Death And The Dying Process
As I was working on a future post about the ways we could pay tribute to our American Military Veterans,? I started to make a list of what would be the most personal and meaningful things for most people to do and for the veterans to receive. ? I came up with sending a short note,? or a seasonal card, or a letter telling them how much they are appreciated,? to veteran in a Veteran's Hospital,? or a Veteran's Home.? I knew that a better thing would? be to make a personal visit to a Veteran's Hospital, or to a Veteran's Home.
I allowed my mind to drift back 18 years in time,? to when a very good friend Dan,? was in a veteran's hospital in West Virginia.? He notified me that the doctors had discovered that he had lung cancer.? I immediately went down to the hospital in West Virginia to see him.? I was there when the doctor told him that the type of lung cancer that he had was in the lining of the lungs and that it was inoperable.? The doctor said to Dan:? "Mr. _______,? you will receive the best medical care that is possible.? We will keep you pain free and will assist you in being able to die with dignity."?
At that moment I made up my mind that I was going to be a part of Dan's "going away party".? Dan's son and I notified his friends of Dan's situation and most of them managed to visit him - entering a dying person's world takes courage.
Some of the servicemen from nearby basis would stop for a visit once in a while.? I was fortunate in that the doctor allowed me to spend time with Dan most of each day.? I had to leave the hospital after the evening visiting hours.? His doctor gave Dan permission to visit his grandchildren in their home on Christmas day.
I got to know many of the veterans in the hospital especially the smokers,? since they had to step out of the front door to smoke.? For the two months that I was there,? they always had cigarettes.? The fellows would stop in Dan's room for short visits and when their clergy came to see them , they made a point to send them to Dan's room as well.
For about six weeks,? every pastor,? priest or rabbi that came into the hospital made it to Dan's room,? before they left the hospital.?
Dan went on to his last post in February.
According to a new study,? When it is confirmed that a patient has becomes terminally ill, the relationships between patients, their caregivers and their primary doctors often become frustrating and uneasy for everyone. ?
The study, looks at what patients and their doctors are thinking and feeling,? as the end of life approaches for the patient.? The study shows that often patients feel abandoned by their doctors and/or caregivers.
It's scary for a lot of people to talk about death.? ?
But let's face it - You Are Going To Die and I Am Going To Die. In about 100 years from now, everyone who is reading this will be just a handful? of dust.?
We need to start talking about it sometime,? somewhere.? I am going to begin here.
The DABDA Theory of Coping With Death
Ellisabeth Kubler Ross
"Dying is nothing to fear. It can be the most wonderful experience of your life. It all depends on how you have lived."There is theory called the "DABDA Theory".? It is probably the most popular theory on understanding and coping with the process of death, that is taught in the colleges and universities in America. It is the accepted model of coping with a terminal illness that many professional people follow.? The theory was developed by the late Dr. Elisabeth Kubler-Ross.? She was a medical doctor, psychiatrist, and thanatologist.
DABDA is named that after the "five stages of coping". ? It involves: Denial,? Anger,? Bargaining,? Depression, and Acceptance.
In 1999, Time magazine named Elisabeth Kubler-Ross as one of the "100 Most Important Thinkers" of the past century.
?? Dr. Elisabeth Kubler-Ross, Early Speech -
?? Experiences With Dying Patients, 1975
In her 1969 book on "Death and Dying",? Dr. Kubler-Ross discusses this theory of coping in a linear fashion. In a linear fashion means that a person moves through one stage to reach the next stage. Dr. Kubler-Ross? later explained that the theory was never meant to be linear nor applied to all individuals. Dr. Kubler-Ross asserted the way a person moves through the various stages is just as unique as the person is unique.? The way in which a dying individual copes with the tragedy is deeply personal.
It is also important to remember that some people will experience all of the stages, some in order and some not in order.? Other people may only experience a few of the stages or they may even get stuck in just one of the stages and not go on to the others.
Very often,? the way a person has handled adversity in the past,? will affect how their diagnosis of terminal illness is handled.? As an example,? a person who has always avoided adversity in their life and has used denial to cope with tragedy in the past,? may find themself stuck in the "denial stage" of coping with their own death for a long time.? Or a person who has often used anger to deal with difficult situations may find themself unable to move out of the anger stage of coping.
Ellisabeth Kubler Ross.
"The ultimate lesson all of us have to learn is unconditional love, which includes not only others? but ourselves as well."
The Five Stages of Coping With a Terminal Illness
(1) Denial - Coping usually begins with the person thinking? "No way, I'm not going to die... not me."? Denial is usually only a temporary defense for most individuals.? Very often it is generally replaced with a heightened awareness of all the possessions and important individuals that will be left behind after their? death.
(2) Anger - "Not me" will usually give way to "Why me?" or? "It's not fair!" as the person begins to accept the reality of the illness and the inevitability of their upcoming death.? As a result they become angry.
(3) Bargaining - As the anger subsides, or even in it's midst, the person may begin to bargain for more time. "I'll do anything for a few more years."? This stage involves the hope that the person can somehow postpone or delay death.? Usually, the negotiation for an extended life is made with a higher power in exchange for their reformed lifestyle.
(4) Depression - When it becomes obvious that bargaining won't work, depression may set it. "I'm so sad, why should I bother with anything?"; "I'm going to die soon so what's the point?".? During this stage,? the dying person begins to understand the certainty of death.? Because of this,? the individual may become silent, refuse visitors and spend much of the time crying and grieving.? This process allows the dying person to disconnect from things of love and affection.
(5) Acceptance - If the person is able to move through one or more of the previous stages, they may be lucky enough to reach the stage of acceptance before death. "It's going to be okay."; "I can't fight it, I may as well prepare for it."? In this last stage, individuals begin to come to terms with their mortality,? or that of a loved one.
Ellisabeth Kubler Ross.
"There is no joy without hardship. If not for death, would we appreciate life?"
"Should you shield the valleys from the windstorms, you would never see the beauty of their canyons."
Dealing With Anger
Anger is one of the stages of DABDA.? Elisabeth? Kubler-Ross theorized that people often go through predictable stages when they are coping with inevitable death: Denial, Anger, Bargaining, Depression, and Acceptance. Not everyone goes through every stage,? and certainly not always in order,? but most dying people will experience a stage of anger and resentment.
Anger is a perfectly normal reaction to any severe loss that we experience.
A dying person stands to lose EVERYTHING and EVERYBODY that is important to him.
He or she feels robbed by their illness.? If they believe in a higher power, they may blame their God for causing their illness or for allowing it,? or for not curing it.
He might even resent his family and friends for continuing to live their normal lives,? while he slowly loses his own.
He may feel that the doctor "didn't do his job" or isn?t being honest with him. ? He may think that his nurses or other care givers don?t respond to his demands quickly enough,? and that everybody in his world has already started to forget him.
Anger is easily projected onto those around us,? so it?s only natural if your loved one?s anger has fallen on you.
?"We run after values that,? at death,? become zero.? At the end of your life,? nobody asks you how many degrees you have,? or how many mansions you built,? or how many Rolls Royces you could afford. ? That's what dying patients teach you."
Some Tips For Dealing With A Dying Person's Anger
(1) Maintain An Adult - Adult Relationship
It?s often easy to treat a sick person like a child;? it?s in our nature to care for and dote over the sick individual.?? When we fall into this pattern,? what was once an adult-adult relationship becomes one of adult-child.? Treating a dying adult as we would a child is likely to backfire and increase the anger the dying person is already feeling.
You may have fallen into this pattern without even realizing it,? and you will likely see anger directed at you for doing so.
It is frustrating and humiliating enough to lose your independence and privacy without being treated like a child.? A dying person typically wants to remain in control of themselves,? their life,? and their decisions for as long as possible.? Giving a dying person the power to make their own decisions,? to express their feelings,? and to remain as independent as possible is an important way to help them move through their anger.
(2) Don?t Take Their Anger Personally
Angry people typically look for someone to blame.? When the anger is directed at you,? it?s difficult not to take it personally and wonder,? ?What did I do wrong??? It?s important to remember that the dying person is not angry at you,? but at the illness and at his situation in general.? Although his anger might be directed towards you,? it is not by any fault of your own.
(3) See Their Anger From Their Point Of View
While it?s impossible to know exactly how another person is feeling, trying to see things from their point of view can help you to understand why they are acting a certain way.? Think about the dying person?s life -- everyone he loves,? the activities he enjoys,? the work he did,? the dreams he has for the future - and imagine how being told he is dying would affect those aspects of his life . Looking at it from this way, it?s no wonder that he is angry!? He stands to lose everyone and every thing that has ever meant anything to him.
(4) Give Permission To Get Mad At The Illness Itself
Understanding where a dying person's anger is coming from, helps us realize that his anger is justified.? Redirecting anger towards the illness can help the dying person cope with their feelings.? It might be helpful for you to be angry along WITH the dying person.? After all,? you are going to lose something as well.? Go ahead and get angry at the illness.
(5) Understand ?Righteous Anger?
A dying person may feel embarrassed,? ashamed, or shocked after an emotional outburst.? He may say something like,? ?I can?t believe I just did/said that. That?s not like me at all!?? You might even be thinking the same thing.? When everybody realizes and accepts the fact that anger is normal and okay.? This will often help a dying person to move through the anger stage of the dying process.
Talking about righteous anger together and sharing in the discovery of feelings of loss can reduce a lot of suffering.
Life Review
(Life Reconciliation)As a dying person comes to terms with their own mortality and begins to prepare for his death,? he may use life review, or life reconciliation, as a way to find closure and a sense of completion.
A life review doesn't follow any predictable pattern.? No two people can be expected to experience life reconciliation in the same way.? Having said that, we use five common stages of a life review that are helpful to understand: expression, responsibility, forgiveness, acceptance, and gratitude.
(1) Expression
Coming to terms with their impending death is extremely difficult for most people.? As a dying person moves through the DABDA stages of coping,? many emotions surface that need to be expressed.? Anger is often the dominant emotion for a majority of this time.
It's important for a dying person to express whatever emotions they are feeling.? Expressing intense feelings and releasing anger is essential to finding peace.? If a dying person is allowed complete freedom of expression,? their true healing on both the emotional and spiritual level is quite possible.
A dying person might need explicit permission to express their anger.? You might have to tell them "It's OK". ? They might fear that by expressing themself they will alienate their loved ones.? They might be angry at a higher power and feel ashamed by those feelings.? By expressing feelings of anger - at the illness,? at the unfairness of the world,? or at a higher power - a dying person is preparing themself for peace and acceptance.
(2) Responsibility
As a dying person reviews their life, they begin to realize how they have played a role in all that has happened to them.? They realize that their actions, their thoughts, and their lives are their responsibility alone.? Most people describe this as a freeing experience.? They come to know that they aren't to blame for their illness and that dying doesn't mean they somehow failed in life.? This realization of responsibility helps the dying person come to terms with all that has happened in their life and it prepares them for what's ahead.
(3) Forgiveness
Dr. Ira Byock discusses in his book "The Four Things That Matter Most",? what most people define as being the most important things to say before you die: "Thank you," "I forgive you," "Will you forgive me?", and "I love you."? Two of the four phrases are about forgiveness. That is a? strong emphasis on how important it is to offer and receive forgiveness before we die.
When you experiences true forgiveness, you release yourself from the bonds of hurt and bitterness. Forgiveness isn't about accepting wrongful behavior; nor is? it about releasing someone from his wrong doing. Forgiveness is about choosing to let go of the hurt and resentment that keeps us from living in peace.A dying person may find it easy to forgive others for past hurts, but they may have a hard time forgiving himself. ? He may wonder whether others can really forgive him for his wrongs,? big or small.? He may spend a lot of time asking others for their forgiveness,? petitioning a higher power for forgiveness,? and even offering his own forgiveness to those that he believes have hurt him.
There are some people will choose to die in unforgiveness,? and that's a valid choice.? Many others choose to invite inner peace before they die by offering and receiving forgiveness.
(4) Acceptance
Acceptance is the final stage in the DABDA theory of coping with death,? and is an important part of a life review.? We seem to have lost the reality that death is a natural process that will happen to each and every one of us,? choosing instead to fight death valiantly until the end.? When a dying person accepts their death as inevitable and stops fighting a losing battle,? they are not giving up on life,? but rather they allowing the natural order of life to complete its circle.
We don't have to like what we accept as reality,? but accepting that life is indeed complete is an important step towards dying in peace.? Just as a woman in labor can't be stopped from delivering her baby,? the final dying process cannot be stopped once it has begun.? When a dying person is able to accept their inevitable death,? they are opening themselves up to experience peace and contentment in their last days.
(5) Gratitude
After experiencing other aspects of a complete life review,? a dying person will often experience extreme gratitude for their life.? He will be thankful for the people in his life;? the experiences he's had,? whether good or bad;? and gratitude towards a higher power,? if he believes in one,? for the life he's had.? He may express his gratitude to his friends and loved ones and feel overwhelming joy.? This is how most of wish we could die, with a joyful heart and a spirit of peace.
Most people, whenever they are given the choice, want to die at home.? Making the decision where to spend the last day?s of life isn?t always easy.? Each choice has its positive and negative points.? Personal preferences are often over ruled by more practical reasons.
Caring for dying person is the ultimate act of love.
Being a caregiver for someone with a chronic or life limiting illness is stressful,? exhausting,? and, at times it is even confusing.? Once the sick person starts the dying process,? the task becomes more demanding and the emotions more intense.? You may find yourself wondering if you?re doing the right thing,? saying the right thing, even thinking the right thing.
If you are to care for your loved one at home during the dying process, keep the following things in mind:
(1) In the hospital, your loved one has several care givers on each of the 3 shifts a day.? You are one (1) person.? You are definitely going to need some RELIABLE help.
(2) The two things you must focus on as your loved one becomes weaker: safety and skin care. Safety may begin as rearranging your home to allow your loved one to move about more easily. ? This is also the time you should consider durable medical equipment (DME), such as a hospital bed, walker, wheelchair, or bedside commode, if you haven?t done so already.? Having the proper medical equipment and enough space to use them properly can prevent falls and other accidents.
(3) Growing Weakness and Fatigue. As a person begins the early stages of the dying process, they will grow weak and become increasingly sleepy.? This becomes more pronounced as the process continues toward death.? This is when caregiving often becomes more difficult, and the work is much more intensive.
Skin care is also vitally important during this time. As a person spends more and more time in bed or sitting in a chair they become at risk for developing pressure sores on their body. Pressure sores, also known as decubitus ulcers or bed sores,? are a result of continued pressure on the skin,? causing decreased blood flow to the area.? The problem may be compounded by friction on the skin from repositioning or sliding down in the bed and from lack of adequate nutrition.
Take care to keep your loved one's skin clean and dry.? If they are wearing adult diapers,? check the diaper at least every two hours while you?re awake and change it if it becomes soiled.
It?s also important to change your loved one's position in the bed every two hours,? while your awake if they are unable to do so themselves. Alternate between laying them on their back and turning to the right and left sides.? Keep a lot of pillows handy.? You will want to place one at your loved ones back,? one between their knees,? and perhaps one under their arm when they are on their side.
Check their skin often,? especially at the base of the spine (the tailbone),? heels,? elbows,? and hips.? Look for any areas of pinkness or redness.? Gently massage discolored areas with lotion to stimulate blood flow.? You may elevate the heels off the bed with pillows by placing the pillow under the ankles with the feet hanging off.? You can relieve pressure on the elbows in much the same way ? place pillows under the upper or lower arm making sure the elbows aren?t touching the pillows or the bed.
If your loved one already has a pressure sore or develops one while you are caring for them, don?t punish yourself. Even with meticulous care, patients can still develop them. Be sure to alert your health care provider to the wound and they can develop a plan to care for it properly. They may also recommend an air mattress to provide additional cushioning and relieve pressure.
(4) Decreased Appetite and Thirst. An appetite that has gradually decreased may dwindle all together as one approaches the very end of life.? Your loved one may tolerate small bites of soft food or may refuse to eat at all.? A time may come that they refuse to drink as well.
This is usually something that is very hard for the dying person?s loved ones to see.? We equate food with health,? and feeding people is viewed as an act of love.? Watching your loved one refuse food and fluids makes their impending death a reality.? Not being able to show your love with food may leave you feeling helpless.
Rest assured that the lack of eating and drinking is causing you more distress than your dying loved one.? Hunger and thirst are rarely a problem at the end of life.? Continue to offer a variety of soft foods as long as your loved one is conscious and allow them to refuse it.? Also continue to offer sips of water or other drinks of choice as long as they are conscious.
While patients rarely complain of thirst at the end of life,? a dry mouth can be a problem.? Lubricate your loved ones lips with a small amount of petroleum jelly or other lip balm to keep them from cracking.? You may moisten their mouth with a few drops of water from a straw or a moistened toothette swab,? which is a small sponge on the end of a stick.? This can be done while they are awake as well as once they loose consciousness.
Terminal restlessness is a syndrome that is seen in many dying persons.? Signs that your loved one is restless may include inability to relax,? picking at their clothing or sheets,? confusion and agitation,? and trying to climb out of bed.
Some causes of terminal restlessness are reversible such as pain,? a full bladder,? constipation,? or side effects of their medication.? If the cause cannot be identified or if the symptoms persist after treatment, your loved one may benefit from an anxiolytic such as lorazepam.? It?s important to notify your health care provider as soon as symptoms of restlessness start.? If your healthcare provider can identify the cause and treat it,? it can make an enormous impact on your loved one's final moments and your experience in caring for them.
"People who are close to death might ramble or say things that seem confused or jumbled. Listen closely to what is said as the messages they are trying to convey just before dying are often of great importance."
The Process Of Dying
The painless death we all wish for is rarely a reality.? The dying process usually begins well before death actually occurs.
Death is a very personal journey.? Each one of us will approach it in our own unique way.? Nothing is absolute. Nothing has to be a certain way.? There are many paths that we can take on this journey,? but all of them lead to the same destination.
As we come closer to death, there is a process that begins.? It is a journey from the known life of this world to the unknown of what lies ahead.? As this process begins,? the person starts on a mental path of discovery. They begin to understand that death will definitely occur.? They will accept their own mortality.? This journey ultimately leads to the physical departure from the body.
There are a number of milestones along this journey.? Because everyone experiences death in their own unique way, not everyone will pause at each milestone.? One person may experience only a few of them,? while another person may pause at each one. They may take their time, along the way.? Some people may take months to reach their destination,? others will take only a few days and some - just hours.
The Journey That Most Of Us Will Take.
Keep in mind that the journey is subject to the individual traveler.
(1) The Journey Begins: It is usually one to three months prior to death.
As one begins to accept their mortality and realizes that death is approaching,? they may begin to withdraw from their surroundings.
They are beginning the process of separating from this world and those who are in it. They may decline visits from friends, neighbors, and even family members. When they do accept visitors, they may be difficult to interact with and care for.
They are beginning to contemplate their life and revisit some old memories.
They may be evaluating how they lived their life and possibly sorting through any regrets.
They may also undertake the five tasks of dying.
The dying person may experience reduced appetite and weight loss as the body begins to slow down.? The body doesn't need the energy from food that it once did.
The dying person may be sleeping more now and not engaging in activities they once enjoyed.? They no longer need the nourishment from food they once did.
The body does a wonderful thing during this time as altered body chemistry produces a mild sense of euphoria.? They are neither hungry nor thirsty and are not suffering in any way by not eating.? It is an expected part of the journey they have begun.
(2) One to Two Weeks Prior to Death
Mental Changes
This is the time during the journey that one begins to sleep most of the time. Disorientation is common and altered senses of perception can be expected. One may experience delusions,? such as fearing hidden enemies or feeling invincible.
The dying person may also experience hallucinations, sometimes seeing or speaking to people that aren't there.? Often times these are people that have already died.? Some may see this as the veil being lifted between this life and the next.? The person may pick at their sheets and clothing in a state of agitation. Movements and actions may seem aimless and make no sense to others . They are moving further away from life on this earth.
?Physical Changes
The body is having a more difficult time maintaining itself. There are signs that the body may show during this time:
The body temperature lowers by a degree or more.
The blood pressure lowers.
The pulse becomes irregular and may slow down or speed up.
There is increased perspiration.
Skin color changes as circulation becomes diminished.? This is often more noticeable in the lips and nail beds as they become pale and bluish.
Breathing changes occur,? often becoming more rapid and labored.? Congestion may also occur causing a rattling sound and cough.
Speaking decreases and eventually stops altogether.
(3) The Journey's End: A Couple of Days To A Few Hours Prior to Death
The person is moving closer towards death. There may be a surge of energy as they get nearer.? They may want to get out of bed and talk to loved ones,? or ask for food after days of no appetite.? This surge of energy may be quite a bit less noticeable,? but is usually used as a dying person's final physical expression before moving on.
The surge of energy is usually short,? and the previous signs become more pronounced as death approaches. Breathing becomes more irregular and often slower.? "Cheyne-Stokes" breathing,? rapid breathes followed by periods of no breathing at all,? may occur.? Congestion in the airway can increase causing loud,? rattled breathing.
Hands and feet may become blotchy and purplish (mottled).? This mottling may slowly work its way up the arms and legs.? Lips and nail beds are bluish or purple.? The person usually becomes unresponsive and may have their eyes open or semi-open, but they are not seeing their surroundings.? It is widely believed that hearing is the last sense to go! It is recommended that loved ones sit with and talk to the dying person during this time.
Eventually, breathing will cease altogether.
The heart stops.? Death has occurred.
I am a Christian who fully believes in the future resurrection of believers,? but I get very upset with those people who shrug off a persons death with remarks like:? "He?s with Jesus?,? ?At least she's not suffering?, ? ?He had a good, long life?,?? ?We will see him again?, ? "... much better off".
Death is an enemy,? not a friend.? The Bible calls death an enemy, an evil, a wicked and grievous thing.? Grieving for a person who has died is not un-Christian,
Losing people that you love hurts. ? It doesn?t matter if they were old, or sick, or in pain, or if their death was expected.? Death has ended my ability to interact with my loved ones.? Deep inside there is a feeling of loss,? just as if it happened today.
Trusting in the promise of Resurrection doesn?t erase that loss:? My loved ones are still gone.
I loved them.? So I will mourn them.
I am not without hope,? but I will still? mourn them.? ?
In my doing so,? I honor them.
Dr. Ellisabeth Kubler Ross
"People are like stained-glass windows. They sparkle and shine when the sun is out,? but when the darkness sets in, their true beauty is revealed only if there is a light from within."?
??? How to Talk About End-of-Life Care.??? The Near Death Experience.
?During my 79 + years,? I have had four (4) near death experiences. The first such experience happened sometime between my third and fourth birthdays. Our family was visiting friends of my father? in Baltimore, Maryland.? I was sitting on my father's shoulders as he was wading in the Chesapeake Bay.? Somehow I slipped off of my father's shoulders and was carried out by a rip-tide. I struggled to breathe until I felt very well and was floating through a tunnel going towards a bright light and I could see someone walking toward me.? Then all of a sudden everything went dark and I awoke on the deck of a U.S. Coast Guard Cutter.? It seems that my body had bounced off the side of the cutter as it was going up the bay.? They said I was not breathing and they could not detect a heartbeat when the pulled me out of the water and so they used a resuscitator.
My second near death experience was when I was 21 and went under ether as an anesthetic.? I? found myself in the left corner near the ceiling of the operating room looking down at the doctor and nurses who were all hovering over me on the operating table.? The doctor later told me that my heart had stopped and they had to get it started again.
My 3rd and 4th near death experiences was when I was 52.? They were 5 weeks apart.? I was having an operation on my right eye in John Hopkins hospital in Baltimore, Maryland.? Once again I found myself hovering near the ceiling? watching the operation.? There seemed to be some excitement within the medical team.? The next thing that I remembered was that I was in my hospital bed talking to my surgeon who explained that my heart had stopped and they had to cut the operation short after they shocked me several times to get it going again.? They rescheduled another surgery for five weeks later.? I told him what I had experienced and about the other two previous operations.? He was skeptical,? but he assured me that he would have their best anesthesiologist on that day.
During the 4th operation, once again I had a near death experience that was similar.? I was near the ceiling watching the operation when the anesthesiologist said "We lost him".? The surgeon replied with an obscenity and there was a flurry of activity at the operating table, and I awoke in the recovery room. A couple of days later the surgeon and I talked and I told him what I saw and what was said in the conversation in the operating room.? He looked at me in amazement and said: "I'll be damned!" ? I certainly hope that he wasn't.
??? The Kubler-Ross Model
Source: http://clydesmomentsintime.blogspot.com/2012/02/death-and-dying-process.html
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