ThanatologyOF THE LAST THINGS OF A MAN

About the death itself

The awareness of one‘s own mortality – a crucial topic in both religion and philosophy

Reflected in the arts

There is a striking contrast between the philosophical, religious and artistic reflection of the topic and the way the death and dying is perceived and faced in our current everyday lives

A tabooed topic

A topic that is too relevant to each one of as well as all of our close ones

How will we face the death (us or our close ones)?

Dying at home x dying in institutionalised care (A familiar, loving environment x specialized care)

The terminal state and the death

The terminal state- The last phase of the life of the man

The health state of a person is not compatible with the life

different attitudes towards it

Stages: pre finem – in finem - post finem

Death

In our cultural field – only a person of medical proficiency can competently declare a person dead

The time of death is set according to the cerebral death

A sudden death-

a death without previous pathological feelings and symptoms, a short duration of the terminal state (up to six hours)

In the current days – a common wish of the healthy (To pass away as quickly and painlessly as possible)

In the past– interpreted as a result of the God‘s fury, as the person didn‘t get the opportunity neither to say goodbye to their beloved ones, nor to prepare for the death (coming to terms with the death, the sacrament)

After a sudden death of a relative or an otherwise close person, the bereaved often experience the feeling of a fatal destabilisation of life, a loss of trust, social isolation, a feeling, that the mourned didn‘t really die, as well as the development of the struggles of the anxiously depressive nature

A comparison: An extremely infavorable prognosis vs a sudden death in a car accident

The medical aims

1. A full healing

2. The management of the suffering of a chronical illness

3. A calm and dignified dying

Often a personal topic for the medical staff:

the willingness to avoid the topic of death (and often the physical avoidance of the patient in the terminal state of the disease)

a treatment and complicated examinations at the time of the inevitable death

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Arguments used for the continuation of the treatment:

• The patient wishes to continue the treatment

• The family of the patient wishes to continue the treatment

• It is impossible to take away the hope from the patient

• It is necessary to try to fight the disease until the very end

A discussion topic – why can those arguments be misleading?

To admit to oneself when the treatment becomes counterproductive for the patient

How to tell the truth without taking away the hope

Who to tell it to? (to the patient - to the family, if the patient wishes so)

When? (when is it too late and when is it too early)

How much? (the patient is the one to set the limits, do not silence him)

Where and how? (dignified conditions)

Individual attitude – the amount of the information - taking the psychological state of the patient into account (depression, dementia)

Always tell the truth - temporary concealing – the truth being given in doses

Preparation for both of the scenarios

Watch out for the false hopes!

How to prepare for such dialogue

Obtain relevant and current information

Consider a team cooperation (a psychologist, nurse, a more experienced doctor. A definite topic do bring up at supervisions)

Relax, don‘t get your hopes too high, work with one‘s own anxiety

Consider to offer the presence of the close ones

Don‘t overwhelm with information, be understandable, talk positively

Be authentic, empathetic and calm in the communication

Don‘t give overly specific prognosis (explain the slippery slope of clinging to statistics)

Give the patient all the time and space they need

Invite the patient to ask questions

Consider the spiritual needs of the patient

Offer a follow-up meeting

Elisabeth Kübler-Ross

 Five stages of mourning 

On Death and Dying, 1969

A key publication on dying

based on interviews with over 100 dying patints

Not all of them go through all the five stagesdepends on the age, the attitude,the reactions of their closest onesand the process of their death(dependence on others, pain, a change of thepersonality of the dying patient)

To a great extent applicable on other crisis situations

Among the others also on the reactionsof the close ones on the lethal diagnosis of the patient(often in a different tempo)

The five stages of the mourning

1. Denial– „I‘m feeling alright.“, „This can‘t be happening, not to me.“, „Ther must have been a swap of the result, this must be some mistake.“ – a temporary defence – a shock reaction, which can last for various legths of time

2. Anger  -„Why me? This is not fair!“, „Why is this happening to me?“, „Whose fault is that?“ - feelings of anger, the cooperation and communication with the medical workers is threatened

3. Bargaining  – „I want to see my grandchildren“, „i will do anything to live on for a couple more years.“ - a hope for postponing or for a change of the situation, turning to a higher power, searching for a miraculous treatment methods or alternative medicine

4. Depression– „I feel so sad, why should I bother with anything?“, „I‘m going to die, so what‘s the point?“, „I lost a beloved one, I have no reason to go on now.“ - feelings of fear, anxiety, sadness and hopelesness

5. Acceptance– „It will turn out okay in the end.“, „There is nothing I could do against it, I should get ready for it instead.“ – coming to terms with the reality, the true acceptance.

Logotherapy

One of the fields of the existential psychotherapy

V. E. Frankl (1905-1997)

What is the meaning of life? x What meaning am I going to give to my life?

The uniqueness of a person, the impermanence and uniqueness of each moment

Three types of values – creative values, experience and attitude ones

Life has a meaning in every situation

Freedom and responsibility

Techniques of de-reflexion, modulation of the stance, (paradoxical intention)

Palliative care

A complex care oriented on the quality of life provided to the patient who suffers an incurable disease in the advanced, usually terminal stage of their disease

Support with the struggles:

• Bodily struggles

• Psychological struggles

• Social struggles

• Spiritual struggles

The spiritual needs

Often becomes pressing as the end of the life approaches

Faith as a possible significant help

Spiritual questions

Sprituality x religiosity

Transcendence

Care for the spiritual needs of the patient in the health care institutions

What do we wish for?

The most common wishes:

I don‘t want to die alone.

I would like to die painlessly.

I wish I had the chance to finish up some of my unresolved things.

I need to someone to bear with me, when I will deconstruct everything I‘ve known.

Reflect the basic areas of needs (social, physiological, psychological and spiritual)

What do we regret the most before death?

I wish I wasn‘t brave enough to live the way I wanted to and lived the way I was expected to instead.

I shouldn‘t have worked so hard.

I wish I let my feelings out more.

I regret not having stayed in touch with my friends.

I wish I would dare to be happier.

(Ware, 2012)

Hospices

A bed form x home care (a mobile care), in some countries also the hospice weekly institutions

Indications for the permanent bed hospice care

• The disease threatens the life of the patient

• The patient needs a palliative care

• A hospitalisation is not necessary

• The home care is not available

The most common diagnosis- oncological diseases– over 90% (Svatošová) – usually with heavy symptoms

Request for the placement into the hospice is written by the doctor – a part of the request must be a free and informed agreement

Hospices

What the hospices have to offer to the patient:

o The patient will not suffer an unbearable pain

o The dignity of the patient will be respected

o The patient will not be lonely in their last moments

Cooperation with the patients as well as their family – including the care for the bereaved (correspondence, contact via telephone, visits, meetings of the bereaved)

http://www.youtube.com/watch?v=FIreRQ6Ovi8

Medical – and legal – declaration of death, communicating the information with the bereaved The death must always be delcared by a doctor – any possibilities of

resuscitation as well as the possibility of a virtual death must be excluded doubtlessly

The precise setting of the date and time of death must be set, as well as the likely cause of death. It must be also decided, whether or not should the body be dissected

After the declaration of death – the relatives and other close people specifically mentioned in the patient‘s informed agreement are to be contaced

Information of death – in case the relatives are not physically present by the bedside – have been commonly transmitted by a telegram in the past. Currently, mostly phone calls are used – once the speaker is properly identified.

A tense, emotionally demanding situation, that is worth being well prepared for.

Mourning

Mourning– a natural reaction to a death of a close person – a process of coming to terms with the loss

Pathological mourning

A ritualised, culturally shaped form of the mourning

The most common strategy of coping with the death of a beloved person

o To try to go on, to face the future

o Activity, a continuous need to occupy oneself (displacement of the mourning)

o Reminding oneself of the deceased frequently and constantly

Mourning as a life crisis

The proces – an analogy for all the crisis situations

The progression is individual

Same phases as in other crisis situations (Kubler- Rossová)

Coping – self-help– informal help (of the friends and other close people) – formalised help

Guidance of the bereaved – consulting for the bereaved – the therapy of the bereaved

The death and the reactions of the bereaved

About 100 000 people die in the Czech reoublic annually, 75% of them in the age of 65 and above.

Most of the people die in an expected time and ways, on a known and diagnosed disease

In the young age, the amount of unexpected and sudden death rates rise

Communication with the close ones about the severity of the situation, the state of the patient and the prognosis

Important for the patients, for their closest, as well as for the general understanding and handling the situation

Explanation of the symptomes of the dying (often attributed to other influences), including a possible euphoria

The farewell

Optionally – a family gathering by the bedside of the dying

Rituals helping with coming to terms with the loss:

THE FUNERAL

the chance to thank the mourned, to show the respect for them, to celebrate their memory, to part ways, to show reverence

consolation of the bereaved (mutual) – the social aspect of the mourning

Several functions – Biological x Social x Psychological x Cultural and Religious

A current tendency – not having/attending the funeral– is potentially risky for the coping with the mourning