LOSS, GRIEVING, DEATH & DYING,

EUTHANASIA, PHYSICIAN ASSISTED SUICIDE AND ADVANCE DIRECTIVE

D eath is the final stage of life. Dying is a process or a preparation for the final conclusion—
death. For some, dead is a four-letter word not to be discussed; to others, the word represents
an unpleasant reality difficult to think about or plan for. Some handle the concept realistically and well.
In many respects, the way people face their dying or their death may be determined by how they live.
Most health professionals will work with clients who die and will respond to their surviving loved
ones. How health professionals face this process may also be determined, in part,
by how they face their own life and their own death. With the added knowledge from this
chapter on dying and death, health care professionals can be better prepared to work with
clients and their families during the dying-and-death process. Caring, understanding, and
compassion are essential ingredients.
Living with Dying
Dying is a personal event. No two people die alike. Some die very quickly whereas others
have time to plan for their deaths. Most hope for an easy death. To attempt to identify particular models
for the “best” way to die is fruitless. None exists. Each person is unique, and the
life experiences brought to the situation are varied. However, some helpful generalizations
can be made.
1. The way people live is often mirrored in the way they die.
2. People with useful support systems, such as friends, family, and faith in life, may find
this support helpful in dying.
3. Experiencing the death of someone close brings the reality of dying more into focus.
4. Intellectual preparation for dying, such as writing a will, an obituary, or planning a funeral may ease
the fear of death.
5. Relationships with families and friends change.
6. Basic personalities usually remain unchanged, but moods may vary radically.
7. Personal goals are reevaluated.
8. Pain, suffering, and dependence are feared most by the dying.
9. Dying is not a casual experience.
10. The age of dying persons in part determines their reaction to death.
11. Persons who experience chronic disease or disability face their immortality more acutely
than others.
12. Cultural mores influence attitudes toward death.
Suffering in Dying
Generally, everyone says they would prefer dying peacefully in their sleep or dying suddenly
without warning or pain. In truth, most of us will lose our lives more gradually. Old age, debility, even
senility may creep in before we realize that we have lost much of what we valued
in our faculties. We may be diagnosed with a life-threatening illness that we believe will
cause our death. Some will suffer in pain and agony. Some will be the object of medical
experimentation and technology. It is this fear of suffering, the fear of dependence, the fear of
loss of control, the fear of leaving loved ones, and the fear of pain that scares us most about
death.
Short-term suffering presents a set of problems different from those of long-term suffering. This can
best be seen in the following situations:
Example 1
A 45-year-old teacher learned in June that chronic myelocytic leukemia accompanied by blastic
transformation was destroying his body. The prognosis was poor. Hospitalization and chemotherapy
followed, with severe side effects and pain. He died 2
months later, never returning home.
Example 2
A 50-year-old electrician was diagnosed as having cancer of the colon. Surgery followed, and a
permanent colostomy was established. Postoperatively, the client did well
and later returned to work part-time. Within a year, cancer metastasized and complications resulted.
Consultation with specialists recommended only symptomatic treatment. Her pain required massive
doses of analgesics to keep her comfortable for the
remaining 6 months. The electrician was unable to return to work but remained home
until about 6 weeks before death, when she was again hospitalized.
ln a comparison of these two examples, time, costs, and dependency are three variables to
consider. Obviously, the time of pain and suffering was longer for the electrician than for the
teacher. The severity, however, cannot be compared. Overall costs are far greater for the
electrician than the teacher, but nothing is known of insurance coverage or family resources.
Either situation could be a financial burden on survivors. Dependency of these clients on
their friends and family is somewhat different. The teacher had to depend on someone to
take care of any personal matters, which might include job, children, and finances, for approximately 2
months. The electrician, however, was dependent on family for physical and
nursing care in the home. She also needed someone to take care of personal matters from diagnosis to
death, approximately 18 months.
Even the length of time is difficult to establish. Time is relative; that is, 2 months and 18
months may both be considered short term when compared with an individual in a state of
semiconsciousness for 4 or 5 years.
Use of Medications
Medications are used by the suffering when dying in both the hospital and at home. The
greatest difficulty with medications arises in long-term suffering. Medications are given for
many reasons, including analgesics for pain, sedatives for sleep, and specific medications for
the particular disease condition. Antidepressants and tranquilizers also may be prescribed.
Medications are to be respected for their intended action and the client’s needs.
Problems arise when family members, friends, and even health professionals circumvent
or question the physician’s orders for medications. This is often disastrous for the client. All

persons close to the client ought to understand the physician’s orders and the use of the prescribed
medications. Family members should know the reasoning of the physician so that any
questions arising are not misunderstood. For example, imagine the fear a loved one feels
when the pharmacist says, “Do you know this is a near-lethal dose?” Unless the loved one
knows that this amount is needed to keep the pain level of the client bearable, the loved one
may withhold the medication and even begin to distrust the physician. Family members need
to understand that medications may be given in different dosages, frequencies, and combinations for
one dying client than for another. Age, weight, illness (whether chronic or acute),
and the client’s threshold for pain all influence a physician’s choice of analgesics.
Sometimes physicians and health professionals are reluctant to prescribe or administer
medications even though they are within the approved dosage range. In fact, in some cases
health professionals will administer less than the prescribed dose because they believe
what was prescribed was too much. Some may fear the client will become addicted. Physicians may
see opioid orders or prescriptions as crimes, not as treatment issues. They
fear investigation. The client or family may want to use less than the amount prescribed
because they believe it is too much. Clients may wait too long to ask for pain medication, thinking they
“can handle it.” All have the potential of working against the clients’
comfort.
Psychological Aspects of Dying
Dying clients differ in their psychological experiences. Although basic personalities remain
the same, changes occur. A person normally calm and loving may have periods of violence
and hostility. A happy person may become severely depressed. In fact, a person who is
nearly comatose or close to death may be unaware of his or her responses to questions or be
unable to make any decisions. An individual who usually is able to accept medical facts may
totally deny a life-threatening illness.
Relationships may change. Some individuals are incapable of continuing a close relationship with a
person who is dying. Closest friends may become aloof and distant. Some may
fear touching or caressing the dying person. The dying person may reject any close contact
or relationships. The following quotation, words from a dying person, illustrates this controversy: “I am
not sure why, but I want to accept, and end up rejecting; I am willing to surrender, but more often seek
to control.”1 The opposite may also be true. A stronger bond of
friendship can develop, and new friendships will be made, possibly from individuals in similar
circumstances. Broken relationships may be healed.
Relationships are important and should be encouraged. They provide strength and support
that may not be available through any other source. The depth of relationships during this
time and the degree of acceptance by dying clients may depend on their self-image. When a
person is ill, is in pain, lives in a deteriorating body, and possibly is unable to perform the
activities of daily living, self-image is fragile. When self-image is lacking, hope is lost;
dying clients feel useless, may think they are burdens, and will have difficulties accepting
help. The psychological effect of a poor self-image may even hasten death.
Dying clients may not be physically able to continue working. If they are sole wage earners, this may
present a financial crisis, especially if the unemployed period extends for a
long time. Unemployed clients may be bored, feel useless, and worry, and their self-image.

suffers. For example, dying clients may worry that they are not fulfilling their usual role in
the family and worry about their lack of control.
Personal goals for the dying person are altered or may even become nonexistent. Goals
such as seeing a child graduate or a grandchild born may be seen as unrealistic to the dying
because of limited time. The dying person either gives up or strives to live until a certain
event takes place. The total loss of personal goals, no matter how insignificant they may appear, can be
devastating to the dying and to persons caring for them. Goals may be different
for the dying than for family members. Indecision is often a psychological dilemma accompanying the
lack of personal goals. People close to the dying commonly recommend goals
and help in the decision-making process. This must be done sensitively and realistically.
Communication may become difficult. Aside from any physiological problems precluding
speech or communication, what dying clients are unable to understand or hear may depend
on what they choose to hear or are ready to understand. Communication may be complicated
further if the client’s condition has not been honestly addressed. Of course, the opposite may
be true. Some dying clients express the ability to communicate with greater depth because of
the urgency of their circumstances.
Many communication difficulties center on the question of whether dying clients should
be told of their terminal condition. How much information should they be given? Some people believe
that all clients need to be told the medical facts by physicians and treated openly
and honestly by all health professionals. They believe informed clients are better able to face
death and are less afraid of the truth than are many health professionals. Other people believe no clients
should be told they are dying, or that only those clients who give some verbal or nonverbal indication
that they want to know should be told.
In some cultures, only family members and not the client are told of impending
death. Only clients who can handle the truth should be told. Some clients may
refuse to set goals, give up hope, and wait impatiently for death.
Fear is often a traumatic psychological aspect of dying. There is fear of pain, fear of long
suffering, fear of losing independence, fear of financial ruin, and fear of death itself. The
client’s fears ought to be recognized and alleviated, if possible. To recognize these fears requires active
and passive listening on the part of all people close to the dying individual and
a willingness on the part of this individual to express those fears.
Much fear can be lessened if people close to the dying anticipate the fear and provide
possible solutions and appropriate resources. Outside help may be sought, if necessary. Social workers,
public health nurses, home health aides, clergy, and other health professionals
can be valuable resources. Clients’ fear should be taken seriously, and reference to their supposed
unimportance should be avoided.
The psychological aspects of death are difficult for family, physicians, and health professionals because
they may not be tangible. They generally are less understood than the physiological aspects of death
and are often left to laypersons rather than professionals. To care
for the physical and ignore the psychological is to treat only half the client.
Physiological Aspects of Dying
Medicine has numerous treatments for some of the physiological problems of suffering and
pain experienced in the dying process. Sometimes the treatments are sufficient; at other

times, they barely address the problem. Untreated or undiagnosed physiological problems
may cause or enhance psychological difficulties for dying clients.
Separating the psychological from the physiological is difficult. For example, pain and
suffering, if untreated by therapy or medicinal means, may prove to be a psychological barrier for
clients, their families, and health professionals.
Loss of communication skills, such as in the aphasic client or in the comatose client, may
be frustrating and unbearable. If clients are indecisive or suffer from dementia because of
physiological changes, they may not be able to participate in the decision-making process of
their life-threatening illness. Family members may need to assume greater roles in talking
for clients and making decisions.
Other common physiological problems encountered include loss of bodily functions; inability to move
or ambulate; inability to eat or drink; and inability to tolerate medications,
treatments, light, or sound. In the hospital setting, these symptoms may be treated without
much difficulty. However, if clients choose to die at home, professional help or training may
prove valuable. If clients become severely disabled physically, they may be reluctant to go
anywhere, even to the ambulatory health care setting. Family members may become exhausted caring
for their loved ones or be unable to administer some of their treatments. The
more severe these physiological problems, the more difficult daily existence becomes.
Physiological difficulties may hinder sexual identity and involvement. The expression of
sexuality may be altered. The physiological and psychological aspects of sexuality are so intertwined
that cause and effect are difficult to determine. It may be difficult or impossible to
have sexual intercourse; however, there are many other ways to express love and caring or to
relieve sexual tension. A discussion of the expression of sexuality and related client problems needs to
be initiated with the client and partner.
Physiological and psychological problems are to be anticipated, diagnosed, and treated as
much as possible. Treating the physiological and psychological aspects of clients enables
total client care.
Stages of Grief
Elisabeth Kübler-Ross defines five stages of grief or responses to dying as follows. There is
no set period for any one stage, nor will every dying person go through every stage. Some believe that
no real grief work begins until you have been through all five stages. Some may
stay in denial until death; others may manage denial and bargaining and stumble in depression. Still
others may move back and forth from one stage to another. Some may move
through some or all of the stages several times. There is no set or acceptable pattern. Each
dying client is an individual, as are family members. However, the stages do offer information on how
to relate to clients and their families, who will experience similar stages.
Elisabeth Kübler-Ross defines five stages of dying and death:
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Denial
Clients may deny their life-threatening or terminal illness or go through periods of disbelief.
Sometimes it is a result of shock when they are first told. Clients commonly say, “This is not
228 Chapter 16 ▲ DYING AND DEATH
happening to me” or “I’ll go to another physician to see what’s wrong.” Denial generally is a
temporary defense and offers therapeutic meaning to clients.
Health professionals should listen to clients during this stage. Trying to contradict clients
or force them to believe what is happening to them will be to no avail. Encourage clients to
talk about death. Listen, listen, and listen.
Anger
Clients suddenly realize “It is me. This is happening to me. Why me?” They may become
“problem clients” and are envious and resentful. Anger may be dispersed in all directions, at
people and toward the environment. Rage and temper tantrums can occur. Professionals and
family members need to be understanding no matter how angry the client becomes. Listening to clients
is important to allow them to vent their own feelings.
Bargaining
During this stage, clients try to make deals with physicians, God or higher being, or family,
usually for more time or for a period of comfort without pain. Clients tend to be more cooperative and
congenial. Common responses include the following: “Please let me see my homeland again.” “I’ll be
so good, if I can just have 3 pain-free hours.” “Dear God, I’ll never … if
you make me well.” Health professionals can listen to dying clients’ requests but not become
a party to the bargain. Some bargaining may be associated with guilt, and any indication of
this should be mentioned to the physician. Bargaining can have a positive effect. It may give
the client the hope and stamina to reach a desired goal. It is OK to mourn and cry. Allow for
silences.
Depression
The dying client’s body is deteriorating, sometimes rapidly; financial burdens are likely increasing;
pain is unbearable; and relationships are severed. All can lead to depression. The
dying are losing everything and everyone they love. Dying may be a time of tears, and crying may
allow relief. Professionals who are happy, loud, and reassuring will not provide
much help to depressed clients. Clients may need to express their sorrow to someone or
merely have someone close. They may have little need for words at this stage. Simple tasks
may be impossible. Helplessness is real.
Acceptance
The final but perhaps not lasting stage is when clients are accepting of their fate. They usually are tired,
weak, and able to sleep. They are not necessarily happy, but rather at peace.
Professionals will be aware that clients may prefer to be left alone and not bothered with
world events or family problems. Family members usually require more help, understanding,
and support than clients in this stage. Touching and the use of silence may prove helpful.