Death and Dying Dr Michael Harper

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Death and DyingDr Michael Harper
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Introduction

• Death is a doorway a compulsory journey through
  the eye of a needle
• To what?
• Who wants to go through the doorway?
• Who wants to die?

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• I am not afraid of death, I just don't want to be
  there when it happens.
• Woody Allen

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IntroductionDeath is

• Inevitable, inescapable
• Usually untimely
• Uncomfortable at best
• Undignified

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IntroductionDying is

• Separating
• Letting go
• Closing down
• Departure
• or
• Embarkation

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Reading the SignsA time to heal, and a time to
die

• Healing
• Or the ultimate healing?
• Healing in dying
• When Im 97a story

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Prognosticating

• Patients perspective How long do you think
  youve got?
• Discerning deaths approach in terminal illness
  Twycross

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Age Concerns Good Death PrinciplesTo have

• Control of what happens
• Control over pain/symptom relief
• Choice and control over place of death, including
• Access to hospice-care
• Control over who shares the end
• Control through advance directives
• Knowledge of deaths approach and what to expect
• Control Dignity and Privacy
• Access to any required information and expertise
• Access to any required spiritual or emotional
  support
• Time to say goodbye, and control over other
  timings
• Control of DNAR/AND decisions

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Reactions to terminal illness5 Stages of
Elisabeth Kubler-Ross

• Denial and Isolation No, its not me, it cannot
  be me.
• Anger Why me?
• Bargaining Ill serve You if You give me more
  time
• Depression Reactive and Preparatory reality
  and consequence
• Acceptance A summons has come and I am ready for
  my journey

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3 Key Areas for the DyingDying thoughts

• Failure or fulfilment?
• Fracture or forgiveness?
• Flying or falling?

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Dying needs

• Love and friendship
• Acceptance and Respect
• Control
• Information the right amount
• A certain Hope

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Ministering to the Dying3 Categories

• Atheists
• Believers
• Agnostics
• ALL have spiritual issues not all have
  religious.

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Ministering to the Dying Defining the terms we
use (1)

• Spiritual
• To do with transcendence
• Something beyond ourselves
• Related to a reaching out, a hunger
• Necessarily, mystery involved
• Purpose, meaning, of my living and my dying
• Fulfilment the filling full
• Eternity
• The thing we have to explore, or we are incomplete

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Ministering to the Dying Defining the terms we
use (2)

• Religious
• Relating to the form of spirituality
• The practice as opposed to the concept
• The framework for the spiritual the rooting
• The corporate as well as the individual
• The liturgies or forms of worship
• The rites and rituals
• Religiousness emanates from spirituality (or
  sometimes upbringing or expectation)

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Ministering to the Dying Preach the Gospel how?

• It is as absurd to argue men, as to torture them,
  into believing. John Henry Newman
• Preach the Gospel at all times and when
  necessary use words. Francis of Assissi
• 2Ti 42 Preach the word be instant in season
  and out of season reprove, rebuke, exhort with
  all longsuffering and doctrine. St Paul

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Ministering to the dying

• Earn ones spurs
• care
• love
• Listen
• Meet the needs expertise
• See the openings
• No force feeding

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Ministering to the Dying Spiritual needs of the
dying

• Do patients with life-threatening illness
  consider they experience significant spiritual
  needs?
• How might those needs vary over the course of the
  illness?
• How do patients and carers think they might best
  be supported in addressing spiritual issues?
• Murray, Kendall, Boyd, Worth and Benton Palliat
  Med. 2004 Jan18(1)39-45

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Ministering to the Dying Spiritual needs
significant

• 20 patients with inoperable lung cancer
• 20 patients with end-stage heart failure
• And their informal carers
• Conclusions
• Spiritual issues were significant for many
  patients and carers in last year of life
• Many health professionals lack time and skill to
  uncover such issues
• Creating opportunity to discuss spiritual issues
  requires highly developed communication skills
  and adequate time

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Ministering to the Dying Benefits of Faith

• McIllmurray, Francis, Harman et al Palliat. Med.
  2003 Jan 17(1)49-54
• Quaire 354 respondents with Cancer in
  Lancaster
• Included comprehensive psychosocial needs
  inventory
• 83 said they had a religious faith
• These patients were
• Less reliant on health professionals
• Had less need for information
• Attached less importance to maintaining
  independence
• Needed less help with feelings of guilt
• Had fewer unmet needs overall

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Ministering to the Dying Spirituality and
wellbeing in terminally ill hospitalized adults

• Reed. Res Nurs Health.1987 Oct10(5) 335-44
• 3 groups of 100 matched (on age, gender,
  education and religious background) adults
• Terminally ill hospitalized patients have greater
  spiritual perspective than non-terminally ill
  hospitalized or healthy
• Spiritual perspective in t-i-h-p is significantly
  correlated with well being

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Ministering to the Dying Effect of spiritual
well-being on end-of-life despair in terminally
ill cancer patients

• McClain Rosenfeld and Breitbart, Lancet.2003
  May10361(9369)1603-7
• 160 patients with life expectancy of lt3/12 Bronx
• Interviewed with a series of standardised
  instruments
• Significant inverse correlations between
  spiritual well being and desire for hastened
  death, hopelessness and suicidal ideation
• Spiritual wellbeing was the strongest predictor
  of each outcome variable (more than depression)
• Depression was highly correlated with desire for
  hastened death in those with low spiritual
  wellbeing, but not in those with high spiritual
  wellbeing

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Ministering to the Dying Assessing the
influence of spiritual beliefs on wellbeing in
hospitalised orthopaedic patients

• Clark, Anniemarie (2000) unpublished BSc. Soton.
  
• 50 orthopaedic patients recruited interviewed
  pre-op.
• 35 returned questionnaires at 6 weeks post
  discharge.
• Curvilinear relationship between spiritual belief
  and well-being.
• Moderate strength of belief correlated with lower
  well-being than in those with no or high belief
• At 6 wks quaires showed more anxiety, pain or
  personal growth in the moderate belief group.

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Ministering to the Dying The role of religion in
recovery of adult burn patients

• Sherrill and Larson South Med J. 1988 Jul
  81(7)821-5 N Carolina
• Some such patients have remarkable emotional
  resilience others not. Why?
• Research shows that when burn patients are given
  opportunity to talk about what helps them cope,
  they frequently credit their religious faith or
  God
• We emphasize the importance of understanding the
  relationship between patients religious beliefs
  and their ability to deal with the stress of a
  traumatic injury

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Ministering to the Dying Assessing the influence
of spiritual beliefs on wellbeing in hospitalised
orthopaedic patients

• Clark, Anniemarie (2000) unpublished BSc. Soton.
  
• 50 orthopaedic patients recruited interviewed
  pre-op.
• 35 returned questionnaires at 6 weeks post
  discharge.
• Curvilinear relationship between spiritual belief
  and well-being.
• Moderate strength of belief correlated with lower
  well-being than in those with no or high belief
• At 6 wks quaires showed more anxiety, pain or
  personal growth in the moderate belief group.

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Ministering to the Dying Spiritual beliefs may
affect outcome of bereavement

• Walsh King et al BMJ. 2002 Jun29 324(7353)1551
• 135 soon to be bereaved in Marie Curie centre
  near London prospective study
• Standardised assessment at 1,9 and 14 months post
  bereavement
• NO belief poor resolution of grief
• LOW belief slow for 9/12 then progressed well
• HIGH belief progressive healthy resolution of
  grief
• Conclusion People who profess stronger
  spiritual beliefs seem to resolve their grief
  more rapidly and completely than do those with no
  spiritual belief

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• Coleman,Speck Mills Belief and bereavement. A
  prospective study of older bereaved spouses post
  1st anniversary
• This looked at
• How well subjects with or without belief
  processed their grief
• Particularly with regard to development of
  anxiety and depression
• Utilizing RFH Strengths of Belief scale

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Results in 2nd year of bereavement
(A) Strong believers and church attenders (32)
with high meaning scores were not depressed
(B) Moderate believers and non-attenders (39)
with low meaning scores showed much more evidence
of depression anxiety
Coleman, McKiernan, Mills Speck. 2002. Quality
in Ageing 3(1)
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Application of findings

• Important to assess spiritual need as part of
  bereavement assessment at time of death, pay
  special attention to moderate-weak believers.
• c/f Walsh, King et al BMJ 2002 absence of
  belief is a risk factor for delayed or
  complicated grief.
• Important challenge to those involved in funerals
  and follow-up of families post funeral.
• (32 of sample had physical role limitations)
  Issues re. Faith Communities role towards those
  unable to attend place of worship in later years
  of life. Interviews of elderly revealed feelings
  of abandonment by churches.
• Especially important for those dying at home with
  less easy access to spiritual care