Class/ SOC of Death, Dying and Grief Assignment Description: integrative Essay #2: Integrate Kubler-Ross, Aries, Gawande and the other materials in this section around a core theme. Be comprehensive but also precise. Use precise citation machinery and a bibliography. 3 pagesBasically, create a core theme from these books and films/ documentaries, and give examples from them. The only sources you can use is these readings and films / documentaries. I attached one of the readings as a PDF and the others I couldn’t. 3 pages ASA format Readings: 1-Aries( Western Attitudes Towards Death) 2- kubler Ross ( On Death & Dying) 3- Gawande (Being Mortal) Films/ documentaries: 1-Facing Death: Elisabeth Kubler-Ross 2- Being Mortal 3- how to die in Oregon
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On Death and Dying By Elisabeth Kubler-Ross
Contents:
* Foreword by C. Murray Parkes
* Acknowledgments
* Preface
Section
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
Title
Page
On the Fear of Death ………………
Attitudes Toward Death and Dying ………………
First Stage: Denial and Isolation ………………
Second Stage: Anger ………………
Third Stage: Bargaining ………………
Fourth Stage: Depression ………………
Fifth Stage: Acceptance ………………
Hope ………………
The Patient’s Family ………………
Some Interviews with Terminally I’ll Patients ………………
Reactions to the Seminar on Death and Dying ………………
Therapy with the Terminally Ill ………………
=========================
Foreword
by C. Murray Parkes
°I wish I could tell people how nice it can be to die of cancer.” These surprising words were spoken
to me recently by a woman who died peacefully a few days later. She never met Dr. Kubler-Ross,
but I do not doubt that, had she been a patient in Billings Hospital, she would have been glad of the
opportunity to talk about dying at Dr. Ross’s seminar and to have attempted to exorcise the
irrational fears to which doctors and clergy as well as patients and their relatives are subject.
Not that it is entirely irrational to fear death. Whatever we believe is to come after death, the loss of
so many of the things that we prize must be painful, and since our own death gives grief to others it
is natural that we feel sad on their behalf.
But the relinquishment of life is possible (particularly if, through illness, our body has lost its
appetite for living), and grief can pass. Those who have the privilege of caring for the person who
is about to die know that the final phase of life can be a time of peaceful acceptance, a time of calm
which contrasts with the tensions and frustrations of the battle for survival.
“Can be”-but, too often, is not. Too many things militate against a fitting approach to death. Despite
all evidence to the contrary, we insist on assuming we are immortal and assuring each other that all
of us are on a space walk, immune from the laws of celestial gravity. “Don’t worry,” says the doctor,
“it’s only a little ulcer”; “Come now,” says the nurse, “You mustn’t talk like that, you’re going to be
all right.”
A well-rounded life should have a beginning, a middle, and an end. Not just for reasons of
symmetry but because, though I may be mortal, the social system of which I am a part is immortal
and my arrival into and departure from that social system are important events which need to be
prepared for. Medicine should not confine itself to the prevention of death any more than family
planning should confine itself to the prevention of birth. But it is, perhaps, no coincidence that the
century which produced
(VIII)
Marie Stopes and Alexander Fleming also produced Grantly Dick Reid and Elisabeth Kubler-Ross.
It seems that incipient mortality, though less easy to predict than incipient nativity, is equally a
proper matter for preparation and study.
Dr. Ross is not alone in her concern for those who are about to die. Important work has been done
in Britain by Professor John Hinton and Dr. Cicely Saunders, and already two scientific journals
are appearing in the United States that deal exclusively with matters pertaining to death and
bereavement.” France too has its “Societe de Thanatologie de la Langue Francaise”, which
publishes a regular Bulletin.
But death (like life) is too serious a subject to be taken solemnly, and one of the most cheerful,
friendly places I know is a small institution in south London which specializes in the treatment of
cancer patients with a prognosis of six weeks or less. Here the aim is to augment the quality rather
than the quantity of the life that remains to each patient, and if there are times of sorrow and regret
when patients and their families face up to the real disappointments that occur, there are also times
of happiness and peace when people stop striving for unreal ends and make a good job of a real
ending.
In this book we shall find described the way in which some American people coped with death.
Despite the cultural differences, they are very similar to people in the United Kingdom and there is
no need for me to attempt to translate the clear exposition which Dr. Ross has given us. Others
might (and probably will) adopt a different terminology when describing the phases through which
the dying patient passes in the course of his illness. Since individual variation is so great, it is
unlikely that any one conceptual system could be applied to all. But the overall picture, and the
illustrative examples on which it is based, must stand. They stand as a reproach to some, an
encouragement to others, and a lesson to all.
This book is important reading for nurses, doctors, clergy, and others whose work brings them into
contact with the dying. It is also recommended to any reader who refuses to believe that the best
way to deal with fear is to run away.
* One has the awesome title of The Journal of Thanatology and the other Omega.
=========================
Acknowledgments
There are too many people who have directly or indirectly contributed to this work to express my
appreciation to them individually. Dr. Sydney Margolin deserves the credit for having stimulated
the idea of interviewing terminally ill patients in the presence of students as a meaningful learningteaching model.
The Department of Psychiatry at the University of Chicago Billings Hospital has supplied the
environment and facilities to make such a seminar technically possible.
Chaplains Herman Cook and Carl Nighswonger have been helpful and stimulating co-interviewers,
who also have assisted in the search for patients at a time when that was immensely difficult.
Wayne Rydberg and the original four students by their interest and curiosity have enabled me to
overcome the initial difficulties. I was also assisted by the support of the Chicago Theological
Seminary staff. Reverend Renford Gaines and his wife Harriet have spent countless hours
reviewing the manuscript and have maintained my faith in the worth of this kind of undertaking. Dr.
C. Knight Aldrich has supported this work over the past three years.
Dr. Edgar Draper and Jane Kennedy reviewed part of the manuscript. Bonita McDaniel, Janet
Reshkin, and Joyce Carlson deserve thanks for the typing of the chapters.
My thanks to the many patients and their families is perhaps best expressed by the publication of
their communications.
There are many authors who have inspired this work, and thanks should be given finally to all those
who have given thought and attention to the terminally ill.
Thanks is given to Mr. Peter Nevraumont for suggesting the writing of this book as well as to Mr.
Clement Alexandre, of the Macmillan Company, for his patience and understanding while the book
was in preparation.
(x)
Last but not least I wish to thank my husband and my children for their patience and continued
support which enables me to carry on a full-time job in addition to being a wife and mother.
E. K-R.
=========================
Preface
When I was asked if I would be willing to write a book on death and dying, I enthusiastically
accepted the challenge. When I actually sat down and began to wonder what I had got myself into,
it became a different matter. Where do I begin? What do I include? How much can I say to
strangers who are going to read this book, how much can I share from this experience with dying
patients? How many things are communicated nonverbally and have to be felt, experienced, seen,
and can hardly be translated into words?
I have worked with dying patients for the past two and a half years and this book will tell about the
beginning of this experiment, which turned out to be a meaningful and instructive experience for all
participants. It is not meant to be a textbook on how to manage dying patients, nor is it intended as
a complete study of the psychology of the dying. It is simply an account of a new and challenging
opportunity to refocus on the patient as a human being, to include him in dialogues, to learn from
him the strengths and weaknesses of our hospital management of the patient. We have asked him to
be our teacher so that we may learn more about the final stages of life with all its anxieties, fears,
and hopes. I am simply telling the stories of my patients who shared their agonies, their
expectations, and their frustrations with us. It is hoped that it will encourage others not to shy away
from the “hopelessly” sick but to get closer to them, as they can help them much during their final
hours. The few who can do this will also discover that it can be a mutually gratifying experience;
they will learn much about the functioning of the human mind, the unique human aspects of our
existence, and will emerge from the experience enriched and perhaps with fewer anxieties about
their own finality.
E. K.-R.
=========================
(I)
On the Fear of Death
Let me not pray to be sheltered from dangers
but to be fearless in facing them.
Let me not beg for the stilling of my pain
but for the heart to conquer it.
Let me not look for allies in life’s battlefield
but to my own strength.
Let me not crave in anxious fear to be saved
but hope for the patience to win my freedom.
Grant me that 1 may not be a coward,
feeling your mercy in my success alone;
but let me find the grasp of your hand in my failure.
Rabindranath Tagore, Fruit-Gathering
Epidemics have taken a great toll of lives in past generations. Death in infancy and early childhood
was frequent and there were few families who did not lose a member at an early age. Medicine has
changed greatly in the last decades. Widespread vaccination has practically eradicated many
illnesses, at least in western Europe and the United States. The use of chemotherapy, especially the
antibiotics, has contributed to an ever decreasing number of fatalities in infectious diseases. Better
child care and education have effected a low morbidity and mortality among children. The many
diseases that used to take an impressive toll among the young and middle-aged have been
conquered. The number of old people is on the rise, and, as a result, there is an increasing number
of people with malignancies and chronic diseases associated particularly with old age.
Paediatricians have less work with acute and life-threatening situations but they see an ever
increasing number of patients suffering from psychosomatic disturbances and from adjustment and
behaviour problems. Physicians have more people in their waiting rooms with emotional problems
than they have ever had before, but they also have more elderly patients who not only try to live
with their decreased physical abilities and their limitations but who also face loneliness and
isolation with all its pains and anguish. The majority of these people are not seen by a psychiatrist.
Their needs have to be elicited and gratified by other professional people, for instance, chaplains
and social workers. It is for them that I am trying to outline the changes that have taken place in
the last few decades, changes that are ultimately responsible for an increased fear of death through
unfamiliarity, the rising number of emotional problems, and the greater need for understanding of
and coping with the problems of death and dying.
When we look back in time and study former cultures and peoples, we are impressed that death has
always been distasteful to man and will probably always be. To a psychiatrist this is very
understandable and can perhaps best be explained in terms of our understanding of the unconscious
parts of the self; to the unconscious mind, death is never possible in regard to ourselves. It is
inconceivable for our unconscious to imagine an actual ending of our own life here on earth, and if
this life of ours has to end, the ending is always attributed to a malicious intervention from the
outside by someone else. In simple terms, in our unconscious mind we can only be killed; it is
inconceivable to die of 1 a natural cause or of old age. Therefore death in itself is associated with a
bad act, a frightening happening, something that in itself calls for retribution and punishment.
One is wise to remember these fundamental facts because they are essential in understanding some
of the most important, but otherwise unintelligible, communications of our patients.
The second fact that we have to comprehend is that in our unconscious mind we cannot distinguish
between a wish and a deed. We can all recall illogical dreams in which two completely opposite
statements occur side by side-very acceptable in our dreams but unthinkable in our waking state.
just as we, in our unconscious minds cannot differentiate between the wish to kill somebody in
anger and the act of killing, so the young child is unable to distinguish between fantasy and reality.
The child who angrily wishes his mother to drop dead for not having gratified his needs will be
traumatized greatly by her actual death-even if this event is not linked closely in time with his
destructive wishes. He will always take part or all the blame for the loss of his mother. He will
always say to himself-rarely to others-“I did it, I am responsible, I was bad, therefore Mommy left
me.” It is well to remember that the child will react in the same manner if he loses a parent by
divorce, separation, or desertion. Death is often seen by a child as impermanent, and therefore little
distinct from a divorce, after which he may have an opportunity to see a parent again.
Many a parent will remember remarks of their children such as, “I will bury my doggy now and
next spring when the flowers come up again, he will get up.” Maybe it was the same wish that
motivated the ancient Egyptians to supply their dead with food and goods to keep them happy and
the old American Indians to bury their relatives with their belongings.
When we grow older and begin to realize that our omnipotence is not really so great, that our
strongest wishes are not powerful enough to make the impossible possible, the fear that we have
contributed to the death of a loved one diminishes-and with it the guilt. The fear remains
diminished, however, only so long as it is not challenged too strongly. Its vestiges can be seen daily
in hospital corridors and in people associated with the bereaved.
A husband and wife may have been fighting for years, but “-hen the partner dies, the survivor will
cry and be overwhelmed with regret, fear, and anguish, and will fear his own death more, still
believing in the law of talion-an eye for an eye, a tooth for .: tooth-“I am responsible for her death, I
will have to die a pitiful death in retribution.”
Maybe this knowledge will help us to understand many of the customs and rituals that endured over
the centuries and whose purpose is to diminish the anger of the gods or society, as the case may be,
thus decreasing the anticipated punishment. I think of the ashes, the torn clothes, the veil, the Klage
Weiber of the old days-they are all means of asking others to take pity on them, the mourners, and
are expressions of sorrow, grief, and shame. A person who grieves, beats his breast, tears his hair,
or refuses to eat, is attempting self-punishment to avoid or reduce the anticipated external
punishment for the blame he expects on the death of a loved one.
The grief, shame, and guilt are not very far removed from feelings of anger and rage. The process
of grief always includes some elements of anger. Since none of us likes to admit anger at a
deceased person, these emotions are often disguised or repressed, and prolong the period of grief,
or show up in other ways. It is well to remember that it is not up to us to judge such feelings as bad
or shameful but to understand their true meaning and origin as something very human. In order to
illustrate this I will again use the example of the child-and the child in us all. The fiveyear-old who
loses his mother is both blaming himself for her disappearance and expressing anger at her for
having deserted him and for no longer gratifying his needs. The dead person then turns into
something the child loves and wants very much, but also hates with equal intensity for this severe
deprivation.
The ancient Hebrews regarded the body of a dead person as something unclean and not to be
touched. The early American Indians talked about evil spirits, and shot arrows into the air to drive
the spirits away. Many other cultures have rituals to take care of the “bad” dead person, and they all
originate in this feeling of anger which still exists in all of us, though we dislike admitting it. The
tradition of the tombstone may originate in this wish to keep the bad spirits deep down in the
ground, and the pebbles that many mourners put on the grave are left-over symbols of the same
wish. Though we call the firing of guns at military funerals a last salute, it is, perhaps, the same
symbolic ritual as the Indian used when he shot his spears and arrows into the skies.
I give these examples to emphasize that man has not basically changed. Death is still a fearful,
frightening happening, and the fear of death is a universal fear even if we think we have mastered it
on many levels.
What has changed is our way of coping and dealing with death and dying and with our dying
patients.
Having been raised in a country in Europe where science is not so advanced, where modern
techniques have just started to find their way into medicine, and where people still live as they did
in this country half a century ago, I may have had an opportunity to study a part of the evolution of
mankind in a telescoped form.
I remember, as a child, the death of a farmer. He fell from a tree and was not expected to live. He
asked simply to die at home, a wish that was granted without questioning. He called his daughters
into the bedroom and spoke with each one of them alone for a few minutes. He arranged his affairs
quietly, though he was in great pain, and distributed his belongings and his land, none of which was
to be split until his wife should follow him in death. He also asked each of his children to share in
the work, duties, and tasks that he had carried on until the time of the accident. He asked his friends
to visit him once more, to bid good-bye to them. Although I was a small child at the rime, he did
not exclude me or my siblings. We were allowed to share in the preparations of the family just as
we were permitted to grieve with them until he died. When he did die, he was left in his own home,
which he had built, and among his friends and neighbors who went to take a last look at him where
he lay in the midst of flowers in the place he had lived in and loved so. In that country today there
is still no make-believe slumber room, no embalming, no false make-up to pretend sleep. Only the
signs of very disfiguring illnesses are covered up with bandages and only infectious cases are
removed from the home prior to the burial.
Why do I describe such “old-fashioned” customs? I think they are an indication of our acceptance
of a fatal outcome, and they help the dying patient as well as his family to accept the loss of a loved
one. If a patient is allowed to terminate his life in the familiar and beloved environment, less
adjustment is required of him. His own family knows him well enough to replace a sedative with a
glass of his favourite wine; or the smell of a homecooked soup may give him the appetite to sip a
few spoons of fluid which, I think, is still more enjoyable than an infusion. I do not minimize the
need for sedatives and infusions and realize full well from my own experience as a country doctor
that they are sometimes life-saving and often unavoidable. But I also know that patience and
familiar people and foods could replace many
a bottle of intravenous fluids given …
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