By Rebecca Gagne-Henderson PhD, APRN, ACHPN
In my last blog I explained the processes that take place in our bodies that are of comfort as we die naturally from natural causes. As we die naturally, most of us will die of dehydration. I promised at the end of the blog to discuss the existential aspects of this process and of dying in general.
Once, having exhausted the technology available to prolong life, I often hear providers say to families and patients, “There is nothing more that we can do.” This could not be further from the truth. We are called to comfort and care for one another, whether family or stranger. Being a caregiver at the end of life to a family member, as a friend or clinician is the greatest gift. It is a gift to the dying, but I would argue, an even greater gift to the individual administering the care. Please note that within the word administer is the root word, “minister”. This comes from the Latin “to serve”. At the end of life, we minister through our presence, to bear witness and affirm life through love and compassion. Since we have already toyed with etymology you may find it interesting that the word “compassion” also come from Latin. That being to sit with suffering (com=with and passion=suffering).
We are not so much actively “doing” as much as we are “being” (1). We can hold the patient’s hand, wipe her brow, and bear witness to her pain and suffering and thus love her. We have the extraordinary yet simple opportunity to exemplify the promise manifested in Abrahamic religions, by not leaving her to die alone. Notably, oxytocin is also released through touch, so that the simple gesture of holding someone’s hand or rubbing her back can be a source of comfort to both the caregiver and the patient (2). As we provide care for the dying patient, simple and basic “nursing” tasks remain, including offering water and food, as she is able and willing to tolerate them. If the patient is not, the caregiver can provide oral care, keeping the mouth moist with a water-soaked swab or cloth. This is important, as it keeps the mucosa moist and keeps the lips from cracking and chafing. We know that dry mouth (xerostomia) is reported to be second only to pain for patients at the end of life. During this time, many wonder whether the patient experiences thirst. There is evidence that as dehydration progresses, the patient exhibits a “thirst deficit,” which often is more pronounced in the elderly. One study found that the relief of thirst was obtained by moistening of the oral cavity (3). In my own professional practice over the course of 27 years, I have found that the first day or two of transitioning to the dying process, when offered fluids with a swab, the patient will suck the water off the swab, but by the end of the second day the patient often resists the swab even for moistening the mucosa.
Medicine has traditionally understood anxiety as a medical or psychological problem. Wisely, this tendency is diminishing with the realization that anxiety is also a spiritual crisis. Paul Tillich, the existentialist philosopher, discusses humankind’s anxiety and fear of death, noting that the healing of anxiety and fear in the spiritual domain is equally important as (and in my opinion, more important than) the cure of physical ailments (4). For believers, healing is what we are promised, and I have witnessed incredible and miraculous spiritual healing in my practice, Christian and non-Christian alike. We need to distinguish between curing and healing, as well as between life and living. As noted by the ecological pioneer Charles Elton and others, one of the processes required to sustain life is symbiosis, or “interaction with other organisms.” Obvious to those who study them, these communal interactions of organisms are necessary for life and survival. As scientists, we know what these interactions look like in a Petri dish or under a photon microscope, yet we may not acknowledge this at the macro-level and sometimes forget that we are organisms. We observe it in the rutting of bucks in the forest during spring, the spawning of fish in a stream, but it also happens when putting your toddler’s shoes and socks on, making a cup of tea for someone you love, holding the hand of your mother in her sickness, and your mother’s gaze into your eyes before she dies. Once these interactions have ceased, so has life. By the way, oxytocin is also released as we gaze into one another’s eyes.
In nursing school, I recall being taught to never tell patients “Everything will be alright.” I was told that this wasn’t true and gave people false hope. With experience I have learned that this advice is flawed. Rather, whatever happens to us, everything will be all right. This is not because we will be cured; rather, it is because for those who have caregivers we are not alone as we die. Interacting with the dying is a symbiotic relationship.
A secular worldview explains that we are born to perpetuate the species. Biology dictates that there are five requirements for life to be sustained: respiration, elimination, secretion, digestion, and reproduction. As offspring grow, the evolutionary purpose of our parents protecting us is so our species may fulfill their purpose of perpetuating the next generation. We are designed to fight, struggle, and compete for survival. Once our time to die arrives, we hopefully have fulfilled this mission. Then we return to our basic elements to become one with the earth and nourish it as we decompose. If this is the case it begs the question, “what is the evolutionary purpose of the mechanisms that comfort us at the end of life”? We have served our evolutionary deeds. So, how does this merciful mechanism serve an evolutionary purpose? Might it be the fingerprint of a beneficent Creator? These are just questions far above my pay grade, but the answers are interesting and of great importance.
1. Howarth G, Leaman O, editors. Encyclopedia of Death and Dying. London: Routledge; 2001.
2. Morhenn VB, Park JW, Piper E, Zak PJ. Monetary Sacrifice among Strangers is Mediated by Endogenous Oxytocin Release After Physical Contact Evolution and Human Behavior. 2008;29(6):375-83.
3. Phillips PA, al e. Reduced Thirst after Water Deprivation in Healthy Elderly Men. New England Journal of Medicine. 1984;311(12):753-9.
4. Tillich P. The Courage to Be. 2 ed. New Haven: Yale University Press; 2000.