Monday, February 27, 2012

The Paradox in Death

I love paradoxes. Well, I should say I find them complex and intriguing; however I don’t relish living with one personally.  The idea that we as humans can live with self-contradicting sentiments does make us unique creatures. It also can make for some intense battles within us. In a specialty like palliative medicine I’ve had to learn to be not only familiar with, but also comfortable with paradox.

I suppose the more extreme the situation, the more extreme the paradox can be. Let’s face it then, what’s more extreme than life and death?  Thus some of the greatest inner struggles come in both patients and families at this time.

For patients, the paradox is usually about life and death itself. Someone will say, “I’m ready to go, I’m not afraid to die, I’ve lived a good life, etc.” But then this same person won’t want to get into their bed because they are afraid symbolically once in bed, they will have given up, and ultimately die.  This is a paradox, and it is self contradicting. They want to die; they don’t really want to die. This is the glorious thing about people; we can hold two completely opposite beliefs at the same time. However, by creating a paradox, there can be consequences. The consequences usually manifest physically in the form of anxiety or delirium, but also sometimes pain. When I see a surge of symptoms such as these, I am prompted to explore this issue.  Almost always, the patient has verbally declared their resolution to dying but hasn’t admitted there is an underlying resistance as well.

For families, while the paradox still involves life and death, it feels very different. Sitting and watching the slow irreversible process at hand, loved ones will feel a sudden wish for this to be over. The desire stems from not wanting to see their loved one suffer, but it still feels like a death wish. Contrast this to a strong feeling of not wanting their loved one to die and wishing for more time and a paradox is born. Equally strong and self contradicting these opposite sentiments usually evolve into guilt and confusion.  Guilt comes because the person acknowledges that they’ve hoped for their loved one to die quickly and this desire feels wrong, and confusion comes because this directly opposes the longing for them to stay alive. 

To both of these situations I’d say, “It is absolutely normal and expected to experience this paradox.” To the one dying, there is less to be done cognitively to ease the symptoms of the contradiction. Thus medication management through hospice becomes critical. To the family members, however, it is the acknowledgement of the ambivalence that is important. The treatment is not to take the paradox away. Our selfish part, wanting our loved ones to live and be with us will consistently fight the unselfish part that hopes our loved ones will escape any suffering and debility they are experiencing. The solution becomes learning to be content with the paradox. Some would even say that this is what peace is; being able to embrace paradox.

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