A series of five unusual surgical patients is reported in which “predilection” to death was a prominent part of the clinical picture.
The common characteristic of these predilection patients is that each anticipated his death at the time of admission. With the exception of a mentally ill woman, they were neither anxious nor significantly depressed. All expressed the conviction that death would occur within a short time, except for a young girl who serenely anticipated death without openly referring to it. The conviction of death was invariably accompanied by an expectation of being killed by another.
Predilection patients may be readily distinguished from preoperative patients with high anticipatory anxiety, depressed patients, suicidal patients, and those rare patients who correctly prognosticate their own deaths and demonstrate no significant lesions at autopsy.
Two men died unexpectedly in the course of convalescence. Three women patients were not only expecting to die but were expected to die because of malignant disease. However, in one woman, the disease had apparently been arrested for 28 yr. Relapse and metastatic lesions did not occur in another patient until after a young man with the same disease had succumbed. A third woman, suffering both from severe mental illness and incurable cancer, became alarmed shortly before death when a palliative procedure threatened to prolong her unhappy life.
Death held more appeal for these patients than did life because it promised either reunion with lost love, resolution of long conflict, or respite from anguish. Each patient was emotionally isolated during the final admission. Their “loneliness” was of several different kinds; one man was a semi-vagrant who had never known emotional intimacy; another man had exiled himself from his family; one woman had suffered successive deaths of her husband and members of her family; another woman had repudiated all but the most formal relationships throughout her life; a young girl had not only lost a close friend by death but was deserted by her physicians and family, who were so concerned that they could not come to terms with her certain death.
Study of the predilection patients has led to an evaluation of the care of the dying patient in general, particularly from the viewpoint of the paradoxical attitudes towards death that are conventionally assumed. The application of psychodynamic principles to the concept of death and the process of dying is based on the hypothesis of the appropriate death.
An appropriate death is one that recognizes the inevitability of personal death as a fulfillment of life. It satisfies four conditions: conflict reduction, compatibility with ego ideals; continuity of personal relations with the living and the already dead; and consummation of phantasies. In short, the circumstances of an appropriate death are the opposite of those in which a patient would commit suicide.
The conditions of an appropriate death have been derived from the distinction between impersonal, interpersonal, and intrapersonal death.
The fear of dying is not the same as the fear of death. The dying process has psychological counterparts in primary anxiety, the sense of imminent disintegration; the fear of death. it has been shown, is a death phobia, indirectly related to “rational” fears.
Appropriate death is an aspect of euthanasia--death without suffering--for patients whose death is imminent. However, the conventional concept of euthanasia as the hastening of the death of incurably ill patients is the antithesis of the appropriate attitude towards death which psychiatric intervention advocates. In conventional euthanasia, the patient's personality is ignored; in the proposal of therapeutic dissociation of the patient from the disease, the personality in its unique dignity is enhanced.
Various practical recommendations for implementing the appropriate death are presented, but no intervention is possible without frankly facing the imminence of death with the patient. Evidence has been presented to indicate that this is usually more difficult for the doctor than for the patient.
Tacitly to impose silence, denial, deception, and isolation upon the dying patient may itself cause suffering and bring about bereavement of the dying, a state of premortem loneliness, emotional abandonment, and withdrawn interest that the survivors impose upon the dying. Examples are cited in which altered interpersonal relationships provide the prodromal intimations of approaching death.
Instead of viewing death as a failure beyond his competence, the physician can extend his care and help his dying patient to achieve an appropriate emotional world in which to die.