DR. ADEWUYI S. A.
INTRODUCTION
Man is mortal, irrespective of riches, education, sex, and religion; man will one day die and be committed to the mother earth (Ruth 1:17, Eccles 9: 1 6). When cure or even prolongation of life is no longer possible, health care providers have one last task remaining and that is to provide expert care to patients at the end of life and support for their families. Despite physical comfort, patients can experience profound suffering from difficulty in maintaining personal dignity, loss of significant aspects of who they were at home, in the community, or in the workplace, lack of closure in important relationships, feeling of spiritual alienation and inability to discern the meaning of their lives. When these problems are addressed, patients have the chance to attain transcendence, a sense that who and what they have been will persist long after they have died. We need never say, “There is nothing more I can do”. Patients rely on us to help them achieve a comfortable death that follows a time when goodbyes have been said, legacies have been established, and relationships have been brought to an acceptable closure. Their families need us to minimise the patient’s suffering, obtain expert palliative care consultation when needed, and communicate clearly and often with them. Currently, however, such care is the exception rather than the rule especially in this environment.
THE CHRISTIAN PERSPECTIVE
For it is appointed unto man to die once and then judgement! (Heb. 9:27). For better understanding, Man is tripartite, has three separate, distinct parts. This concept is based on: – 1 Thess. 5: 23. ‘May God himself, the God of peace, sanctify you through and through. May your whole spirit, soul and body be kept blameless at the coming of our Lord Jesus Christ.’ And also in Heb. 4: 12, Eph. 2: 1-3. From the biblical theory, the Tabernacle concept of Martin Luther is a practical three in one model: one Tabernacle and yet three distinct parts. The whole would be incomplete without all of the parts. The duty of the Christian care giver is to meet the physical, emotional and spiritual needs of these patients. The Christian caregiver must always see himself as the last person most likely to minister to the patient before he dies and must try the very best possible to reconcile man with man and man with his Creator, God. In the words of John the Baptist, John 1: 31 ‘I did not know Him, but so that He might be manifested to Israel, I came baptizing in water’. The doctors, nurses, pharmacists, paramedics, and all other professionals should know for certain that the primary reason for God entrusting the work they are doing is to ultimately make Christ manifest and known to others, especially the lost and the dying. If the dying is already a Christian, then all efforts is channelled to ensure he sees death as going home to the Lord Jesus and should never depart from the faith even as he goes home. Christian caregivers are soldiers of the cross equipped in all aspect of life and sent for rescue mission. In hospitals, hospices, homes, on the roads, we have many horribly wounded soldiers and civilians (christians and unbelievers) and our duty is to rescue them from danger to safety, to snatch them from going to hell into heaven. Christian health workers are privileged to be members of this rescue team; to render spiritual and physical services to humanity and secure eternal rest for the souls of men.
World Health Organization defines the care of the dying (palliation) as “the active total care of patients whose disease is not responsive to curative treatment and death is imminent; control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of this care is achievement of best possible quality of life for patients and their families” (W.H.O. 1990). This definition includes the care of the family of the dying patient. Death could result from old age and diverse ailments like malnutrition, cardiac failure, diabetes, HIV/AIDS, cancers, accidents, etc. To achieve the goal outlined by the W.H.O., it is pertinent for the caregiver to recognize when patients are dying, affirm life and regard dying as a normal process, provide relief from pain and other distressing symptoms, integrate psychosocial and spiritual aspects of patient care, provide support for carers and enable patients to die in the place of their choice.
Recognizing when patients are dying
It is pertinent for the attending clinician and other health team members to recognize when death is approaching. Some of the signs and symptoms in recognizing approaching death include profound weakness, gaunt physical appearance, drowsy/reduced cognition, diminished intake of food/fluids, and difficulty in swallowing oral medication although these symptoms are not specific and a lot of experience is needed. The physicians must be clear about prognosis, and not overly optimistic. Timely, truthful, compassionate communication among patients who are dying, their families, and their physicians is needed to dispel fears (e.g. of unrelieved pain or of abandonment), to promote feelings of autonomy and control, to set goals of care, and to enable patients and families to be prepared for what is to come. It is of necessity for the patient to be informed of imminent death so that he can name a proxy to make healthcare decisions, know what to expect as their physical condition deteriorates, put their financial affairs in order, know that the doctor is comfortable talking about death and dying, feel that the family and they themselves are prepared for their death, have funeral arrangements in place and have treatment preferences, especially about resuscitation. Similarly, it enables the patient and families to say goodbye and be present when death occurs, talk about their fears, and talk about the death with the clinicians. For them to be prepared, physicians must be clear about prognosis.
Affirm life and regard dying as a normal process
Euthanasia which is defined as mercy killing; the deliberate ending of life of a person suffering from an incurable disease is being practiced in some developed countries. Those involved in this practice have given all sorts of explanation to justify their action but the stand of the bible which is the final authority for the Christians is very clear on this matter. Thou shall not kill is God’s commandment (Exodus 20:13). Dying is one of the deepest experiences in the life of a human being, if not the deepest. The whole person–spirit, soul and body–is involved in it especially if the patient and the family are informed. Being terminally ill (ending in the death of a person) evokes a real crisis in the life of the human being. This crisis manifests itself in the spirit, soul and body. The fear of death has led many to commit sins which they would not have committed. Nothing else on earth shakes man vigorously as death. There is a risk factor which creates fear and this has been settled on the Cross of Christ. People fear death because they don’t have a guarantor against death. The only assurance against death is you knowing whom you believed that is Jesus Christ! The experiencial knowledge of Christ destroy the fear of death (I Cor. 15: 55 58) and it is the duty of the health worker to allays patient fear.
Provide relief from pain and other distressing symptoms
Symptom control becomes very important because symptom like pain can destroy the “quality of life” and prevents patient’s ability to focus on the things that are important to him; for example his family, prayers/meditation, making peace, e.t.c. Pain is a terrible lord of mankind and a man can curse God when in serious pain. In developed countries, with the help of medication 95% of patients can at present be kept free of pain without serious impairment of consciousness. For the other 5%, pain can be controlled at a bearable level with medication. In this environment, managing pain is a problem because the various non-invasive strong analgesics are not readily available. It is often helpful to think in terms of “total pain”, encompassing the physical, psychological, social and spiritual aspects of suffering. Many factors are implicated in lowering or raising pain threshold. For example, anxiety, ignorance, insomnia, previous experience can lower the pain threshold of a patient significantly. Similarly, the control of other symptoms–good quality sleep, a feeling of security, psychological support, explanation, resolving emotional conflicts, relaxation/ massage, diversion activities, treatment of anxiety or depression–can raise the pain threshold. Other frequently occurring physical problems in the life of the dying patient requiring medical attention include weight loss, nausea/vomiting, hiccups (frequent, long), dry mouth/thirst/dehydration, dyspnoea, dysphagia, cough, anxiety, confusion/unrest, incontinence, constipation, diarrhoea, itching, decubitus ulcers, and deformities.
Integrate psychosocial and spiritual aspects of patient care
The news that death is imminent creates a crisis in the life of the patient and this crisis manifests itself in the spirit, soul and body. There is need for the health care provider to integrate these psychosocial and spiritual needs and conflicts in the care of the patients. The psychosocial problems. of the dying person include loss and grief, loneliness/isolation, fear/insecurity, stress swing reactions.
1. Losses and Grief
Losses are always accompanied by feelings of grief or mourning. In the course of the disease, the patient may suffer different degree of loss. The most common losses are the loss of normal physical comfort, mobility, physical self-control, external dignity, physical strength, mental dignity, identity, psychological dignity, relationships (family & friends), work and financial security, social status (reputation, honour, independence), possessions, immediate future, loss of his body and for those not born again, loss of his last chance to save is soul and spirit from second death. The patient grieves and mourns for himself. For what he was, is, and hoped to be or become. Mourning begins from the moment a terminal illness is suspected and is repeated with each new loss. Patients who can express their grief and emotions outwardly often work through their sorrow better than the ones who suppress or hide them. With the prospect of these losses, the dying person’s value system is suddenly challenged. In fact, the whole meaning of life is lost when he focuses his attention on temporary things. Now the time has come to point him to Jesus Christ and to the absolute value of a life founded in Him.
2. Loneliness/Isolation
This is an individual process and different social factors intensify the loneliness which the patient goes through. Higher life expectancy, hospitalization, urbanization, the very nature of illness evokes isolation and generally added to by the medical staff and family. In the situation of loneliness and isolation, counselling and the presence of family members and ministers go a long way (Isaiah 41:10).
3. Fear/Insecurity
The dying patient is insecure about the nature of his illness, his future, and significantly, the future of his family. This insecurity manifests itself as different fears or anxieties and as guilt feelings. Common fears of dying patient include progressive dependency on others, helplessness, to be a burden, to be left alone, to be abandoned, to suffer and have pain, to die without someone knowing, humiliation, loss of physical control and disability, an emotional breakdown, separation from loved ones; fear for the future of his family, the unknown, punishment, submission to strangers and the common guilt feelings of the dying patients are concerning. Past irresponsible lifestyles, good things they failed to do but were planning to do or had promised to do and unresolved conflicts. This situation provides a sensitive Christian health care provider the opportunity to get the patient thinking about life after death and the need to reconcile with God so as to avoid second death.
4. Stress Swing Reactions (Instability)
Each life crisis introduces confusion and inner struggle. It shocks his inner balance and makes the patient emotionally unstable. Most patients will experience this instability in the form of psychological and spiritual swing reactions in the dying process. Types of stress swing reaction include denial, anger/protest, rebellion, criticism, sadness, depression, guilt feelings, despair, fear, disappointment, distrust, bitterness, restlessness, and doubt. All this scenario provides a soldier of the cross ample opportunities in redirecting the patient from looking at his present circumstances to looking at Jesus Christ who is able to give peace to his spirit and soul (John 14: 27).
To provide support for carers (family members)
In a situation like this, the family is also stressed to the limits. The care provider can be of immense help to the family in recognising their situation, offer the support you have, keep them informed mindful of patient confidentiality, allow time to assess and discuss their needs. The needs of the family include religious and emotional support, practical advice and help, information as to the changing needs of the patient, e.g. feeding and knowledge as to realistic expectations from the patient. The family has to be prepared for the death of the patient and the bereavement/mourning period. Healthcare providers have obligation to ensure that bereavement support is available to families and family members, they have the right to remain with a dying patient. The presence of the family member does not mean professionals no longer have a role but also ensure that the relatives have the time they require with the patient after death. The strict adherence to visiting hours as used for other patients may not be applicable to this group of patients. Ministers of God may be encouraged to spend more time with the patient and family members as the end approaches. At this stage, all restrictions may have to be relaxed! Similarly, provision should be made for the carer in view of grief and bereavement. Skilfully communicating the diagnosis and terminal prognosis, providing emotional, psychological, and spiritual support and physical comfort, helping families resolve outstanding issues, and making the death as peaceful as possible are all measures that diminish the suffering of the survivors.
To enable patients die in the place of their choice:
This is ideal in countries with very excellent palliative and end of life care services. In countries where oral morphine is readily available to the patient, where excellent care can still be rendered to the patients in their homes and in countries with established hospice system and sophisticated medical care, this is the ideal. The above-listed condition is far from what is obtainable in this environment. The writer is of the opinion that patients should be managed in hospitals closest to the home of the patient to ease the stress on the patient and the family members except where there is provision for the patient to be managed effectively by medical personnel at home or otherwise.
CONCLUSION
Despite the fact that the patient is dying, the various medical problems, psychosocial and spiritual problems the patient may be having must be attended to in order to improve the quality of life for the remaining life span. Iatrogenic problems must be avoided. In the course of drugs administration, the route with least pain should be used. Except if no alternative is available, surgical intervention should be avoided. Christian doctors are soldiers of the cross equipped and sent for rescue mission and our duty is to rescue them from danger to safety. Christian health workers are privileged to be members of the rescue team; to render spiritual and physical services to humanity and secure eternal rest for the souls of men.
REFERENCES
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Dr. Adewuyi S. A.
Clinical & Radiation Oncologist Radiotherapy and Oncology Center, Ahmadu Bello University Teaching Hospital, Shika Zaria P. M. B. 06
E-mail: sadewuyi2003@yahoo.com
#Career #Ethics #2007