Management of the terminally ill patient

Dr Prabhakar Korada MBBS., FCGP., DNB (Psychiatry)., FIPS

The present day doctors are well equipped to deal with diseases. They are trained to have control over life and disease. Their minds become so technically oriented that they seem to forget the reality of life. Unconsciously they often try to play ‘God’ and feel themselves omnipotent. And when faced with a dying patient, they lose nerve, because their science has not prepared them to accept death as part of life. They either avoid him, dislike him, or are afraid of him, because the dying patient is perceived as a failure of the medical profession; the dying patient reminds them of their own fears of death. They are embarrassed when the dying patient or their relatives ask them genuine questions. The doctor’s ignorance is masked with irritability or bland emotional neutrality in the guise of professionalism.

Nowhere in the medical course do professors prepare the students to deal with the terminally ill. All that they are taught is how to manage bedsores, and how to prolong life. Not much is said about how to offer solace to the patient and prepare him to accept death in a dignified way; nothing more for the bereaved family and their psychosomatic problems.

Thanatology is the science of the study of psychology related to death, the dying patient, and the surviving members of his/her family. Having the basic knowledge of this subject prepares the medical personnel to be qualitatively more humane and enrich the lives of people who they come across in their profession. Interestingly, in the process, they themselves feel spiritually elevated and learn to look at death as an essential friend of all life forms.

It prepares the doctor to be not just a ‘medicine giving machine’, but a complete being who is truly a friend, philosopher and guide to his patients and their families, in life and in death too.

To be efficient in this area, a doctor needs to have a clear concept of death. According to modern science which depends mostly on direct observation of what can be seen, felt or heard, death is said to occur when there is brain death including the cessation of function of the brain stem. Beyond this, it is religion and philosophy which can give a more satisfactory explanation of life and its inevitable cessation. Oriental religions have dealt in more detail about death and the transition of the soul, and the concept of the hereafter.

What happens in the mind of the patient who is told that he or she has just a few months to live? Is it necessary to tell him? Or is it better to tell a falsehood and escape as happens in many cases!

What volcanoes erupt in the mind of a person who suddenly gets the news that his dear one is dead! How can he be helped to cope with the sudden loss!

Well known psychiatrist and thanatologist Dr.Elizabeth Kubler Ross has proposed five stages of reactions of patients who have been told of their impending death due to the terminal stage of their illness; such as advanced cancer.

Although no two persons react the same way, the following are generally found

They are:

1. Shock & Denial,
2. Anger,
3. Bargaining,
4. Depression and, finally,
5. Acceptance. 

Similarly Bowlby had proposed the four stages of reactions of individuals who lost some one close to them

They are

1. Acute despair characterized by numbness and protest,
2. Intense yearning and  searching for the person who is dead
3. Disorganization and despair leading to listlessness and apathy
4. Reorganization where the reality of death sinks in —- the memories of the dead person become less painful, and the grieving person begins to return to normal life. 

Awareness and exchange of ideas on the above psychological reactions would help health care professionals to offer the much needed solace to the terminally ill patient, as also to those families who recently lost a loved one, without themselves getting caught up in the emotional lives of their patients.

While grieving and mourning are themselves normal psychological processes that should be allowed to resolve over a period of time, physicians should be alert to the possibility of normal grief becoming abnormal and evolving into clinical depression which ought to be treated without delay. The risk of suicide in the survivors should always be born in mind.

Interestingly, the psychological reactions that we discuss in Thanatology, seem also to apply to other life situations like separation and estrangement. When compared to estrangement, the death of a person is decisive, and irreversible. Whatever pain it causes has a course and is perhaps easier to get over with because of the knowledge of its irreversibility. Social support and sympathy is always forthcoming. But estrangement, separation and divorce could possibly be more painful emotionally; the reason being —-  here, there is a certain amount of hope that things could be reversed; this kind of hope, albeit false most of the times, makes the person to cling to his memories, and brood over them and continue to suffer. Apart from this, there is also the factor of social accountability in divorce and separation. Individuals would often have to answer odd enquiries. Lack of empathy from the rest of the society, is a further drain on the psyche of the estranged or the divorced.

Thus the knowledge of Thanatology can be of help not only in the management of the terminally ill patients and their families, but also in cases of divorce and separation. An analogy can be drawn between death of a being, and death of a relationship. Both are painful, perhaps the latter is even more so. The principles of psychotherapy and family therapy in thanatology could be used in divorce and separation too.

In normal grief following death of a close one, it takes around six months to get over the intense initial pain, after which there is apparently some amount of adjustment. But after a year, an anniversary reaction takes place. The first death anniversary triggers memories when feelings again tend to become intense. The risk of physical health problems worsening during this period should be kept in mind, and the individual forewarned. It takes from two years to five years to gradually get over the pain of death. After this period the deceased person’s memories become pleasurable rather than painful, and the irreversibility and the reality of death is accepted by the mind. It also takes similar amount of time for the wounds of divorce to heal.

Grief can be subdivided into the following:

• a) Normal grief
• b) Pathological or abnormal grief
• c) Anticipatory grief
• d) Childhood grief
• e) Parental grief

Normal grief should also be differentiated from depression. For the inexperienced both may appear similar. But grief is normal and should not be interfered with, and depression is pathological and requires early intervention.

Apart from depression, since the overwhelming majority of the terminally ill patients happen to be the elderly, geriatric problems such as dementia complicated with psychotic symptoms should be anticipated. In such cases it is best to take the help of an experienced psychiatrist. Dealing with active persecutory hallucinations and delusions could be very demanding for non mental health professionals.

Finally, a doctor who is comfortable in the face of his patients’ death, can make the patient feel more positive and accept the inevitability of death with dignity and hope, and also help the rest of the family focus on the patient rather than on extraneous conflicts in the family that usually tend to surface during such crises.

Dr.Prabhakar Korada MBBS., FCGP., DNB (Psychiatry)., FIPS
SURYA Brain & Mind Specialty Clinic,
SECUNDERABAD – 500026