Dying, Dignity, and New Horizons in Palliative End-of-Life Care

Abstract

Palliative care practitioners are now better able than ever before to ameliorate endof-life symptom distress. What remains less developed, however, is the knowledgebase and skill set necessary to recognize, assess, and compassionately address the psychosocial, existential, and spiritual aspects of the patient's dying experience. This review provides an overview of these areas, focusing primarily on empirical data that has examined these issues. A brief overview of psychiatric challenges in end-of-life care is complemented with a list of resources for readers wishing to explore this area more extensively. The experience of spiritual or existential suffering toward the end of life is explored, with an examination of the conceptual correlates of suffering. These correlates include:hopelessness, burden to others, loss of sense of dignity, and desire for death or loss of will to live. An empirically-derived model of dignity is described in some detail, with practical examples of diagnostic questions and therapeutic interventions to preserve dignity. Other interventions to reduce existential or spiritual suffering are described and evidence of their efficacy is presented. The author concludes that palliative care must continue to develop compassionate, individually tailored, and effective responses to the mounting vulnerability and increasingly difficult physical, psychosocial, and spiritual challenges facing persons nearing the end of life.

Suffering and healing – our core business

“…The literature on effective psychological interventions is rich and persuasive. 6,7 However, I agree with Kellehear that more studies grounding within each person or group's narrative, and thick with detail, need attention and wider academic exposure. Through these, we may see the authenticity of success in sharper relief if its backdrop is each uncompromising story, reworking to a new whole.…”

“…It also seems to work. 6 Next, Frankl's monumental work plants firmly the acquisition of meaning at the heart of success in transforming and transcending suffering: meaning as the pursuit of alternative accounts of experience that make more sense as a personal narrative of what has hitherto been a suffering. 8 Kissane's group have approached the problem from the perspective of meaning with both empirical and narrative methods with four goals: to acknowledge suffering, offer ways to encourage and foster a search for meaning, strengthen connection with others and ensure optimum physical care.…”

Assisted death: a basic right or a threat to the principal purpose of medicine?

“…Most patients are knocked sideways by a terminal diagnosis. 16,17 Many of them veer from hope to despair and back again, with depression and fear alternating with acceptance. 18 Many visibly struggle to come to terms with their mortality; feeling a burden to others fuels suicidal thoughts.…”

Reading Illness in Leo Tolstoy’s The Death of Ivan Ilych: Perspectives on Literature and Medicine

“…Gerasim gives the dying Ivan Ilych the care he needs. Harvey Max Chochinov (2006) (in an elaboration of the knowledge and skills necessary for recognizing and addressing existential, psychosocial, and spiritual aspects of patients' dying experiences) argues: "Within the field of palliative care, developing compassionate and effective responses, which are individually tailored and sensitive to a patient's fluctuating deteriorating health status, is a critical challenge" (p. 100). As compared with the decay of his master's body, Gerasim stands for force and vitality.…”