Healthcare Ethics Dying Tereza Stehlová, Bc. Semester essay 2022 Table of Contents Home. 3 1 Stages of dying. 4 1.1 The first stage of so-called denial or closing one's eyes to reality and loneliness... 4 1.2 Second stage - anger. 5 1.3 Third stage-negotiation. 5 1.4 Fourth stage-depression. 6 1.5 Fifth stage-consent, acceptance. 6 2 Communication with terminal patients, elderly people. 7 3 Family after the death of a member 8 4 Death. 9 5 Euthanasia and assisted dying. 9 6 Conclusion. 11 List of literature used. 12 Home I have chosen this topic for my semester essay because death and dying is generally considered a controversial topic in our society and in my opinion, society is unable to grasp it properly, to accept it as part of a natural process and therefore people shy away from talking about it, because it evokes only negative emotions and they are not able to view the dying process from the perspective of the dying person, who should be given maximum understanding, his needs should be taken into account and, above all, he should be perceived as a person, creating a peaceful passing and ideally a pleasant environment in the family circle. Even medication can be replaced by something more pleasant, such as a glass of wine, kind treatment, the closeness of loved ones or one's family. The dying person should not die alone. In earlier times, people believed more in God, in a better next life, in an afterlife that would free people from suffering and pain. Pain was a part of our lives, more natural than today. Dying and death had their logical meaning at the end of every human life. On the fear of death "Grant that I may not ask for protection from danger, but the courage to face all dangers. Grant that I may not beg for the alleviation of my pain, but the strength to endure all the pain. Let me not seek allies in the battles of life, but only your own power within yourself. Grant that in my anxious fear I may not ask for salvation, but let me hope in patience that I shall reach freedom. Don't let me be a scaredy-cat, who feels your grace only in what he does well, but may I find a firm grip on your hand even in difficult times." Rabindranath Thakur - Gathering Fruits." 1 Stages of dying 1.1 The first stage is called denial or closing one's eyes to reality and loneliness. Most of the patients reacted very surprised to the discovery of their disease and this reaction is naturally very common. Patients often ask the question, "Me? That's not possible! It doesn't concern me!" Often, patients do not even acknowledge the disease after being told their diagnosis. It is a kind of defence. An escape from reality. They keep lying to themselves that, for example, the doctors made a mistake in their diagnosis, etc. They therefore demand further examinations to disprove the current diagnosis. It is a kind of imaginary escape from reality, a reflex defence against the terror of reality. It is a kind of self-delusion, a turning a blind eye to one's illness. Coping with chronic illness can be overwhelming for patients and caregivers and can be hindered by the mechanism of denial, and therefore denial is a major issue for healthcare professionals. Assessing illness denial is far from easy and there is a lack of concise tools appropriate for the medical setting. [5] Often these patients avoid the statements of doctors and nursing staff, because they are the ones who bring the patient back to the harsh reality. A sensitive approach by doctors, medical staff or family is important. To be able to put oneself in the shoes of a person who has just discovered the seriousness of their illness. The ability to listen, to respect the patient's needs, to gain his or her trust, forms the basis of all communication between doctors, nurses or people who are close to the patient. The patient has the right to refuse treatment, but it is always advisable to sit down with the patient and offer possible alternatives. It is then up to the patient to decide whether to accept the treatment. The patient can settle down at this stage of denial and negation and never leave. He isolates himself from the outside world, the people around him or his family. [1] What is important is again our understanding, listening, knowing and being able to empathise with the patient's situation. To give the sick person the comfort that can "break the ice" and then the sick person can talk openly about his or her accumulated thoughts, fears and anxieties, unease and discomfort, and ideas. 1.2 The second stage - anger After the first phase, the second phase, the stage of anger, resentment, envy, usually follows. This is a very difficult period, when the patient's surroundings, medical staff, families have a very hard time with the patient in the angry phase. The patient often asks himself the question: 'Why me? Why not that one? Why did it have to happen to me?" In this phase, the patient is full of anger, annoyance, irritability, negative emotions. It is very important to give the patient enough time and attention. Our helpfulness, listening skills, attention, empathy, tolerance to justified or unjustified anger, recognition of this anger will sooner or later calm the patient down and he will better bear the last months, days, hours of his life. He will no longer express his desires and wishes by shouting and anger. He will get the feeling that he still counts.[1] 1.3 Third stage-negotiation This third phase is rather fleeting, less known, but very important for the patient. In this phase the patient tries to discover the arrival of the inevitable, it is a kind of negotiation, a plea. The sick person pleads, negotiates, changes tactics, promises and believes that he will be rewarded for his good behaviour, that his life will be prolonged, that he will not suffer pain and difficulties. The sick person bargains for a reprieve, promises good behaviour, sets himself a deadline after which he will no longer require anything. But none of the sick keep their promise. Usually the sick person makes a bargain with God and keeps it a strict secret. Some patients, as the price of a longer life, declare that they will dedicate their lives to God and the service of the Church. Others promise to donate their bodies to scientific purposes after death. [1] These promises can also come from a hidden sense of guilt. Therefore, again, it is very important not to ignore the comments of the sick person and try to find where the guilt comes from. It is a kind of reaction to the suspicion that the illness is serious. The patient is capable of making many efforts and sacrifices to reverse this situation. He adjusts his scale of values, looks for alternative ways of treatment. Anyone who is close to the patient should realize that the patient needs time to accept the reality of impending death. Give the sick person enough time. Talk to the sick person about things and people that are important to them. To be tolerant, empathetic, a point of support in such a difficult situation. 1.4 Fourth Stage-Depression When the sick person is aware of the nature of his illness, knows and experiences its attacks, feels himself to be increasingly weak, is constantly and more often hospitalized in the hospital, can no longer delude himself, the stage of depression sets in. Depression in older people is a major public health problem. As the response to antidepressants is often unsatisfactory in this age group, there is a need for evidence-based non-pharmacological treatment options. [6] The anger, the bargaining, the bargaining, the denial of the disease takes a back seat to the sense of terrible loss. For example, a breast cancer patient is distressed by her changed appearance, but this is only one of the other losses in this case. The sick person loses much more. In many cases, sick people lose their jobs, and sick mothers cannot take care of their families and children. At first, the sick lose some of their daily pleasures or activities, later they are isolated in a hospital environment and, slowly and surely, they can be said to lose everything. On top of this, they have to cope with a great deal of pain and accept the fact that their departure from the world is imminent. It is a time when there are empty feelings, deep sadness at the loss of health, new possibilities and sorrow in the soul. The sick person is confronted with the fact that death is approaching, the end of everything. The sick person may also get the impression that this period lasts forever.[1] 1.5 Fifth stage-consent, acceptance If the sick person has had enough time to go through the previous stages, he is now in a state of reconciliation, acceptance. In this stage he does not feel anger at his fate, he is not depressed, he does not mourn the impending loss of so many people important to him. It is in the stage of so-called silent expectation. It is a slowly growing need to prolong the part of the day represented by sleep. It is not an escape from reality or from pain, resignation or despair. The time for final rest is coming, the battle is fought, the pain is gone. The sick person wishes to be alone, avoids news from outside, avoids visitors. Verbal communication is replaced by non-verbal communication or moments of silence. It is important that the dying person gets the feeling that he or she is not alone even at this moment. Our closeness or the closeness of the family can only reinforce this feeling. He is not communicating with us, with his family, he is weak, tired. All it takes is a simple squeeze of the hand, to be able to listen and share his peace and expectations. Say nothing, just be near him, be with him. The stage of consent must not be understood as a happy state, but it is a state when the sick person is freed from harsh feelings and the time has come for the last peace before the long journey. In this period the family of the sick person needs more help and support than the dying person. The latter has attained a certain degree of peace and his interests have been reduced to a minimum. At the end of our days we return again to the stage from which we have emerged. The circle of life is closing.[1] 2 Communication with terminal patients, elderly people Communication with people, with terminal patients or the elderly, forms the basis of all our actions, activities, living. To truly communicate with sick people, it is very important that we let them know that we really want to share their sorrows, their worries, their thoughts. We ourselves, before we enter the patient's room, must be ready to communicate with them, have enough experience, be mature enough. We ourselves must have a sufficiently studied attitude to the question of dying and death to be able to sit down and talk with a patient with a terminal illness or an old person calmly and without anxiety. The doctor, the nurse, the therapist, the chaplain, everyone who comes to the sick person must make it clear to him or her by his or her demeanor, by his or her actions, by his or her words, that he or she is willing to talk openly and frankly with him or her without fear or anxiety. To give the sick person hope that all is not lost. The presence of an understanding person who is willing to sit down and listen is important. Not to impose anything on the sick person, to be kind, empathetic, helpful, respectful of the needs of the sick person. Not to condemn the patient for his unkind, aggressive behaviour and to show our understanding and concern for him. To help him find answers and solutions to his questions. It is relatively easier to communicate and work with patients who are able to express their needs, thoughts, attitudes, intentions, feelings in words. But much more we meet with sick or elderly people who cannot talk to us due to their illness or senility. With patients who are so weak and tired from their illness, patients on ventilators, after strokes, unconscious, it is very important not to walk away from them. To be able to sit with them and share their thoughts. To be able to caress them, to hold their hand and to surround them with love, understanding, friendship, closeness, concern and perfect care. Even these sick people hear us and feel us. In a dying person, when the pain has ceased, the need for food has disappeared, and the sick person is almost imperceptible, silence is of much greater value than words. To stay silently and without words by the dying person and hold his hand. Quietly and without words, to surround the dying person with love and the feeling that he or she is not alone even in this difficult moment. [2] As is evident, by all our actions, appearances, and communication, we can greatly alleviate the suffering of a sick or dying person. To help him or her cope better with difficult moments, to help him or her find answers and solutions to his or her questions. To show them our sympathy, interest, understanding, sense of belonging, love. To make the sick person feel that he/she is not alone in all the problems and pain, even in the worst moments. 3 Family after the death of a member There comes a time when a family has lost a loved one or relative. They agonize and question their conscience about whether they could have done something more, something different and better. If she has already gone through all five stages before the death of her loved one and was already in a state of reconciliation, she may go through these stages again and much more difficult. Now the family of the deceased is in a grieving process in which the bereaved mourn the loss that has already occurred. This grief usually lasts for an extended period of time. During this period, again, the family must deal with the problems that have arisen. Relationships between relatives may also be disturbed if, for example, property settlements are to be made. It is essential to help the family to reach a stage of reconciliation. Recognise that everyone has to die at some point. To realise that our loved one has died, but other people who need us are here with us. To lend a helping hand, to be tolerant, to respect the processes of experiencing. Not to give back with the same coin if the family is in a state of anger or despair. [2] It would be good if we could be helpful to the relatives. Let them talk, let them scream, let them cry, let them express their feelings, what is bothering them. The bereaved have a long journey of pain and grief ahead of them. They need help and support, from the time their loved one was misdiagnosed to the time that may last for many months after the patient's death. The presence of a human being, a friend, is important, but it doesn't matter too much whether it is a doctor, a psychologist or a priest. Some don't even need the help of a professional. My opinion is, and the text makes it clear, that kind treatment, respect, understanding, a kind word, a caress, an understanding smile on the face, the art of listening, giving a helping hand without anger or judgment, is sometimes much more than any medical therapy. This treatment is very effective in any situation. 4 Death Our only certainty, our only certain future, is death. The life we live in this world is only a tiny fraction of it. If we live right, it means we learn to love and never have to fear dying. All those who die at the moment of death experience the same thing. But dying and death need not be feared. Dying is a human process just as it is at birth. Death is analogous to birth, birth into another existence, transition to a nicer home. Dying is such a moving to a nicer life, one might say. Death is not a matter of faith, but a matter of certainty of knowledge. Death is merely a transition from earthly life to the other side, to another state of consciousness in which we are still growing. We lose only our physicality. In this state we experience a sense of peace, harmony, perfect and unconditional love. We are not judged here. We are in a state without any negation. We are in a much more beautiful life, a life of love. In a life after life. Near-death experiences, out-of-body experiences, make some people smile. Belief in an afterlife is perhaps, according to Haskovcova, one of the defense mechanisms that people seek and need because they cannot imagine and accept that it does not exist, that it was not. [2] 5 Euthanasia and assisted dying Assisted dying is a highly controversial moral issue involving both physician-assisted dying and voluntary active euthanasia. End-of-life procedures are debated in many countries, with assisted dying receiving varying attention in different jurisdictions. Advocates of assisted dying focus on respect for autonomy, self-determination and the prevention of suffering. On the other hand, concerns have been raised about the interpretation of the constitutional right to life and its balancing with the premise of assisted dying, along with the impact of assisted dying on the doctor-patient relationship, which is fundamentally based on trust, mutual respect and the premise of 'first do no harm'. Most physicians remain untrained in such decision making and are concerned about crossing key ethical divides. Given the increasing number of assisted dying cases, this topic will certainly be mentioned more and more frequently by the public. [3] The problem of suffering in people with chronic and terminal illness cannot be ignored. Compassionate, effective and ethical solutions must be found. In the Netherlands, where assisted suicide is practiced but remains officially illegal, 85% of assisted suicides occur in the elderly and most of them involve the help of general practitioners.[4] 6 Conclusion I am convinced that for many people the idea of dying and death is unimaginable. They fear the moment of pain, suffering, dying, loneliness, death, leaving everything they love so much. For all these reasons, any talk, imagination or thought of death is banished from our consciousness. We don't talk about the subject, we avoid it. It was Elisabeth Kübler-Ross who attempted to speak publicly on the subject. She spoke to the dying, the elderly and their families. On the basis of these conversations, she described and defined the five stages of coping with a serious illness. Her work was imbued with love and a desire to help others; it was her mission and purpose in life. As a health care professional, it is important for me to know and understand the stages that patients go through, because there will come a time when I too will be sitting next to a dying family member, relative or friend, and perhaps I can more easily identify with the situation and find understanding for their suffering and needs and be able to make their last moments more comfortable. In my seminar essay I have tried to outline how people in the terminal stage react and what they experience in the course of their illness, and what difficulties the family of the sick or deceased person goes through. I also sought to clarify what death means to me and how I view death. List of literature used [1] Kübler-Ross Elisabeth. 1993. On Death and Dying 1St Collier books trade ed. New York Toronto New York: Collier Books ; Maxwell Macmillan Canada ; Maxwell Macmillan International. [2] HAŠKOVCOVÁ, Helena. Thanatology: the science of dying and death. 1st ed. Prague: Galén, c2000. 191 p. [3] Fontalis A, Prousali E, Kulkarni K. Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate? J R Soc Med. 2018 Nov;111(11):407-413. doi: 10.1177/0141076818803452. PMID: 30427291; PMCID: PMC6243437. [4] Koenig HG. Legalizing physician-assisted suicide: some thoughts and concerns. J Fam Pract. 1993 Aug;37(2):171-9. PMID: 8336099. [5] Rossi Ferrario S, Panzeri A, Anselmi P, Vidotto G. Development and psychometric properties of a short form of the Illness Denial Questionnaire. Psychol Res Behav Manag. 2019 Aug 22;12:727-739. doi: 10.2147/PRBM.S207622. PMID: 31686929; PMCID: PMC6709814. [6] Jonsson U, Bertilsson G, Allard P, Gyllensvärd H, Söderlund A, Tham A, Andersson G. Psychological Treatment of Depression in People Aged 65 Years and Over: A Systematic Review of Efficacy, Safety, and Cost-Effectiveness. PLoS One. 2016 Aug 18;11(8):e0160859. doi: 10.1371/journal.pone.0160859. PMID: 27537217; PMCID: PMC4990289.