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TERMINAL ILLNESS: DEATH AND BEREAVEMENTTOWARD AN UNDERSTANDING OF ITS NATURE RICHARD A. OBERFIELD* I am now 50 years old. For almost 20 years as a medical oncologist, I have taken care of patients with advanced cancer and have been involved intimately with their dying. Eighteen years ago my wife had faced her first battle widi cancer and won, but 2Vz years ago she died after a 1 V2year struggle with a second cancer. During this last period of time, I lived many roles—as husband of a very much loved wife dying of cancer ; as father of two daughters aged 20 and 13; as a physician often asked by my wife for understanding, reassurance, and help in important medical decisions—including the terminal one; and as a colleague ofmy feUow physicians who took care of her. I hoped diey would assume the full medical responsibility, but often this became difficult. Not to be involved precluded caring, considering my role in life as an oncologist and as part of an extended family trying to guide and interpret medical dilemmas for close family members, being a widower with responsibility for raising two chUdren, and continuing my professional career while going through the difficult process of bereavement hoping I would survive and eventually create a new life for myself and my family. During and since die time ofher illness, I have tried to make sense ofmy Ufe and my relationships with those I have cared for to enable me to go on providing strength for myself and others. During this time I have reviewed much ofthe literature, in both scientific and lay press, relating to the dying process, ranging from psychoanalysis, psychiatry, neurobiology , psychopharmacology, anthropology, and child development through the personal memoirs of others with similar experiences. As a result ofmy experience and readings, certain concepts have evolved that provided some answers to the questions I have had in relation to my own life at such times. I will discuss the concepts that have been meaningful *Secdon ofOncology, Lahey Clinic Medical Center, 41 Mall Road, Box 541, Burlington, Massachusetts 01805.© 1984 by The University of Chicago. AU rights reserved. 0031-5982/85/2801-0401$01.00 140 I Richard A. Oberfield ¦ Terminal Illness for me. Some are personal ones; some may provoke controversy and you may disagree with them; but I have found them helpful in my journey toward an understanding of what the dying process means—the necessity of grieving for the restoration ofone's health, enabling one to get on with life. Relationship between Life (Existence) and Death (Nonexistence) Behavior exhibited during illness, especially terminal illness, is that related to facing death. Death implies loss, and loss implies separation from life. Throughout life we are involved in diat struggle—that existential dilemma ofproviding a meaningful life for ourselves yet realizing our own mortality, that death arrives for all. It is not always that our loss means death. It may imply illness, and even here our behavior still reflects impending concern for separation from life even if not a final separation. The behavior to cope with illness recapitulates a basic existential conflict—that of death, one of the four ultimate concerns described by Yalom [I]. The existential anxiety and how we defend ourselves to reduce that anxiety define our behavior. The givens of life can be discovered by deep personal reflection and solitude with time, silence, and the freedom to arrive at the givens of existence. What are these ultimate concerns? From an existential position, Yalom discusses those of death, freedom, isolation, and meaninglessness. DEATH How do we make sense of living knowing that we will aU ultimately die? How does one live with vitality and with courage, knowing it will all end in death? The conflict is between awareness of inevitable death and the wish to continue to be. This is similar to what Freud discusses in Beyond tL· Pleasure Principle [2], that is, the life instinct (Eros) versus the death instinct (Thanatos). According to Freud, the aim of all life is toward death—the state ofbeing inorganic, which existed before life was attained. Living things possess an instinct, the urge inherent in organic life to restore the earlier state of...


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