Certainty of Death and the Reflections of a Physician

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“Every soul will have a taste of death: and only on the Day of Judgment will you be paid your full recompense. To be saved from the fire and admitted to Paradise is certainly a great triumph. The worldly life is no more than a deceitful possession.” (Qur’an 3:185)

Regardless of our station in life, one thing that unites all of humanity is the reality of death. All religions feel that their way of thought is correct. Culture, ethnicity, life experiences, personal study, upbringing, psychological predispositions and peer groups are some of the factors that shape our outlook on the spiritual world.

In my contact with dying patients, I often have wondered what is the ideal way to die regardless of spiritual belief? The book Rules Relating to the Deceased, translated by Shaikh Saleem Bhimji and published by the Islamic Humanitarian Service, provides an excellent guideline for Muslims. But, I have often wondered how can we help the actual process of death be as peaceful as possible from a healer’s perspective?  Recently, I had the pleasure of attending a Grand Rounds lecture by Susan Block, MD, Professor of Psychiatry and Medicine at Harvard Medical School and the Chief of Psycho-Social Oncology at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Block, who also happens to be one of the founders of a course taught to first year Harvard medical student entitled “Living with a Life-Threatening Illness”, is an internationally recognized leader in studying the mental health issues that the terminally ill face.

In her lecture, Dr. Block addressed the factors that lead to a peaceful death and the factors that lead to a complicated and eventually unsatisfactory death. The classical model of the acceptance of death is Elizabeth Kubler-Ross’s five stages. When the person first hears of the news that they have an incurable disease, (s)he first experiences denial (“No way, I can’t have cancer.”), followed by anger (“Why me?”), bargaining (“I will be religious; I will feed the poor in Timbuktu if I am cured.”), depression (“I will miss my loved ones.”), and then acceptance. Ideally, prior to death the terminally ill will reach the stage of acceptance, thereby achieving a certain level of peace at death.

Imam Ali (peace be upon him) eloquently stated, “when you have to depart from this world and have to meet death (eventually), then why wish delay (why feel nervous about delay).” In her lecture, Dr. Block listed ten components of peace at death:

  • Acceptance of the diagnosis
  • Feeling of being well loved
  • A sense of inner calm, harmony, and tranquility
  • Tolerant of changes in physical appearance
  • Able to enjoy life despite illness worries
  • No sense of unfairness
  • A sense that life is not yet over
  • Lack of anger about the illness
  • Not feeling beaten down by illness
  • Lack of shame/embarrassment about the illness

Sura Fajr summarizes the above ten components wonderfully. “(To the righteous soul will be said): O soul that is at peace and rest: return to your Lord, well-pleased (with Him), well-pleasing (Him). Enter, then, among My devoted servants! And enter into My garden!” (89:27-30)

These ten components are helpful but cannot be attained without cognitive and emotional acceptance of the inevitable. Cognitive acceptance is defined as awareness that one is terminally ill, and emotional acceptance is the ability to be at peace with, rather than struggle against, the prognosis. The best outcome exists in a patient that has both cognitive and emotional acceptance according to Dr. Block.

Some concrete factors that can lead to a peaceful death are:

  • Therapeutic alliance with the physician
  • End of life conversations with your physician, especially focusing on the prognosis
  • Relationship with dependent children
  • Family acceptance
  • Religion/spirituality
  • Race and ethnicity (in conjunction with the above factors and personal outlook)

It is astonishing that only 30 percent of advanced cancer patients reported end-of-life discussions. Multiple factors lead to this from the patient and physician perspective. It appears to be that both sides are reluctant and have fears. However, studies have shown that end-of-life discussions (months before death) were not associated with psychological harm (e.g. depression, anxiety and other psychological symptoms). It is not surprising to see that patients with dependent children are at less peace at death. Many in this situation choose to have more aggressive methods of care prior to death.

A resounding 88 percent stated that religion/spirituality were important. Personally, I have always felt that people who come from marginalized groups have an inherent advantage in forming empathy: thereby having a stronger ability to accept life’s challenges. Is this not one of the many lessons of Ashura?  Therefore, it was not a surprise to see that African Americans and others from traditionally marginalized groups felt that religion/spirituality was especially important.  Overall, spiritual support was associated with increased quality of life and peace at death.

As stated earlier, the best outcomes were seen in patients who had both cognitive and emotional acceptance. Only 20 percent of the participants in the study cited by Dr. Block achieved both. The fortunate 20 percent were found to have lower psychological distress, higher rates of advanced care planning, and highest quality death.  Another aspect that is often overlooked but is equally important is that their caregivers were more physically and mentally healthy six months after the death of their loved one.

The final days of one’s life can often be the most expensive, especially if ones final days are spent in the ICU (intensive care unit) of a hospital. It was found that as the number of aggressive procedures increase, quality of death declines. This desire to forestall the inevitable is exemplified in Sura al-Waaqia: “Why can you not help a soul dying right before your very eyes? We are closer to him than you, but you cannot see. If you are true to your claim that there is no Day of Judgment, why can you not bring it (the soul) back (to life)?” (56:83-87)

When the number of days with palliative care services are increased (e.g. hospices), quality of death increased, emphasizing the importance of submission and acceptance. This gives scientific proof of Sura al-Jumu’ah: “Say (unto them, Muhammad): (As for) the death from which you flee, that will surely overtake you, then you shall be sent back to the Knower of the unseen and the seen, and He will inform you of that which you did.” (62:8)

The author is an attending psychiatrist and a clinical instructor in psychiatry at Harvard Medical School.

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