Education And Debate Coping with loss

The dying adult

BMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7140.1313 (Published 25 April 1998) Cite this as: BMJ 1998;316:1313
  1. Colin Murray Parkes (cmparkes@aol.com), consultant psychiatrist
  1. St Christopher's Hospice, Sydenham, London SE26 6DZ

    This is the seventh in a series of 10 articles dealing with the different types of loss that doctors will meet in their practice

    This paper focuses on two common problems that arise when people come close to death, fear and grief. Fear is the psychological reaction to danger; grief the reaction to the numerous losses that are likely to occur in the course of an illness that is approaching a fatal outcome. Both can be expected to arise in patients, their families, and—though we are reluctant to admit it—in their doctors and other carers. Both fear and grief need to be taken into account if we are to mitigate the psychological pains of dying.

    Summary points

    We should never assume that we know what people with terminal illness fear

    Most patients will benefit if we can help them to feel secure enough to share their fears

    Fear can aggravate pain, and pain fear

    Patients with life threatening illnesses experience a series of losses as the illness progresses

    Grief is natural and needs to be acknowledged and expressed

    Fear

    Though it may seem obvious that people who are dying are likely to be afraid, we should not assume that we know what they fear. The box shows the fears, in approximate order of frequency, expressed to me by patients in a hospice. It is clear that fears of death itself come quite far down on the list. Difficult to quantify but of particular importance is reflected fear, the fear that people see in the eyes of those around them or hear in the questions that are not asked.1 Many problems in communication arise out of fear, and we may need to take time to create trust and a safe place in which people can begin to talk about the things that make …

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