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Posted February 14, 2006

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Elderly Behavior: Discussing Impending Death

Q. Regarding end of life, what are some good icebreakers for discussing dying with a terminally ill loved one? Are there questions to ask someone who is dying? Do you know of any way to approach this subject with the patient, or family, who struggles to bring it up? Often, it is a difficult subject for patient, or family to talk about. I work for a hospice, as a medical social worker, and sometimes patients need to talk about their future, the illness, or end of life, and the family may not want to discuss it. Sometimes the family wants to discuss the subject, but not the patient. There are things that need to be openly brought forth, to ease the dying in some cases.

Larry M., Lockport, New York

A. Before answering your question, there are a few points to really consider.  Few people actually sustain true denial until the end of an illness.  Dr. A. Weisman uses the term "middle knowledge" to refer to the fact that individuals drift in and out of the awareness of dying -- sometimes talking about it, sometimes not, or one day tearfully (or perhaps not) talking about their death and the next day telling you about their plans to redo the den when they recover.  This is a very normal process.  The key question is not "Does the dying person deny or accept death,” but rather, "Where, with whom, when, and under what circumstances does the person talk about death?"

 
Your questions are good ways to convey that you have a willingness to address such conversations, should the patient or the family have a need to discuss it and choose to discuss it with you.  Remember, too, that both the patient and family may choose not to address the question -- or not to address with you.  For example, when my father was dying, he quoted Woody Allen's comment: "I do not mind dying. I just do not want to be there when it happens" to signal that he wanted even in his last days to focus on other things. 
 
Others may have issues they want to discuss and will appreciate the opening your question allows -- including a possible follow up question that specifically asks, "Is there anything you need or  want to say or do?"  Again, be sure it is the patient's agenda. Shneidman reminds us that "no one has to die in a state of psychoanalytic grace" -- that is, discussing death or finishing business.  Sometimes we have to really be sure that we convey a willingness to the patient that should they wish to talk, we are open to such conversation, rather than express our own needs for the patient to talk so we feel useful.
 
Remember, too, that patients may express their awareness of death in less obvious ways -- such as sensing death, talking of seeing or dreaming of dead relatives or friends, or travel.  Callahan and Kelley's excellent book Final Gifts discusses these issues.  In these cases, sensitive follow-up discussions might offer the patient opportunities to address any issues that they wish

This answer is provided by Kenneth J. Doka, PhD, M.Div., Senior Consultant, Hospice Foundation of America (HFA). Dr. Doka also is a professor of gerontology at the Graduate School of The College of New Rochelle in suburban New York City. He has written or edited 16 books and published 60 articles and book chapters, and he is editor of Omega, a professional journal, and Journeys, HFA’s monthly bereavement newsletter. Dr. Doka was elected president of the Association for Death Education and Counseling (ADEC) in 1993. He was elected to the Board of the International Work Group on Dying, Death and Bereavement in 1995, and served as chair from 1997 to 1999. In 1998, ADEC recognized him for outstanding contributions in the field of death education. Dr. Doka is an ordained Lutheran minister. He can be reached through HFA at questions@hospicefoundation.org.

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