Toward a Better Death

Dying people are surrounded by a "conspiracy of silence, denial and dissimulation" that dehumanizes them and increases instead of easing their psychological suffering. That is the conclusion of Harvard University Psychiatrist Avery Weisman, one of the experts in the rapidly growing science of thanatology--the study of death. In an effort to break that conspiracy, Weisman has written a perceptive book, On Dying and Denying (Behavioral Publications; $9.95), which he hopes will help human beings to face death "with clarity, equanimity and acceptance."

Because man "is frightened to death by the specter of death," he tries to pretend that it does not exist, at least not for him; in the subconscious mind, "it is other people who die." Studying 350 terminal patients, Weisman found that denial can take many forms. Often a gravely ill patient, alarmed at being in a hospital, may say, "My doctor wants to be sure I don't have anything serious." Sometimes a sick person, worried about his loss of weight, may go on a diet to have a reassuring reason for the loss.

Despite his denial, a terminal patient nearly always knows the truth. Discouraging him from talking about it puts him under great strain. Even when his knowledge is unconscious, it is generally so close to the surface that the struggle to suppress it only compounds his anguish. When the struggle ends, the patient is "fortified, not undermined," Weisman says. He cites the case of a patient close to death who asked a hospital social worker how to find a nurse to look after her "when she went home." Because the patient had earlier talked freely about her death and her fear of dying, the social worker decided it would not help to play the denying game. Instead, she suggested gently that perhaps the patient was again afraid. "The patient agreed at once. Her distress abated promptly, and she commented that everyone in her situation must go through similar periods of disappointment and self-deception." She also said serenely that she hoped she would not live much longer. Taking her hand, the social worker agreed, and the patient smiled and thanked her.

This approach is rare, for people around the dying, reminded of their own mortality, use denying tactics themselves. They treat dying patients as objects of dread instead of as human beings "whose thoughts and preferences matter." Such behavior makes a "good death" impossible by failing to distinguish between survival, or biologic existence, and "significant survival," which requires control of pain, respect for the patient's autonomy and preservation of his emotional ties to other people.

According to Weisman, psychological suffering cannot be relieved until physical pain has been eased. Yet doctors may refuse sufficient medication, sometimes on the ground that they fear addiction--a meaningless concern on the eve of death. Too little medication lets the doctor pretend, subconsciously, that the patient is not sick enough to die and may betray the doctor's unwillingness to admit to himself that he is not a "magic healer" who can save every patient.

Own Funeral. This does not mean that all patients must be drugged into insensibility. Rather, each should be asked what degree of consciousness he prefers. Some want to be alert despite pain so they can talk or think. Others prefer undermedication for more complicated reasons. In one case, a girl who needed morphine to curb the pain of advanced kidney disease asked instead for the less potent drug she had been given at earlier stages of her illness. The weaker drug reminded her of the hopeful mood she had had when she was less seriously ill. Though she did not re-experience her hope, she was comforted by the reminder and was "exercising freedom to die in her own way."

Permitting patients to make such choices helps prevent despair, Weisman believes. Hope requires only a degree of autonomy, a "conviction that we can change the world a little bit." One way of supporting a sick person's autonomy is to let him refuse "heroic" treatments that demean him by causing him to suffer "without adding significant survival." Another way is to let a patient plan his own funeral if he wants to. He should also be allowed to talk about his grief at dying and the probable reactions of his survivors without being told that he is morbid. Lastly, Weisman writes, dying patients must be granted the option of seeking out or refusing to see particular people.

Usually a dying patient longs to stay close to those he cares about. Very often one of the most helpful things a doctor can do is "to encourage final farewells and, if necessary, reconciliations." It is not only the dying person who benefits from a deathbed meeting but his survivors as well, because, Weisman concludes, "we can enhance the meaning of being alive by touching the edge of a life that is slipping away."

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