Living With Dying
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If you are afraid to talk about death, you are not alone. Death has been a "hush-hush" topic traditionally in America. Coming to terms with one's own feelings about death has not been achieved by most people. Free and open discussion of death usually has been nonexistent.
Reasons for silence about death vary. Medical technology has contributed to a shift in causes of death and the ages of the dying population. Today, more people die of degenerative diseases than of childhood communicable diseases. Heart disease and cancer are typical causes of death of the older population. More people die in hospitals and nursing homes now than at home. Removal of this experience from the home and lack of exposure to the death of younger friends means that people grow up today personally unfamiliar with death before they reach adulthood. Death remains a mystery to most adults.
A change is occurring, though. There is a growing interest in and willingness to discuss death and dying more openly. This discussion is important to increase understandings about death - to help people understand themselves and their friends or family members as death comes. Recognizing the normal psychological stages people experience when facing death or grief crises can contribute to this understanding.
There is no "normal" way to react to approaching death. All people react individually - differently. However, psychologists and sociologists have isolated some of the standard reactions to accepting death. Elizabeth Kubler-Ross, noted for her writings on the five stages of mourning, also says that all people do not progress through the grief processes in the same sequence. Neither do all people necessarily proceed through all stages. Nevertheless, a knowledge of these stages can help people in such a crisis and may help others provide emotional support to family members or friends more effectively as they face these situations.
Shock and Denial
When people first discover they have a potentially terminal illness, the reaction is one of numbness and denial. They have difficulty accepting the reality of the predicament. Most people can't believe it is happening to them. To think "No, not me" is typical.
Defense mechanisms are used to buffer shocking news. Some people wish at this time to get another diagnosis and check out several opinions. Listening without hearing is common. Talking about the truth in a detached manner sometimes occurs. There is an attempt to put off and allow time for gaining self-control. Denial may also be used more extensively with family or friends who cannot cope with the situation.
Family, friends, or clergy help by being available if needed during this stage, when someone appears to be having difficulty believing what is happening.
One way to help is to double check - find out if this is really the problem of the dying person. Some people only appear to be in this stage of denial. They realize the truth, but sense that friends or relatives cannot talk about it. "Whenever you feel like talking about it, I am available" is the type of statement that keeps the doors of communication open and permits the person to share feelings when ready.
Being sensitive to clues of how much reality a person wants to face at a given moment is the key to helping ease the crisis situation.
Anger and Strong Emotions
Sooner or later, further denial of the death or grief situation is no longer possible. Outward signs of disease or accumulated circumstances gradually bring the truth home. The reaction then may be one of "Why me? There are others less worthy than me."
As the impact of the loss becomes real to a person, natural feelings of helplessness, hurt, frustration and resentment occur. Often anger is expressed to almost anyone around regardless of the actions of those individuals.
In fact, one's anger may become more intense when confronted by happy and energetic individuals who represent so vividly to the dying person what will be lost. At any rate, it seems that typically "whatever others do, nothing is right."
To help the person who is feeling angry, consider these guidelines:
a) Understand that these people are not angry at others, but what they represent. To take this anger personally is a mistake and does not help the dying person. Remember, this anger is really a compliment instead of an insult. The angry person is reminding healthy, active people of all the things they do and take for granted until it is lost.
b) Know that the feelings of anger are natural and try to accept that the person has a justified right to be angry. Many authorities believe that by "letting" the angry person be angry without guilt, the process of grief proceeds without interference and the end result is a fuller recovery. No apology is necessary for grief emotions.
c) Communicate reflectively and nonjudgementally to validate anger. Statements like "I would be angry too; get it off your chest," helps others ventilate it.
For most people, talking openly helps them lose feelings of anger. A grieving person needs trusted friends and relatives who listen acceptingly. They need to know they won't be rejected when they reveal how they feel. The need for an answer to the question "why me" becomes much less important when dying people can pour out their feelings and know they are being heard. Fortunate are they who have a family member or friend who can fulfill this important role of listener.
Bargaining Stage
At last, when the person facing death knows "I am the one" and has expressed rage and strong feelings, it is not unusual for him or her to become more cooperative and attempt to make an argument (usually with God) to postpone the inevitable death. There is, in this brief and sometimes secretive stage, usually the promise of good behavior in exchange for a prize. This bargaining usually includes a self-imposed deadline. For example, "If I can just live until my birthday or my child's graduation," is common. Promises include such things as "a life dedicated to God" or "a life in the service of the church."
What is promised is not important. The fact that they have to some degree begun to accept the reality of the impending death is important. However, the acceptance is not at a deep level, for once a bargain is made and fulfilled, the patient is faced with keeping the promise, and often wants to bargain again.
When relating to a person in the bargaining stage, recognize that bargaining is a normal defense mechanism. Accept the behavior even though the person's promises or wishes seem unrealistic.
A clergy member can play a constructive role in helping this person deal with promises that may be associated with guilt.
Depression (Preparatory Grief)
When people realize they are unable to stop the disease that is destroying body and life, and that they can't continue to bargain, they begin to prepare for final separation from this world. They grieve and mourn for themselves. It is understandable when a widow grieves a year at the loss of a spouse. Is it difficult to understand that anticipating one's own death is harder? Dying people must face the reality of losing everything they know and love.
To be able to cope with this overwhelming loss, one "weans off." Each daily separation points out a final separation. People become silent, engaging in minimal conversation. They may begin to limit visitors, dismissing friends one by one until only immediate family or a close loved one is left.
To encourage the depressed people to look at the sunny side of things is to ask them to not contemplate impending death. To tell them not to be sad would not be appropriate. All of us are sad when we lose someone we love. Dying people are in the process of losing everything and everyone they love.
By expressing sorrow, they find final acceptance easier. They need someone to sit with during depression, letting them be sad. This may be difficult. Many people, because of their own needs, are unable to tolerate sadness over a long period of time, especially when feeling completely helpless.
Understand that people must have a great deal of courage in order to face this situation. Men especially may need to feel that this courage is admired and that it is not unmanly to cry. It is understandable that people would cry over such a great loss. It is not easy to say goodbye to all they have loved. If people are allowed to grieve before it happens, then they can more readily reach the last stage, the stage of acceptance.
Too often the dying person must contend with well-meaning denials by family and friends and never has opportunities to bid comfortable goodbyes. Many feel, "I know I'll never be well again. Please cry with me." When experiences are not shared, a cruel kind of isolation develops that makes the grief process more painful for the dying patient.
Acceptance and Peace
Given enough time, people finally stop struggling and await the inevitable end. Completing the grief work, they accept it with peace and tranquility. Unfinished business is taken care of. They begin to separate from the outside world, choosing only one or two people to stay with them until the end. During this time, nonverbal communication is often more meaningful than verbal communication. They are ready to let go. This is not to be confused with people who go to the nursing home saying they have no reason to live. Resignation has bitterness. Acceptance has a measure of peace.
It is important that family and physicians recognize this stage of acceptance. Some patients fight to the end for life. Many deny death almost to the end. Others give up too early. How does one differentiate this from the stage of acceptance? If family members differentiate these stages, they can more easily know how to help others die with dignity and peace.
One of the primary problems in this stage is that friends, relatives, and physicians cannot let go - they believe their duty is to prolong life. Some people are ready to die but are not allowed to do so. They cannot die with peace and equanimity because others are making them feel guilty for dying! When people around the dying person can reach the stage of acceptance before the death, the dying person is fortunate.
When family members are concerned not for cure primarily, but for the meaningfulness of death for the one dying, they are more able to help the dying person tend to unfinished business.
New facilities in or near hospitals are being provided to help bring dying patients and family members together during the last stages of this family crisis. More patients are being encouraged to spend the last days at home when possible.
Death is as natural as birth and should be thought of in that way. In Death: The Final Stage of Growth, Kubler-Ross claims the stages of dying apply to any significant change in a person's life such as retirement, moving away, changing jobs or divorce. She says that if people can face and understand their ultimate death, they can probably learn to face and deal productively with other changes that occur in life.
And when people know there is only limited time for everyone before death, they value every day and use the gift of life as happily and productively as possible.
This page last updated: March 05, 2007.