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The role of palliative medicine during last days of life

Holistic approach as far as care for the dying man seems to be inconceivable today without any correct intervention of palliative care. Palliative medicine helps man to cope with such situations which are medically impractical. Palliative care is an approach that focuses on a quality of patients’ life and their families, who face with interaction with impregnable disease, and its aim is mainly management of pain. Not just only for your information palliative medicine is called comforting, including the psychosocial and spiritual component. Palliative care is most provided in hospices. The task for the hospice is to literally fill the days with life and consciously create conditions which can help the dying man to solve him the most important issues or personal matters. Is not a secret that many of these individuals in hospice or in home hospice care settle personal relationships, which had been unsatisfactory by now or frustrating for the client. There are known cases that during safe conditions of hospice system people become reconciled after years, go through hierarchies of values and refine them. From the experience of a psychotherapist in home hospice care I can point out that such a healing process at the end of life it not only liberating for the dying man who is can communicate with somebody who he had not talked to for many years, but the relief is also experienced by relatives.

Palliative care supports life and considers dying as a standard process, does not make death faster or slower. It respects the needs of a dying man and apart from primary goals, such as symptomatic treatment, including emotional and spiritual help for the client [1].

A number of seniors perceive hospitalization as an extremely psychologically tense situation. They are pulled out from their known environment; their needs are not respected as they are used to. There is very often a high loneliness and depersonalization. After all a man longs for the opposite, longs for saturation of needs in his known environment and to have an adequate rest. Doctor Jan Hnízdil has left a practice of a “standard“ doctor and at the moment he is involved in complex medicine especially psychosomatic disorders, which are created by an incorrect lifestyle, according to the doctor, when the individual is not able to use a correct stress coping and suffers emotionally. Even a leading Czech psychosomatic doctor Vladislav Chvála takes the view that medicine works well as far as professional point of view, nevertheless the individual suffers in psychological and spiritual needs. While in the past the cause of suffering was mostly lack of care, on the contrary there is its surplus of care nowadays. Do not be afraid to say that often at the expense of the satisfaction of the psychic or other needs of the dying man [2].

Palliative care is an approach that makes patients’ and their families ´ life quality better, which face with such an incurable disease and focuses on the pain treatment and other physical, psychosocial and spiritual issues. Indication of palliative care is as following:

- Mitigates pain and other stressful symptoms,

- Accepts dying as a normal process,

- Does not make death faster or slower,

- Integrates psychological and spiritual aspects into patient´s care,

- Before client dies, offers and supports patient´s life in its full according to its system,

- Offers help to the family of a dying man during his disease and helps to cope with family members´ suffering,

- Improves quality of life,

- Palliative care specialists cooperate with other professionals who want to make client´s life longer by chemotherapy or irradiation and enter into further patient´s care that should reduce the distress of clinical complications [3].

According to Sláma palliative medicine seeks to prolong and preserve life that will be acceptable for the patient in a certain quality. Respects and protects the dignity of incurably ill. Furthermore it respects patients’ wishes and needs to become aware of the values of priorities. Next palliative medicine creates conditions so that the patient could spend his last days of his life together with his dear ones, in dignified and friendly environment [4].

Patients with a disease that threatens their life or clients in a terminal phase need to develop ways of coping with treatment and life changes effectively. The extent to which these capabilities are developer depends on how patients perceive the suverenity of their disease. Disease might be perceived as a challenge, opportunity, an insurmountable obstacle or even a punishment. The answers could be different, from maladaptive, non-effective up to constructive and we dare to say even meaningful. The patient, who during an oncological finding tries to consolidate the family, starts to handle his last will without any emotional load to relatives, represents an example of such a constructive behaviour. These people can even so called comfort their dear ones.

Some people just fix to information about their impregnable disease. Even though some patients accept their disease as a challenge, to make their correct “answer“ in a balance for the disease is not always lucky for everyone. Just let´s give an example of a woman who suffered from a breast cancer, but with a great prognosis (she had 95% chance to live according to statistics). However this patient refused a traditional medical treatment and tried to find her own way of healing. Most of her time she spent by reading books which dealt with breast cancer, she spoke with several “knowledgeable“ persons, so that she could find even more information, she continually tried new techniques (special diets, doses of megavitamins, physical exercise, relaxation techniques for psyche, musical and dance therapy and acupressure), which should have helped her to heal. She attended psychotherapy sessions several times. One can say that she “made a breast cancer carrier“, that activity became the content of her life. Nevertheless, two years after the treatment, which she appointed herself, did not return her to work. The patient had chosen a totally inefficient way of coping with her disease, made the situation worse instead of forcing her power in a different direction [5].

One of the most difficult tasks for the client is to cope with the situation when she/he learns infaust prognosis in a creative way. In such a case there logotherapy which is highly beneficial. The thought, that the diagnosis of unreachable disease might even bring something good is actually very brave. It is linked with the term crisis. In Chinese language the word crisis is created from a combination of words danger and opportunity. The real opportunity is represented in the fact that people who use their experience in a positive way, take out something that is important and apply it in single each item in their lives, thus to dying. When we learn to understand our deepest life experiences, we become more compact, complete beings; we are generally more open to changes in our lives. This is reflected in the ability to communicate better, in improved relationships with other people and in feelings of a total internal reinforcement [6].

As far as we know from the experience of a therapist in hospice care, how different clients cope with for example with an oncological finding, which seems to be incurable according to medical point of view. There is a case of one female patient who has a double-sided breast ablation, after detection of a malignant tumour and after chemotherapy was made. Her attitude to cope with the disease is to build a house. Does this idea seem “crazy“, but who from us could tell her how long she will be here and that she should not build any house…?

The aim of a palliate care is on one hand to provide for a patient, who is terminally ill, not only relief from physical symptoms and to alleviate pain, but on the on the other hand to observe the client psychologically [7]. Palliative care maximises the treatment benefits – to live long – as long as possible – quality life, consist of giving true information, especially, when the patient requires them. In addition to correctly submitted information, social welfare, rehabilitation, spiritual care and mastery of grief is important.

Palliative care is most provided to people with oncological finding, neurological disease, and degenerative disease of nervous system, dementia and others. Another group of patients, who are indicated for palliative care, are the ill ones, whose key body organ fails, such as lungs, a heart, kidneys or livers. These patients are not of course the “right“ candidates for palliative care until they are not identified as terminally ill, because to that point they can still use “benefits“ from a medical treatment.

David Field identifies two differences among patients with cancer and the ones whose body organs fail such as liver, lungs, kidneys, etc... The first difference is that how the disease progresses. There are medical procedures and treatments for patients whose body organs fail, which can be considered as good. The second factor is that there is not certainty in the diagnosis itself and its life length at noncancerous patients. Therefore the noncancerous patients are not considered to be suitable candidates for palliative care until it is definitely clear that they are so called sick to death [8].

Most people, who are dying, would like to end their lives in conditions similar to palliative care – i.e. holistic approach including that a patient is in the centre of an interest, so called his level of quality of life is determining. From the experiences is clear that not all dying ones desire to have they dear ones during their last phase. There are also known cases, when a partner of a dying man accommodates in a hospice and the ill man dies within a short time, when the companion recedes. Some relatives as if to blame themselves, that they did not catch up with their dear one “at that time“, on the contrary it would rather be in place to emphasize with the dying person and try to understand that he wanted to leave alone and was waiting for that moment.

The role of logo therapy in the search in terms of suffering and death

Many patients feel sorrow face to face of suffering and death, some even frustration. There might be several reasons of this behaviour. From a complete failure to accept the end of life up to the point of a total frustration of inability to fulfil life as a man desires. Some people seem to have failed to live their life in accordance with their values. There is not one universal meaning; each person has a very specific meaning here, purpose.

People very often feel emptiness, that they did not live their life as they had wished for. Once the man is turned to his life reality offer, he starts to accept happiness and pain at the same time. According to this point of view the man is also open to everything what comes in life, i.e. even suffering and death and these phenomena do not look so dramatic. People, who work in hospice care, often talk about the fact that when in a danger of one´s life a man notices more important things and starts to distinguish what is essential and what is marginal. People who work with dying ones very often face a kind of value transformation, when a man matures to a true inner size. As well as life can get its last sense not only by death, but also in during death. Life can be fulfilled by even something that seems “unsuccessful“, because failure does not mean unconsciousness [9].

Suffering from the loss of a close one has a profound sense. What is the meaning of dying and death according to logo therapy? Logo therapy just offers a way for the ones who see no sense in death. Logo therapy as a psychotherapeutic method, which main centre is meaningfulness, offers clients a variant, that everything what we do in our lives or what we perceive has a sense, whereas we admit, that more difficult life situations are, worse is to find the sense of the given situation. Effort is the main aim of logotherapy, so that people could be aware of their potential and perceive their life as meaningful. Important to say, that people should realise that life is transistory, that death is simply a part of life and we should remember the importance to have life in our centre. We somehow return back to life in death and dying, clearly recognize the importance of each moment, each day. It is the quality of life that is often mirrored in the attitude of dying and death. The life that a man lived and left behind, as it answered the questions about its sense and responses, that might seem as a “good life“ there is pain and suffering that accompany the man´s end of life.

Logo therapy is an approach where is natural to talk about end of life, where even the meaning of life is being seeked in the face of death face to face. We can change our attitude to death in direct proportion of our life conditions and desire to understand one self, our values. Understanding of own desires, values, what is important in the world, might lead to an open attitude to dying. The most difficult situations in this field are from the introversion, taboo from something, that none of us misses out, taboo of dying questions. It is quite natural, that a man thinks about questions about dying more when he is over 70 years of age.

Elderly people are afraid of dead from three reasons: sorrow arising from the perception of reality, to leave this world soon, lack of certainty, that there is life beyond death and also people are afraid of their own process of dying. Most people perceive this process linked with suffering, pain and feeling of helplessness. Therefore this process is often associated with addiction to others, depression, loss of dignity, movement and apathy. Most people really wish to die in their flat or a house and in their bed.

However, perception of death can be also happier, when fear does not prevail, but gratitude from well-lived life. Such an approach is not that usual, but deeply experienced. Death might also bring such understanding and sense, that we are not able to understand now. For man death should be as important as birth. It is about ending life, throughout perceived pain and fear, and could be described from people´s experience so far that could be perceived in hope and a proximity of something meaningful, what closes up everything that had been lived through. Many people change their approach to death as well as to life exactly at the moment when dying and death are very near. For example there is a main character Ivan Ilyich, in a book by a Russian giant Leo Tolstoy. This character, Ivan Ilyich, changes his life value hierarchy just near the touch of death, from a shallow man focused on a memental experience changes to somebody with a huge human dimension and an ability of a self-transcendence [10], what represents an example just for us, who try to look at death and dying from a logotherapeutic point of view.

The logotherapeutic angle of view is well illustrated by an example of one doctor, who came to Viktor Frankl with a request to alleviate suffering that he perceived during a loss of his beloved wife. It had been over a year when he lost his wife but still could not shift from a relatively great suffering. Victor Frankl asked him quite simply, what would have his wife felt if the situation was vice versa and he had died first. Apparently the moved man told him that he could not even think of that, his wife would have suffered inconceivably. Frankl replied that she avoided that fate and it is him who pays by his suffering now when he is weeping. The doctor understood the sense of suffering and sense of sacrifice. He understood that is not possible to change a destiny, therefore is necessary to accept it because the choice had been taken [11].

Logo therapy encourages man to accept facts, reality, especially when it cannot be changed. This is not a “surrender“, accepting the fact is more or less an active step that requires an attitude which is based on values that cultivate individuals. Frankl compares a human life with work on a stone. The hammer that works on the stone gives it certain form and makes a statue out of it and at the same time we do know when the work is completed. Even some unfinished pieces of work are beautiful – e.g. Mozart´s symphonies. The fact that work is not completed does not mean that it loses sense. In practice we meet with such experience thus during dying, unfortunately of dying children. It is hard to find sense here. The fact, that a 40 year of woman is dying is terrible, however if we remain with this claim, we do not help anyone, nor a husband, nor parents not even her children. Even in hard life situations we still seek for matters of fact in logo therapy, which seem to relieve the difficult situation itself and turns towards man´s life, saturates him by what was beautiful in life, what went well, continue in memories, and never ends even by death.

The assurance of death enhances the awareness of life´s fullness, its every single moment. It leads us to realize, that we are responsible for every single moment in our lives, because our life is limited, which just makes life meaningful. When we accept the transience of life, therefore its single moment is special and that gives us sense to live life intensively. A human being asks himself a question about the meaning of life just at the time in a hospital or approaching death. Viktor Frankl in an interview with Pinchas Lapide said that there is sense in suffering that can be perceived by a man. There can be a deep sense found throughout suffering and followed by “sacrifice“. Suffering might lead towards greater, might shift our personality into a nobel level. Many people who suffered are witness of this daring but a real thesis. The fact that a man accepts suffering and does not become resistant, quite the contrary, accepts what is given and still “uses“ it for his benefit, shows a certain quality and his spiritual dimension and humanity.

Eckhrt Tolle even talks about the fact that if there is no way to escape, there is only one way its mastery-face it. Pain should not be averted. Feelings of self-pity and identifying with the victim´s role, causes the extension of suffering [12]. What leads man to free himself and often restructuring his values is to accept suffering and do not run from pain, but to realize it fully. Often, at this stage, man becomes aware of what is essential and what is not.

There are circumstances that we cannot influence in a particular of a unique life. There are things beyond that we would love to have under a control but we cannot. These are death and dying. Otherwise everyone has it given. We cannot influence it significantly. But what we can is how we face those circumstances. Thus in logo therapy and existential analysis we are guided by away and an attitude, how we can face. The sense of life is not in what we are able to create and perceive. Is important to create and perceive certain values but often belong to a part of our life where we can make decisions, where we are so called “under control“. If we are not able to make it, either by being ill or old, than there is another possibility offered by logo therapy-these are attitudes’ values.

Attitudinal values are the nucleus, toil; thanks to them we are able to carry some circumstances. We are as if on the artery of life. The active period of our life ended and there is a concrete illness or ageing that we bear. This is not an easy situation, of course, even Viktor Frankl himself showed by his example that to carry illness and ageing can be carried with dignity and so called with a chin up. Thus logo therapy mobilizes man´s spiritual side, which is in every one of us and offers us space to express humanity and great freedom despite life limitation.

Palliative medicine is generally known that it plays a significant role at dying patients. From psychotherapeutic experience in home hospice care, one can say, that palliative medicine is there on a daily basis. Hospice´s role is to often fulfil days with life, because a man is in the space and time, when he can settle his most intimate matters, an individual represents a spiritual human being and in the terminal phase of life people are often literally hungry to saturate mental and spiritual needs. Proper palliative medicine fully saturates these needs. Work with dying clients is based on holistic approach, therefore includes body, soul and spirit care.

Demedicalization of dying is a natural need for the dying ones. Death is not a loss of doctors, as it is often perceived. Man, who dies, should have a choice to choose a place, where he wants to spend his last days of his life, a circle of life and his real needs should be upheld. Emphasis should be put on the uniqueness of the dying person and his individual needs. This can be ensured by palliative care or home care, which fulfils all important aspects of human existence – physical, mental, social and spiritual. Apart from the fact that palliative care relieves pain, anxieties, tries to keep the person not to be alone, helps to saturate the man´s spiritual needs.

question about the sense in logotherapy is highly essential especially in existential questions which are out of our control, i.e. dying and death. Logotherapy offers a wide range of ways, how one look for the sense, and even though is not easy, it teaches us that are possible. Life has a great sense when face to face of a time limit of approaching death-redistributing values, there is often encumbrance and values such as wealth, career, and symbols of status seem like not very important. A new value might arise – freedom and idea of near death makes life valuable during the last days of life.