Saul Ebema, D.Min.

There are many psychological issues that affect the terminally ill under hospice care. Some of these issues are;

Depression

                Depression is another emotion that the dying person experiences. It is a normal reaction to death and dying. It could be triggered by different factors as the terminally ill patient begins to contemplate death. Sometimes depression can be triggered by a need for reconciliation with family members or friends before the death occurs. Depression can also be associated with the loss of control over life events experienced by the patient. As death nears it is easier to slip into a state of passive resignation and despair.

Depression in dying persons may be either ‘primary’ (the person is pre-disposed to depression in response to stress) or ‘secondary’ (depression is a result of the disease itself, the result of treatments designed to halt the disease or the result of medications prescribed to modify the side-effects of the treatments).[1]

Depression can also be caused by the impeding losses due to death. People who are dying prepare for their death by mourning the losses that the death will bring. The anticipated separation from family and friends is an obvious one.

The pleasures of living may be grieved too. People may reflect on their past and relive great moments and disappointments, and mourn for missed opportunities. Looking to the future, they may grieve the loss of much-anticipated experiences such as a child’s graduation or the birth of a grandchild.[2]

Some of the symptoms of depression found in the terminally ill patients are:

• Feelings of emptiness.
• Feelings of deep sadness
• Patient seems withdrawn and losses interest in people or activity
• Changing appetite and increased weight loss.
• Disturbed sleep patterns, such as insomnia.
• The patient is easily agitated.
• Fatigue and loss of energy.
• Intense feelings of helplessness, hopelessness, worthlessness, isolation/loneliness and guilt.
• Suicidal ideation without a specific plan for committing suicide.

The Fear of Loss of Identity

As the death approaches, the terminally ill patient relies more on other people for basic human needs. The losses of body structure and function, friends, self control, and consciousness threaten the patient’s identity. “Confronted with the threat of dissolution, the dying person is faced with the tasks of attempting to retain self respect, integrity, and dignity in the process of dying.”[3]

Affirming the patient’s sense of personhood is vital. If the patient is able to make decisions, encourage them to do it. If the patient is able to participate in family gatherings, they need to be encouraged to be part of family gatherings or activities. Helping them to retain some normalcy is vital.

Suicidal Ideation

Those who work with the dying know that the subject of suicide comes up from time to time. Few people who are enrolled in hospice care actually commit suicide, yet a number of them have thoughts of killing themselves or of finding someone who will assist them in the act of ending their lives. When patients ask about suicide, it is an indication that something is seriously wrong. They may be quite depressed. Sometimes this suicidal ideation is triggered by loss of control.  I remember visiting a patient who was contemplating committing suicide. When I asked him why he wanted to commit suicide, he said, “My life has no meaning. I can’t do anything for myself. I have to rely on other people for everything. I can’t stand it, I would rather die.”

For others, suicidal ideation is triggered by being dependent on family, friends and caregivers. Some people do not know how to deal with the fact that they are dependent on others. Others with advanced illness see no value to their existence. They see no future, and the present is filled with discomfort and often, severe pain. For some, suicidal ideation is triggered by fear of abandonment. Many older people have seen, or heard stories, about what happens to dying people in some hospitals and nursing homes and they would rather consider killing themselves than be part of that distressing scenario.

The most common reasons patients give for wanting to commit suicide are:

• Current pain and suffering;
• Fear of pain and suffering yet to come.
• Loss of control over what is happening.
• Fear of becoming even more dependent.
• Fear of abandonment, isolation, dying alone.
• Inability to cope with the impact of the illness on family and friends.
• Loss of personal integrity, fear of disfigurement.
• Economic impact of further expensive care; exhausted financial resources.
• Desire to “join” previously deceased spouse, parent, child.

Anger and Hostility

This feeling is experienced both by the dying and the bereaved. The reality of impending death often causes; frustration, resentment, and hostility. These emotions can easily be turned against others or on the self. Family members, friends and healthcare professionals are likely to bear the brunt of this anger. The reactions of the recipients of anger may include withdrawal, anxiety, defensiveness, and anger in return. This will only complicate an already tension-filled situation. When the patient’s anger is internalized, it leads to self-recrimination, self-blame, guilt, and lower self-esteem. As many psychologists have pointed out, anger turned on the self often fuels depression.

If there is one fundamental principle of counseling with the dying person, it is to facilitate communication about their needs. A primary task of pastoral counselors is to assist the terminally ill in meeting their individual needs as death approaches. Of course, each one has different needs, depending on life history, personality, and many other factors, but there are some common needs shared by most dying people. These needs include, but are not necessarily limited to, security, affection, support, self-expression and dignity.

Sources

[1]Mathew Hotopf, Jayne Chidgey and Julia Addington-Hall, “Depression in advanced disease: a systematic review Part 1. Prevalence and case finding.” Journal Palliative Medicine (2002): 11.

[2] Therese A. Rando, Clinical dimensions of anticipatory mourning: theory and practice in working with the dying, their loved ones, and their caregivers (Champaign, IL: Research Press, 2000), 81.

[3] Therese A. Rando, Grief, Dying and Death: Clinical Interventions for Caregivers (Champaign, IL: Research Press. 1984), 27.