Coping With Impending Death

How to prepare yourself and your loved ones for the inevitable.

From the WebMD Archives

As the recent series finale of HBO's Emmy award winning series, Six Feet Under, implied, no matter how accepting we think we are of death, coming to terms with the loss of a loved one as well our own mortality can be shocking, divisive, and devastating.

This drama focused on the life and times of the Fisher family, an eclectic clan who ran a funeral home and as such, experienced death on a daily basis. The series wrapped up by focusing on the aftermath of the death of the family's older son -- a death that ripped the family apart, leaving each member with regret, anger, guilt, fear, and sadness.

And while nothing can ever fully prepare us for our own death or that of a loved one, there are things to do now to help prevent such spiraling particularity after a long illness, experts tell WebMD.

Set Things Straight

"There is only so much you can do in anticipation of a loss, but you can prepare yourself by trying to review your relationships and tie up loose ends," says Gerald Shiener, MD, a psychiatrist at William Beaumont Hospital in Royal Oak, Mich. "Go over mixed and negative feelings and regrets in a given relationship and take the opportunity to put things into words that you have never had a chance to say."

If you are the ill party, "try to take an inventory of how you lived your life and how you want to be remembered," he says. Trying to make amends for anything you may regret and to make apologies to anyone who may have misunderstood your intentions can also be helpful, he says. "This is your final opportunity to clear up misunderstandings," he says.

"If you know its end-stage cancer and death is inevitable, you have the time to prepare -- unlike an accidental death," says David Baron, DO, chairman of psychiatry and behavioral health sciences at Temple University School of Medicine and Temple University Hospital in Philadelphia.

"If you can plan for a death, you do have the opportunity to say things, and oftentimes individuals who aren't given that opportunity with a sudden death are left with agonizing feelings. It gives us an opportunity to say goodbyes in a meaningful way," says Baron, who began his career as a psycho-oncologist who counseled advanced cancer patients at the University of Southern California's Norris Cancer Center in Los Angeles.

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"If you know death is coming, value the time you have left," he tells WebMD. "It's about not being afraid to say goodbye and saying the things you want to say."

Not doing so can be devastating. "If the individual passes away and the family member says 'I never really told him or her how much I cared for or appreciated X, Y, or Z,' it can make it worse," he says.

"Yes, its a sad time, but it also can be a time to underscore all the good times you have had together and provide an opportunity to say, 'I never told you how much it meant that took on a second job, so that I could go to college,'" for example, Baron says.

"If you are dying, it is your opportunity to say your goodbyes and don't be afraid to share your fear, frustration, and anger," he says.

Can't Rush Grief and Mourning

Grief comes in stages, says William Beaumont Hospital's Shiener. "We initially react with disbelief or denial and then we get angry because we see how inevitable death is and how helpless we are and then we start trying to accept it piece by piece," he says. "We get a sense of sadness when we see the magnitude of what we are facing and then comes a degree of acceptance."

And everyone has his or her own schedule of how long it takes to go through these phases, says. Shiener.

"Emotions are not light switches that we can turn on and off, agrees Temple's Baron.

Let People in

"There's a lot you can do to prepare for an inevitable death, but there are a lot of obstacles to people doing it," points out the Rev. Janet Frystak, a chaplain with the Palliative Care and Home Hospice Program at Northwestern Memorial Hospital in Chicago.

When someone is dying, there is an incredible range of emotions -- anger, shock, denial, numbness, intense sadness, guilt, anticipatory grief -- and the family goes through a lot of these emotions as well, she says. "A lot of times, the pain is so overwhelming that people shut down and engage in coping mechanisms such as displacing their anger onto the medical community and/or getting lost in the medical minutiae."

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Often the family will need outside help to deal with their emotions, she says.

"Outsiders come in and can offer a more objective perspective," she says. "There is the belief that to speak of death brings it about faster and indicates the loss of hope, and that is just irrational. If you can overcome the avoidance of the subject, ask your mom, dad, brother, sister, or spouse what has been most meaningful in their life and what are their greatest joys and greatest sorrows," she says, calling this exercise "a life review."

Talking About Tough Death Decisions

Oftentimes, "people are alienated and marginalized once they have a terminal illness, and that is a psychically painful phenomenon," she says.

Frystak says it is also important to talk about funeral planning. "These are hard conversations to initiate, but you need to step up to the plate," she says.

However she admits that some people just can't deal with these things head on. "And for them such a direct discussion won't be helpful, so they have to find other ways to cope," she says. "Humor is not a bad way to go for some families."

It is crucial to have an honest conversation about the inevitable, says Betty Ferrell, PhD, RN, a research scientist specializing in care giving at the City of Hope Cancer Center in Duarte, Calif.

"If it was my mother, I would want an honest conversation to say 'we are doing all that we can, but the reality is the tumor is really bad and despite what we offer, she may die in the next four to six months," she says. "Once you have heard devastating news, a social worker, bereavement counselor, or someone should be available to get you through this tough time."

"It is ideal if bereavement therapists enter the picture when a person is first diagnosed with a life-threatening illness and say: 'I hear you just got bad news, what is that like for you?' to help facilitate the conversation," she says.

Bringing Up Hospice Care Earlier

"When you are told of dire diagnosis, it's time to introduce hospice care," she says.

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"Nobody thinks about hospice care, so we wait the next four months and treat problems as they come, but yet we still avoid reality and then two weeks before she dies when you are back in the emergency room, we panic, and say, 'Gee maybe its time for hospice,'" she says. Hospice care does not prolong life or hasten death, but it can help improve the quality of a patient's last days by offering comfort and dignity.

Other activities that can help you cope include creating a scrapbook of memories and pictures throughout life as a legacy, she says. Next of kin should also know where bank accounts are and get affairs in order during this time.

Better Treatments Change Landscape of Grief and Loss

"We are really in a different era than in previous decades because even 25 years ago when someone who you loved had a heart attack or cancer or another serious illness, the event happened, there was a short period of time and then the person died," explains City of Hope's Ferrell.

"If someone who you know was diagnosed with lung cancer 15 years ago, it was clear that they would die, but now we have any interesting dilemma," she says as there is often a long, bumpy trajectory following the diagnosis of serious illness. "If your mom is diagnosed with lung cancer, she is offered surgery and a little better than two months later, it has spread so she tries chemotherapy and radiation."

"It's a roller coaster," she says. "You don't know if you should be hopeful or not or if you are preparing for her to live or die."

In some ways, Ferrell says, "families are less prepared for death today because they are accustomed to having so many ups and downs and recoveries that the possibility of death often feels far away."

There are also more difficult choices today, she says. "If you do you undergo chemotherapy it can prolong your life, but what we also know is that it can bring about more symptoms," she says. "Avoiding death can have impact on the quality of life. Treatments may prolong life for a few months, but what will those months be like?"

WebMD Feature

Sources

Published Aug. 26, 2005.

SOURCES: Gerald Shiener, MD , psychiatrist, William Beaumont Hospital, Royal Oak, Mich. David Baron, DO, chairman, psychiatry and behavioral health sciences, Temple University School of Medicine and Temple University Hospital, Philadelphia. The Rev. Janet Frystak, Palliative Care and Home Hospice Program, Northwestern Memorial Hospital, Chicago. Betty Ferrell, PhD, RN, research scientist, City of Hope Cancer Center, Duarte, Calif.
© 2005 WebMD, Inc. All rights reserved.

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