Friday, July 12, 2013

Readiness and Dying

To parents the concept of readiness is very familiar. The idea implies that there are certain milestones a child will not achieve until they are ready. I have heard the term associated with first words, toilet training, writing the alphabet, and reading. It helps explain some of the frustration parents go through when struggling with why one child could write their name at 3 and another sibling exposed to the same environment didn’t write their name until 5. 

There is another type of readiness that I see frequently surrounding end of life issues and that is the readiness of patients and families to accept a prognosis.  The futility parents feel with wasted efforts trying to get their toddler to write the letter ‘E’ when the child only knows scribbling, can feel akin to the frustration medical personal and family members feel when trying to get a patient to realize how close to death they really are.

There is tension when two parties have different perceptions on what the reality of a situation is. Usually the more logical, realistic person feels the need to convince the more hopeful and potentially even delusional person, of their faulty views.  “Mom has to realize that she’ll never be able to take Dad home again!” or “Doctor, you must convince my aunt that she’s dying!”

There are two questions this brings up. First, is it really necessary to force someone to accept reality on their death bed? And secondly, is it even possible? It is with the later that the concept of readiness plays a role. If a patient, or even a loved one, is not ready to acknowledge their prognosis, then frankly it is wasted energy on anyone’s part to try a forceful approach.

In such cases, I have found it helpful to do the opposite. By simply respecting their perspective, thus taking away the battle of wills, a safe place is created by which time becomes the ultimate revealer of truth. In other words, when someone in denial no longer must spend all their energy convincing the world of their perception, suddenly that extra energy and time can be spent reflecting on the reality of what is right in front of them.

In our impatience, we often want this process of acceptance done immediately; but readiness is still at play, and despite all our efforts at respecting, arguing, teaching, or waiting, the truth is many still will never get to that place of acceptance.

Which leads us to the first question; is it really necessary to know we are dying?

I have been with patients incapable of knowing their prognosis due to dementia or other serious illnesses. Those deaths have been just as peaceful as those in whom knowingness existed. I have also sat with patients who were very capable of reality, but because of unreadiness, did not accept that truth. Their deaths still occurred, but often were not as peaceful as others.  It may not be necessary, however, I have watched as hospice has supported patients and families, moving them to readiness. In these individuals the transformation from denial to acceptance can be as rewarding as watching my kindergartner learn to read. 

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