Dying: Out of Darkness

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>Resentment is succeeded in turn by bargaining—a campaign, often undetectable, to somehow stay execution of sentence. A difficult patient may abruptly turn cooperative; the reward he seeks for good behavior is an extension of life. The author cites the poignant case of an opera singer, her face consumed by a fatal malignancy, who begged for a chance to sing one last time; thus, death would have to wait. She did —and it did.

> After the bargaining stage, the patient generally sinks into a profound depression. This stage, the author believes, has a positive side. The patient is weighing the fearful price of death, preparing himself to accept the loss of everything and everyone he loves.

> The fifth and final stage is acceptance, when at last the condemned patient bows to his sentence. "I think this is the miracle," the seminar was told by one woman who had steadfastly refused to accept the fact of her impending death. "I am ready now and not even afraid any more." She died the following day.

Dr. Kübler-Ross warns that the patient's final resignation should not be mistaken for euphoria, as it sometimes is. Passivity is a better description: "His circle of interest diminishes. He wishes to be left alone or at least not stirred up by news and problems of the outside world." The patient's family often misinterpret this state as rejection. "We can be of greatest service to them," the author reasons, "if we help them understand that only patients who have worked through their dying are able to detach themselves slowly and peacefully in this manner. It is during this time that the family needs the most support, the patient perhaps the least."

Even after acceptance of the inevitable, it is the rare terminal case who abandons hope. When that occurs, says the author, death is imminent. In an age in which religious faith seems to be crumbling, hope provides the means of enduring the months and years of suffering and of living with the foreknowledge of death. "I don't think about dying, I think about living," said one indignant 53-year-old patient; his losing struggle was then in its 20th year.

Dr. Kübler-Ross concludes that the patient who is not officially told that his illness is fatal always discovers the truth anyway, and may resent the deception, however well meant. Her message is above all for those around the dying patient, and it is one so obvious that it has long been overlooked. The dying are living too, bitter at being prematurely consigned—by indifference, false cheerfulness and isolation—to the bourn of the dead. It is not death they fear, but dying, a process almost as painful to see as to endure, and one on which society—and even medicine—so readily turns its back.

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