ATTITUDE AND COMMUNICATION WITH A TERMINAL PATIENT

Dr. José Martínez-Romero Gandos – 2012.

Versión castellana más abajo.

                                                         

“Learn to get in touch with the silence within youself,

and know tht everything in life has purpose.

There are no mistakes, no coincidences,

all events are blessings given to us to learn from.

Elisabeth Kubler-Ross

I read a web page on "Psychology and Death Science”. I read, also, some articles about patients who confront a terminal illness. They do not convince me because I find a coldness in the speech that will not be pleasing to a reader who happens to this situation.

I do not believe in the "chances" nor in the "causalities" from an infinite multiplicity of factors. Someone of these factors puts me in touch with an ex-patient in consultation does more than twenty years that writes to me:

 I feel better in my fight against the "ca. of pros" (cancer of prostate), which after many years it developed a metastasis of the bones (I felt it in the waist) and after treatment against the pain I initiated the treatment of chemotherapy . When it began years ago I received your help. Now I remembered those help and I fight against my illness as hard as I could (it refers to the psychotherapy received by having discovered the cancro), this time with the support of … (… wife, daughter, grandson). And thinking about God and the Virgin, under diverse dedications, I am improving. Or it's the least that I could do. I am grateful for the help received in that opportunity, which is a very useful today. With all my affection for you, XOSÉ. "

After a lot of time of that meeting between psychologist and patient I felt sadness. Our encounter today is not based on the words that we say but in our common feelings.

"Now I remembered those help and I fight against my illness as hard as I could”, said my old patient. This words help us to remember something that comes from the past and is updated in a present attitude to face the uncertain future.

For the Psychologist to share the feelings of a patient is "to be arranged", is to agree to offer support still in the distance or in the time. Is to update the commitment when he chose to be a professional and when he accepted the encounter with any patient. The professional commitment implies helping other one in its entirety while we offer him the possibility of choosing to be helped in agreement to his way of being-in-the-world, to his unique and particular way of facing the death. To respect his project to be and take charge of his imminent and emergent need of facing the death. We all will face some day the death but today this behaviour becomes "clear".

We think that is the "fact” of his disease that modifies him and forces him to choose his new way to live or to die.

It is less complicated for the Psychologist to help to diminish his physical and psychic pain if the patient knows diagnosis, treatment and prediction. The Psychologist must continue with the assistance (as in this case also does the family) in order that the patient does not feel alone or even abandoned.

The professional don’t places the patient in a situation opposite to his transcendency, the proper function of a religious who assist it, but it help to understand that “when we are no longer able to change a situation – just think of an incurable disease, say, an inoperable cancer – we are challenged to change ourselves” (V.E.Frankl, “The unheard cry for meaning” p.39). Probably now in a form of being more near the others who love him and allow him to understand the valuable thing that has been to live "his own life”.

I answered, immediately, their mail: "I’m very happy for the improvement and be sorry about the complications that have derived from the treatment of the prostate. I’m glad, yes, that you can share everything with his family because it favours a fullness in the sense of life. To feel well with others helps to value the positive of the life, valuable for having being lived. And a very important thing is that you don’t forget lady Hope. The Hope is the weapon of the defenseless ones. For that reason has efficiency. Hope opens the possibility of future in the worst circumstances of the life. Think that life always needs be lived with intensity."

Doctors and Psychologists not always have a clear attitude when they treat patients who does not know his real diagnosis and prediction. The legislation indicates the obligation of the professional to communicate the diagnosis. Not always it happens this way. The consideration of impediments for motives of medical or psychological care can be justified and the professional postpone the advertisement. His professional performance is lawful always and when these actions do not constitute a projection of fears before the proper death or waiting for possible negative reactions of the patient.

The suitable information is indispensable when a patient has demonstrated his "real" desire to be able and capable to bear the situation. If this information is denied to him, if he is prevented from knowing the truth and cannot choose, we are in a situation of denial of death’s dignity. The patient is a human being, free and responsible, who has right to develop according to his temporality, corporeal nature and the “cure” of his existence. 
Otherwise will be "treated as an object”, pushed to an "unauthentic" life, without weapons to confront the future, freed at random of the doubt and will not have the possibility of an organization of the rest of his existence, how he wishes. The patient may use a battery of values that he will find in the experience of his life.

If we consult the bibliography about this matter we find numerous examples that support our quotations. We can select writings of Jones, Freud's biographer. Dr. Freud fall very ill with a cancer and his doctors and relatives thought the possibility of doing a report about the fatal diagnosis. Finally they agreed to comment on this situation to Freud. Surprised he threw a look to his environment and then, infuriated, said to his speakers: - “With which right would you have done it?”

Very different it is the situation when the patient "chooses" not to be able, not ask, not find out about anything brings over of the process of the disease and his possibilities of survival.

This situation reinforces, in many opportunities, the cultural influence, tabúes proper of his community or very deep fears on the nature of his disease and possibility of death.

What attitude must professionals and family assume in this situation? Basically to support the decision of the patient, to analyze especially every case and to elaborate the convenience or not from the elaboration of the problem to familiar level. The professional must have to his disposition a great quantity of technical elements that offer him the certainty of the diagnosis, allowing him to communicate it in the opportune moment, avoiding irreparable damages.

The Psychologists not always we are inserted in an interdisciplinary team (doctors, psychologists, social workers, attorneys) that allows us to act with rapidity and adequately in each of the mentioned cases.

If the Doctor cannot assume the whole responsibility of a psychological treatment of the patient's crisis, he can delegate in the Psychologist the task of "accompanying". In this case the Psychologist act with independence and professional suitable criterion.

The Psychologist will clarify his role perfectly in his interview with the patient or with his family, which will be his responsibility and the differences with the medical treatment. He will avoid the confused, contradictory or ambiguous informations since it is necessary to consider the patient as a "totality", without dichotomies between his "psyche" and his "soma".

Who does take charge of the Man? It's necessary that every person, doctor, psychologist, family and friends, with a permanent communication, they try not to lose this perspective of "totality": that is the demand of the situation. They will continue communication in a relation with the evolution of the patient.

The Psychologist, by his profession and training, is treating to establish an "effective" and "affective" communication with patient and family. This "encounter" will not limit itself to the situation of "crisis", but he will continue in the future, preparing the whole range of modifications that each one will face in the future. This is the theory of 'healing through meaning' posited so many years ago by Dr. Viktor Frankl.

His relation will be "authentic", removed of the promotion of a false climate of pity, with a normal "encounter" of development of the existence of this being that is trying to assume his new "way–of-being-in-the-world-in-the-love” (L. Binswanger) and to be realized "yet in the worst circumstances" (V.E.Frankl) since the suffering, that it is not typical of the Man, but it raises him across the others, now with meaning and transcendence in his existence.

The pity would reduce the patient to the condition of a “thing” to which to treat without consideration of his possibilities, of his choice, of his responsibility, of his temporality and of his corporeal nature.

In simple words to allow to others choosing what to do with his time, with his body and with his existence in hole. To leave it that he does not anticipate, prematurely, the closing of his life and to open it for the Hope. To allow him to share his distress and to tolerate it. Because the opposite is an evident manifestation that we cannot take charge of our own fears, distresses and objections before the death.

Our task like Psychologists is centred in showing to relatives and friends that the care of another one, of the patient, does not imply limiting or abstaining before them. We take care of our own existence if we deal, jointly, with other one who suffers. It is the essence of "cure" (From latin: to take care of other one).

If they are capable of to take part in the project of his own lives across the care of another one, probably the patient will not share all these projects. But he will be present across the absence and of those who "were" in his presence or assistance.

“Life is never lacking a meaning. To be sure, this is only understandable if we cognize that there is potential meaning to be found even beyond work and love. Certainly we are used to discovering meaning in creating a work or doing a deed, or in experiencing something or encountering semeone. But we must never forget that we may also find meaning in life even when confronted with a hopeless situation as its helpless victim, when facing a fate that cannot be changed. For what then counts and matters is to bear witness to the uniquely human potential at its best, which is to transform a tragedy into a personal triumph, to turn one’s predicament into a human achievement. When we are no longer able to change a situation – just think of an incurable disease, say, an inoperable cancer – we are challenged to change ourselves.” (Frankl, V.E., The unheard cry for meaning, pag. 39, 1978)