People no longer die in large numbers at home. The majority of dying takes place in hospitals, nursing homes, and other long-term-care institutions. Extensive, even heroic, efforts are often made to keep patients alive as long as possible, but the outcome is inevitable—at least, in the long run. Although a certain number of patients sign living wills to the effect that they do not wish extraordinary medical procedures to be employed when death is imminent, most patients still want to live as long as possible.
Observations by Glaser and Strauss (1968) of dying patients and the way they were treated by medical personnel in six care facilities revealed that the appropriate treatment depended to a large extent on whether the patient had a lingering or a quick-dying trajectory. The treatment of patients with lingering trajectories consisted mostly of comfort, care, and custodial routine, with an emphasis on patience and inevitability. The treatment of patients with quick-dying trajectories, on the other hand, depended on whether a quick death was expected or unexpected. The latter tended to create a crisis atmosphere in the hospital or long-term-care institution, particularly in the rare case where death occurred on an obstetrical ward (Mauksch, 1975).
Nursing homes are usually better equipped than hospitals to deal with patients having lingering trajectories, because hospitals are oriented more toward recovery and cures than dying. Doctors and nurses in nursing homes are more likely to let terminally ill patients die without making extensive efforts to sustain or resuscitate them by mechanical, electrical, or chemical procedures.
The treatment of all dying patients emphasizes comfort and pain control. Hospice treatment has stressed the control of pain and discomfort by means of Brompton's mix, a mixture of morphine, cocaine, ethyl alcohol, and a sweetener, or even by morphine alone. Rather than being a specific place, a hospice is an organization that provides services to dying patients and their families. Hospice care may take place almost anywhere—in a hospital or other institution, or even in a private residence. In addition to controlling pain and discomfort, hospice care involves discussions of death and dying between patients and the medical staff, and the right to die with dignity and a sense of self-worth rather than feelings of isolation and aloneness (Saunders, 1980). Only patients who are dying from cancer or another terminal illness are accepted for hospice treatment. In addition, the prognosis of death must be in terms of months, not years, and the patient must live within a reasonable distance of the hospice. Finally, a primary caregiver must agree to assume continuing responsibility for the patient's care.
Wherever a person may die—in a hospital, in a nursing home, in a hospice, or at home, it is never a pleasant experience. Consequently, it is typically accompanied by evasiveness and often a so-called conspiracy of silence on the part of caregivers not to talk about death at all with the patient. Reassurance, denial, changing the subject, fatalism, and discussion are among the strategies used by medical personnel and others in responding to dying patients (Kastenbaum & Aisenberg, 1976). Most desirable and effective of all, however, is open communication with patients, many of whom are eager to share their thoughts and feelings with other people. Dying adults of all ages are usually grateful at being told the truth concerning their condition, and they welcome the opportunity to discuss it (Glaser & Strauss, 1965; Puner, 1974). Although dying people need to be aware of their impending death, they can deal with the information better when it is presented by a compassionate, companionate person. Then, the patient can feel free to express his or her fears, make whatever confessions need to be made, and obtain understanding, support, and forgiveness from a sympathetic, caring listener.
Psychological support to dying persons may be provided by family members, medical personnel, clergy, and even by professionals who specialize in counseling the dying. Professional counselors, who must be careful not to impose their own values on patients, may employ a variety of techniques. Among these are uncritical acceptance, attentive listening, reflection of feelings, life review, and group-oriented therapy (Kalish, 1977). The specific goals of such counseling depend on the patient and the situation, but the general aims are to help the patient overcome his or her feelings of sadness and despair, resolve remaining conflicts with family members and others, and acquire insight into the meaning and value of life.
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