suicide but because it also interferes with whatever enjoyment of life the patient is able to find; it interferes with relationships and creates anguish, of course, for those who love him. It reduces the ability to find meaning and purpose and can interfere with treatment adherence. Depression shortens life, in some diseases and – when the patient has died, the bereavement outcomes are worse for family members.

 

*

 

Sources/Recommended Reading

1) Jean Shinoda-Bolen, M.D., Close to the Bone

2& 3) Dr R. Buckman:  I don’t know what to say: how to help and support someone who is dying (Pub: Papermac)

 

*Jane Feinmann and Clive Peterson:  How to have a good death; preparing and planning, with informed choices and practical advice. (Pub: Endemol.uk. productions)

* Louis Heyse-Moore Speaking of Dying: a practical guide to using counselling skills in palliative care

* David Kuhl, M.D What dying people want: practical wisdom for the end of life

* Mark Williams, John Teasdale, Zindel Sega, and Jon Kabat-Zinn The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness

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