On Death and Dying (Paperback)

I gather that 'On Death and Dying' (now about 30 years old) is something of a medical classic, and from my experience it seems that it's main finding - the need for honesty and compassion in dealing with dying patients - has been thoroughly incorporated into the practices of the National Health Service (Or was I just lucky?). The process of denial and anger leading to depression and eventual acceptance is now familiar enough to seem unsurprising. My main problem with this book is that it consists largely of interviews with patients. They come from a both sexes and a range of ages and backgrounds and display various attitudes towards their illness. However, every one of them, without exception, sooner or later mentions their religious faith as a factor in their experience. This is fair enough - anyone who has a religious faith is bound to use it to rationalise their impending death - but America in the 60s is a long way from the far more secular society of Britain in the 90s and it does mean that the book really seems to have nothing to say to atheists like myself.

Speaking as an atheist, I found my lack of faith a great comfort in facing the possibility of imminent death. One is able to face the end untroubled by doubts about resurrection, fear of punsihment, guilt about past sins or anguish about whether it all has any meaning (There really are atheists in foxholes!). Only towards the end of the book does Kuhler-Ross remark that though most of her patients professed some religious belief she felt that very few had a genuine, intrinsic faith. She then makes the surprising statement that the small number of genuine believers were most like the true atheists in that they were able to face death with relatively little conflict and fear. This is the only acknowledgement in the whole book that there may be non-religious modes of coming to terms with dying. An interview with even one non-religious patient would have given people like me somebody with whom we could identify.

I realise that I am being unfair in that the book was intended to advise health-care staff rather than to help patients or their relatives. But I am also aware that patients and relatives may well read it in the hope of understanding the traumatic experiences they are undergoing. All I am saying is that unless you want to believe it is all God's will, look somewhere else.

(Try Marcus Aurelius. Just a suggestion.)

Kübler-Ross also spoke to families, and followed people through their ailments, sometimes to recovery, but most often to their death. She let the people guide her in her research: 'We do not always state explicitly [to the patient] that the patient is actually terminally ill. We attempt to elicit the patients' needs first, try to become aware of their strengths and weaknesses, and look for overt or hidden communications to determine how much a patient wants to face reality at a given moment.'

This caring approach was often an aggravation for Kübler-Ross and her staff, because they would know what the patient had been told but was not yet ready to face. Kübler-Ross recounts stories of attempts to deal with death in different ways; denial, anger, bargaining, depression, acceptance -- in fact, the various stages of grief were first recognised in Kübler-Ross's research.

There are those who dislike the `stages' theory of grief, but it is important to know (as the quote above indicates) that these are not set-in-stone processes, but rather dialectical and perichoretic in nature, ebbing and flowing like the tide, so that where a person was `stage-wise' would vary from meeting to meeting.

Kübler-Ross explained her interest in this research by saying that `if a whole nation, a whole society suffers from such a fear and denial of death, it has to use defenses which can only be destructive.' Her work is primarily geared to health-care providers, and provides verbatim transcripts of conversations with a wide range of people in different classes, races, family situations, education levels, and ages. The reader can then get a sense of how to better communicate with someone in a terminal situation.

'Early in my work with dying patients I observed the desperate need of the hospital staff to deny the existence of terminally ill patients on their ward. In another hospital I once spent hours looking for a patient capable to be interviewed, only to be told that there was no one fatally ill and able to talk. On my walk through the ward I saw an old man reading a paper with the headline "Old Soldiers Never Die". He looked seriously ill and I asked him if it did not scare him to `read about that'. He looked at me with anger and disgust, telling me that I must be one of those physicians who can only care for a patient as long as he is well but when it comes to dying, then we all shy away from them. This was my man! I told him about my seminar on death and dying and my wish to interview someone in front the students in order to teach them not to shy away from these patients. He happily agreed to come, and gave us one of the most unforgettable interviews I have ever attended.'

She concludes with a chapter explaining the reactions of doctors, nurses, counsellors and chaplains, professionals who deal with the dying every day, on how the kinds of listening and care she outlines can change their work and lives as well. It is remarkable to see some of the transformations which take place among these people.

I have used the advice and insight given by this book in my own ministry, and heartily recommend it to everyone, regardless of medical or ministerial intent, for it can give guidance on how to deal with the deaths of friends or family members and, ultimately, our own death.

Death will never be a happy subject, but it needn't be a dark mystery devoid of meaning and guidance.

I also recommend: What the Dying Teach Us: Lessons on Living by Samuel Oliver