Terminality

Terminality is the end stage in a person's life when a terminal diagnosis is evident and death is imminent. Communication challenges arise from the existential/spiritual crises patients and family members face at impending death. Unfortunately, few communication scholars are exploring the therapeutic benefits of communication in this setting. As Roxanne Parrott notes, the absence of spirituality in health communication research and practice persists despite the evidence of a relationship between spirituality and health.

Hospice founder Cicely Saunders wrote of five kinds of pain that suffering patients endure. Patients and their families at end of life (EOL) frequently face the pain of physical symptoms, and much of the medical literature addresses relief of physiological pain. Yet, according to Betty Ferrell and her associates, who write extensively about patients' suffering in the nursing literature, psychosocial and existential/spiritual issues may be of even greater concern to dying patients than their physical pain and symptoms.

Confronting one's death naturally entails psychic pain in many patients. One of the factors compounding this pain, particularly in end-stage cancer patients, is the existential anguish that can be caused by futile treatment at EOL. Patients often mistakenly assume that chemotherapy and other aggressive, allegedly curative treatments at EOL will cure their diseases. Often patients, family members, and medical staff collude about disease outcomes with an optimistic bias, even when prognoses are grim. When patients finally understand that aggressive treatment not only has been futile but also has diminished quality of life while preventing them from squarely facing impending death, anger and anguish can erupt. Misunderstanding the costs and promised benefits of aggressive treatment can compromise quality of life by diverting patients from preparing emotionally and spiritually for EOL; by delaying their entrance into hospice, which offers physical, emotional, and spiritual benefits at EOL; and by compromising their abilities to make informed treatment decisions that match their preferences for quality of life. Thus, medical and palliative care teams must strive to communicate treatment options clearly, candidly, and sensitively such that [Page 1384]informed consent is truly informed. Intercultural, racial, and religious factors as well as patient preferences must also be considered.

As psychosocial and existential suffering and distress are major issues facing many dying patients, the need arises for interventions that might help alleviate them. Yet there are few non-pharmacologic interventions designed to ameliorate emotional and existential pain at EOL; rather, the intent of many interventions is to make patients less aware of their suffering. Some successful therapeutic interventions involve brief counseling sessions centered on helping dying patients and their families find meaning in their suffering. Harvey Max Chochinov's dignity therapy, for example, asks patients to discuss issues that matter most to them; sessions are transcribed and can be bequeathed to a person designated by the patient. Patients report satisfaction with this therapy in that it increases their sense of dignity, purpose, meaning, and will to live while concomitantly decreasing their depression and sense of suffering. Yet the relationship between therapeutic communication and health and well-being outcomes has not been studied sufficiently.