“You slip in and out of my room, give me medication and check my blood pressure. Is it because I’m a nurse or just a human being, I can sense that you’re scared? And your fear increases my fear. Why are you scared? After all, I’m the one who’s dying!”[1].

[1] E. Kübler-Ross, Death: The Final Stage of Growth.

Introduction

Dear Reader, I would like to invite you on a difficult but important journey. This journey is related to death and dying: a part of life that most of us find distressing, to say the least. Although it is not an easy journey, I am of the opinion that for those helping others, it is one of the most important ones. I do this regularly, working with professionals for whom the death and dying of others is almost a daily occurrence. As it turns out, the day-to-day itself does not make these experiences any easier to bear.

It is with deep humility that I will share the reflections that have emerged from my personal and professional experiences related to death. I will also draw on two special people’s reflections resulting from their many years of work with patients. The first of them is the late Elizabeth Kübler-Ross, a psychiatrist and world authority on the subject of death and dying. The second one is Irvin D. Yalom, Professor Emeritus of Psychiatry at Stanford University’s School of Medicine in the United States, an internationally respected therapist with a wealth of experience and achievements and, above all, one of the few who devote so much attention to working with the fear of death in his therapeutic work.

The fear of death

We are beings of high intelligence and derive innumerable benefits from this fact. These include scientific developments that have led to an increase in the length and quality of our lives over the centuries. Our advanced brains allow us to plan future activities and indulge in dreams of experiences we desire.

“I have a dream” is the title of a world-famous speech given in 1963 by Martin Luther King. His speech was devoted to the racial inequality of US citizens, and it moved the public opinion. Dreams have also been a source of motivation for other prominent figures in human history, such as the Wright brothers, who, despite many failed attempts, believed that if they could build a flying machine, they would change the world. And this is exactly what they did. These are just two of many examples.

While our ability to be self-aware and forward-thinking gives us the opportunity to constantly evolve and do extraordinary things, it also has a cost. It makes us aware of our mortality.

We all fear death in a more or less conscious way. For some, the fear of death is so difficult to bear that it significantly impedes their enjoyment of life and their further development.

From an early age, we are taught to deny the fear of death. A child who expresses their concern about passing is likely to cause discomfort to adults and will be quickly consoled. Such child is likely to hear that someone close to them still has many years of life ahead. They may also be introduced to the story of eternal life in heaven.

Over the course of a human life, the level of awareness of death’s inevitability fluctuates. A particular interest in this topic can be observed among teenagers. For example, computer games involving the mass taking of lives of virtual characters are typical for this stage in life. Attempts to cope with the fear of death are revealed by telling rough death-related jokes, dark stories or passionately watching horror films. Some may ‘tame’ their anxiety by engaging in risky behaviours, like speeding.

For most of us, the next time when we experience a growing fear of death is when our work activity decreases or when our children grow up. It is then that we become more intensely aware of our own passing again. At this stage, for some, acquiring more wealth, even more professional prestige, having grandchildren, being dedicated to an idea or having a strong faith in life after death become the coping mechanisms. No matter what strategies we use, it is impossible to fully get rid of the fear of death.

The difficulties we experience as a result of the fear of death are not necessarily directly related to death itself. Think for a moment: have you ever, while watching an old film, experienced mental discomfort at the thought that the actors playing in it are long dead? Perhaps there is a particular image that always makes you anxious? E.g., the thought of falling from a great height or being stabbed in the chest? Perhaps over the years, a chilling dream has been recurring on a regular basis and keeping you up at night? E.g., you wake up in a coffin and your cries for help go unanswered.

Exploring one’s own fear of death makes a great deal of sense for each of us, especially for those who are in regular contact with sick or dying people. It can take place in psychotherapy, but you can also face your fear of death on your own, by reflecting and pondering over your experiences. Night terrors are also worth our attention. They confront us so strongly with the risk of death that they can interrupt our sleep. Sometimes death is revealed in them in a symbolic form, such as through the difficulty of catching up with a loved one, or literally.  Then the risk of loss of life is illustrated, for example, by a killer or animal attack.

Sometimes it is the circumstances of real life that create a strong fear of death in us. This can be triggered by a real threat to our safety, such as a fall during a routine morning run, a fire, a break-up with a loved one, a robbery attack or surviving a rape. Other real-life situations that increase our fear of death include: our own serious illness or that of someone close to us; confronting a threat to someone’s health, life or the potential death of ourselves or someone close to us; and the risk of death or the death of a patient.

In this article, I will mainly focus on the impact of contact with a sick or dying person. When I work with people who have professional contact with the ill, I often ask them how they feel when they come into contact with someone who is sick or dying? The most common answer is, ‘It’s difficult’.

‘The key to the mystery of death opens the door of life[1]’

It is only natural that contact with a dying person is extremely difficult. Living in a culture that represses death, we are taught to cope through denial. In direct contact with the patient, this can manifest as avoiding them, additionally shortening the contact time and suppressing the emotions we experience. Contact with a dying person generally reinforces, or makes us more aware of, the fear of death that we feel. It has a certain particular characteristic. When we do not realise what it actually concerns, it can ‘find itself’ another focus. This means that some other event or person may start to cause us fears that will not be justified in the eyes of other people. Examples include a panic fear that something bad will happen to someone close to us, or general anxiety that ‘something’ will happen. Professionals confronted with illness and death are particularly intensely exposed to the awareness of human transience, and some may experience discomfort and a sense that life has no meaning when it is composed entirely of transient things.

Regular contact with patients’ disability and death results in psychological pain. Thus, for nurses and doctors death becomes something personal and close, ceases to be something distant that affects some absent ‘other’. They are beginning to find it even more difficult to deal with terminally ill patients or anyone whose life is in any way endangered. Such contacts require us to cope with our own fear of death, something we are not used to. Usually, no one mentions to us either what, in the long run, the most beneficial coping mechanism is. Doctors and nurses should be supported early on in their education in dealing with their own emotions and fear of death.

In practice, anyone who has taken the time and energy to work through their attitude to their own mortality is likely to be more accepting of not only their own passing, but that of others, to cope effectively when they find themselves in a difficult situation or when others are in it. For some, accepting contact with their own fear of death can be the driving force behind the changes needed to experience more satisfaction in life or work. It is due to this mechanism that, for some people, a car accident or a serious illness ends up being the biggest and most valuable change in their lives.

An intuitive attempt to avoid talking about death is a behaviour often exhibited by families of patients and health care staff. It may stem from the fear that nothing can be said or done that will comfort the patient. In her work, Elizabeth Kübler-Ross emphasised that for many patients it was already comforting to be able to talk about their fears and experiences, and to be heard. As is the case with healthy people, genuine consent for ill and dying people to share their feelings is an opportunity to bring them some relief and peace.

It is physical or mental loneliness that enhances the drama of dying. This is a difficult issue for the patient’s next of kin and for the medical staff, as on the one hand there can be a lot of concern about what to say or do when dealing with a dying person so as not to cause them additional pain. On the other hand, as I mentioned above, there is a natural confrontation with one’s own mortality. This state of seclusion can be further reinforced by the dying person, who themselves limit conversations about what they are going through in order to spare other people a difficult experience.

None of us will manage to be in mutually beneficial contact with a dying person unless we can face the fears associated with our own mortality and fragility. It is about accepting one’s own emotions and one’s own psychological pain while interacting with another person’s suffering and emotions. It also cultivates readiness to talk frankly about the anxieties experienced by the dying person. In the situation I am writing about, from a psychological point of view, a dying person probably cannot be offered anything more valuable than an attentive presence.

We all have to face our own transience

Like a mantra, at this stage, I will repeat the message that the effective way to cope with passing is not to deny the existence of death and avoid a confrontation with it, but to achieve a deep emotional acceptance thereof. Working on accepting death involves learning to enjoy living the life as it is in the moment, approaching the fact that we are alive and capable of experiencing it as a certain privilege. People who pursued their dreams, who were able to love, who experienced the love and care of others, who succeeded in bringing some value to other people’s lives, who took the opportunity to examine who they are as human beings and, above all, who did not deny death but were constantly aware of their mortality, find it easier to accept mortality.

Cultural attitudes towards death

The biggest risk of how we intuitively deal with death is reinforcing the denial and negating difficult emotions such as anger. The culture we identify with has a huge impact on how we deal with the ill and the dying. In Europe, as in the United States, we have an unusually great need to control life expectancy.

For many people in our culture, unfortunately including professionals, the diagnosis itself rather than death as such, is seen as the end of growth. I once had the opportunity to hear a spontaneous comment: ‘What can you do for a dying person?’ (implying that the answer is ‘nothing’). If we maintain this attitude, we will find contact with the ill extremely difficult and will probably be overwhelmed with a sense of embarrassment and impotence.

In 1975, Murray Trelease described the approach to dying taken by Native Americans living in Alaska. This community takes very much into account the subjectivity of the dying person and, unlike Western culture, does not limit itself to the assumption that the main need of the dying person is comfort. The question “What do you wish for?” asked of the patient in this culture is a question about needs that he or she can fulfil at this stage of life, such as meeting someone with whom he or she has not had contact for a long time, asking about matters that have not been clarified by him or her, and so on.

Jewish culture, on the other hand, emphasises the dignity and importance of death, with the dying having the opportunity to sort out material matters, pass on blessings to the family and share information important to them. In this culture, great importance is placed on reducing the anxiety of the dying person, rather than simply increasing their physical comfort. Dying is seen here as a time when the role of those closest to the patient is to be in contact with the ill person and to offer him or her consolation.

Like Americans, Poles are inclined to deny death, which is sometimes reflected in a tendency to avoid the dying person and an inability to communicate with them honestly. Perhaps worth drawing from Jewish culture is the belief that a dying person is still capable of deciding their own affairs and participating in relationships with other people until the end of their life.

The Judaic tradition also seems to be of interest. According to it, there is always someone at the sick person’s bedside who accompanies them. On the one hand, it gives comfort to the dying person, and on the other, it adds dignity to their dying. This also has a soothing function for those close to the patient who are not there at the time. Moreover, the Jewish funeral is characterised by realism and simplicity, in contrast to our cultural tendency to deny death. This manifests itself in paying great attention to body cosmetics, elegant cushions, coffin upholstery, etc.

Jewish culture also notes that the family of the deceased may feel a whole spectrum of emotions, including guilt over possible conflicts from the past, or anger over abandoning the loved ones. Such feelings are accepted and treated as a natural part of experiencing grief.

In this tradition, there is a clear message that someone who visits the sick person should, first of all, create the conditions for them to vent their feelings or, if need be, accompany him or her in silence and simply be there.

In contrast, other traditions, Hinduism and Buddhism, emphasise that accepting death is very important for achieving a full and satisfying life.

These are just selected examples of cultural approaches that have the effect of increasing or decreasing our effectiveness in dealing with transience.

How to cope?

Dear Reader, at this stage, I would like to invite you to reflect briefly. Please read the following questions and ponder the answers:

• What would happen if you found out you had very little life left?
• Would you change the way you currently live?
• Is there anything you would like to do before you die?
• Do you fear dying or death itself? What exactly are your concerns?
• Think for a moment about the death of someone you love. What would you say to a dying loved one?

The journey through the subject of death is a difficult experience for most of us. In order to cope with the passing of time, it is not enough to have an intellect and an understanding of it. It is also important to be ready to feel and accept what mortality arouses in us.

It may happen that, despite the best intentions and openness, the patient rejects us. Our role is to be able to deal with the thoughts and feelings this will bring up in us. Whether it is frustration, anger or simply the sadness of rejection. The challenge for nurses and doctors is to be in touch with a patient who is rejecting, despite the patient’s anger. The point is not to perceive this as a personal grudge, but as an expression of a completely natural human need to cope, in this case through anger, and a certain reaction to the role that the professional plays through his or her function in the hospital or other health service.

In her book Death: the Final Stage of Growth, Elizabeth Kübler-Ross points out that if we expect students to be able to show genuine respect to their patients in the future, they themselves need to be treated with respect from early education onwards. I have repeatedly listened to doctors’ stories that indicate a completely different trend. From this perspective, the task of the education system is not just to train competent professionals, but professionals who will also be able to deal with their own emotions by accepting them and then using them in their work as a source of additional motivation to interact with patients, rather than as a cause of discomfort that interferes with work.

It is worth remembering that the feelings we experience when dealing with an ill patient are often information about who we are, rather than about the patients themselves.

There are different strategies for coping with passing. Some people are consoled by the idea that, over the course of a lifetime, everyone will be touched by both the joys of various aspects of life and the fears associated with our transience. Others are comforted by the idea that the time before birth and the time after death are identical, and we are used to not worrying about the former, while it is the latter that scares us. There are some people who find it easier to accept the inevitable passing of time by creating and leaving something behind, such as offspring, a piece of art, a place.

It is worth remembering that health professionals perform their work in a certain context. This context is determined by the specific procedures, the specifics of the facility, the colleagues and patients with whom that professional interacts. It will be difficult for those nurses and doctors who are only focused on external constraints beyond their control to achieve job satisfaction. Even if they do not have the opportunity to change numerous aspects of their job, as a support, I recommend reflecting on the fact that it is ultimately up to us to decide whether we will continue to work in this job or pursue this rather than another profession at all, even if we do so only because of rational arguments, such as the need to repay a mortgage.

When we decide to stay in our current working environment, let us not forget that we can also react differently to external circumstances beyond our control. A person will react differently if they see their job as an aggravating and frustrating punishment and differently if they see it as their decision to pursue a profession fraught with numerous challenges and requiring a great deal of commitment and intrinsic motivation.

I would also like to reassure those readers who harbour fears that direct confrontation with their own emotions, those of the patient or the awareness of death will lead them to reduce their enjoyment of life or to their own illness. In fact, it is denying death, suppressing emotions or cutting them off that adversely affects further experiences and work and probably contributes to professional burnout.

Summary

Dear Reader, as you continue to work on getting in touch with your own mortality, imagine your life one, two or five years from now. Think of the grief that may have built up in you over this time. Give yourself a few minutes to do this. Now ask yourself, what can you do now to make that regret go away? In your reflections, try to be authentic, show empathy and self-respect. Finally, ask yourself, what can you in the short term so that in one, two- or five-years’ time, you don’t feel the discomfort you imagined? I encourage you to discuss your thoughts with someone you trust.

Finally, I would like to emphasise that satisfaction with our work and our lives depends to a large extent on how we interpret the experiences that confront us, and not by the experiences themselves. Different emotions and thoughts and questions may arise in you when dealing with a dying patient: Would anyone else be able to help? Am I making a mistake? Whatever you are experiencing and whatever thoughts appear in your head, above all I encourage you to accept them as part of a natural, albeit difficult, experience and to seek support from others by sharing what you are experiencing in your work with other people. It turns out that the opportunity to be heard and the acceptance of the emotions experienced are in themselves reassuring and can relieve the worries not only of sick people, but also of those who are completely healthy.

Bibliography:

• Fengler J., Pomaganie męczy. Wypalenie w pracy zawodowej. Gdańskie Wydawnictwo Psychologiczne, Gdańsk 2000.
• Kübler-Ross E., Śmierć. Ostatni etap rozwoju, MT Biznes, Warsaw 2008.
• Yalom I.D., Patrząc w słońce. Jak przezwycieżyć grozę śmierci, Instytut Psychologii Zdrowia, Warsaw 2008.
• Yalom I.D., Psychoterapia egzystencjalna, Instytut Psychologii Zdrowia, Warsaw 2008.

[1] Op. cit.