Death, Clinical Perspectives

The clinical perspective of death involves the person, as a whole, dying. From the perspective of physiology there are many ways to die, and there are many physiological ways to describe the death of a body. But any discussion of the clinical perspective of death should never be limited to these physiological aspects of death because the clinician is concerned with persons, not merely with bodies.

Many variables affect the manifestation and progression of death in different people. From the clinical perspective there are many ways in which, even without the pursuit of “cure” physicians and other caregivers attend to a person as dying progresses—maintaining their integrity as a person, their intimate relationships, the viability of attainable goals, and the maximum joy with minimal suffering each day, and toward the end, each hour. To adequately respond in this way, it is useful to know particulars about the person who is dying. The fears that often attend the process of dying can lead to great suffering. These fears can be of many different types. The clinician, who must understand the physiological aspects of the dying process and who must be able to manage the physical symptoms that can afflict a person who is dying, must also pay attention to the particularities of an individual person's experience of dying, including their fears and their hopes for whatever time remains. This is not the same as discussing issues of pain medicine dosing, survival data, and other quantitative information. And yet, awareness of a patient's fears can drastically change the way the clinician weighs the many options available for intervention and the way he or she presents the options.

In addition to this, often people die in the context of families who will affect the person's experience of death and who will be left standing by the bedside after the patient has died. Long-term medical care typically involves a small set of people—often only the patient and a spouse, friend, or parent. But at the time of death, many who are important to the patient will arrive at the bedside. The work a patient and a close friend have done over time to get ready for death may not have been done by extended family and friends. In such crucial hours questions may arise from new arrivals that seem not to mesh well with the clinician's experience of the patient and the most intimate associates. And yet, the clinician must remember that the extended family and friends, whatever their views, play a role in the patient's experience of life and death that simply cannot be fathomed in a short period of time. These aspects of the end of life are important in fully understanding the clinical perspectives of death. But again, for many clinicians, they are the hardest to fully understand, especially as they are not always emphasized in the education of clinicians.

A Three-Step Process Perspective on Dying

There are three steps that a clinician can take to gain a fuller, more adequate perspective when caring for a dying patient. The three steps are relationship, negotiation, and the establishment of a plan.

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