Invited commentary on Death and dying in literature

Why? … because. This commentary to John Skelton's paper (Skelton, 2003, this issue) addresses the question, ‘Why should I, a busy consultant serving a population of 40 000 in north Lincolnshire and having considerable difficulty in keeping up with the latest developments about antipsychotic drugs, use my precious time for CPD reading about death and dying in literature?’ The answer is two-fold: death and dying is intrinsically an important and relevant subject for psychiatrists; and literature gives useful opportunities for modelling, comparing, contrasting and experimenting with circumstances removed from the patient's immediate situation but still recognised as ‘real life’. Great literature demonstrates authenticity. If the experiences described are true to life, perhaps the strategies that were used in this literary work, or are suggested through their absence, may be effective in your patient's (or even your own) predicament. Literature, or ‘the humanities’, can enhance good practice in medicine (Evans & Greaves, 1999).

East of the Mountains, a gritty story by David Guterson (1999), concerns a recently retired and widowed cardiologist. He knows that he is dying from carcinoma of the colon, which has metastasised to the liver, and he does not like what he knows. He leaves his home in Seattle to return to the apple-growing countryside where he had been a child, taking his dogs, his gun and a more than half-formed intention of turning the gun on himself. The story is of his journey, both geographical and psychological, and of his intimate involvement on the way with many people, all totally different from himself. To write more would spoil the story for you, but the themes are the inevitability of, and also the potential for nobility in, the process of dying.

In his editorial in Advances in Psychiatric Treatment, Powell (2001) reminds us that our patients do not share our embarrassment and incredulity concerning matters of the spirit or soul: ‘Fifty per cent of service users hold religious or spiritual beliefs that they see as important in helping them cope with mental illness, yet do not feel free, as they would wish, to discuss these beliefs with the psychiatrist’. In none of our work as psychiatrists, is recognition of, and appreciation for, the spiritual needs of our patients greater than when dealing with concerns over death and dying. In this context, one uses the word spiritual for any or all of the following meanings:

1. • aims and goals, meaning in life;

2. • the interrelatedness of all human beings;

3. • dealing with whole people – body, mind and spirit;

4. • the moral aspect – good, beautiful and enjoyable;

5. • awareness of the connection between God and man.

Such ideas are clearly of importance for both patients and their doctors (Sims, 1994).

For most people in the world, their notion of spirituality is closely linked to their religious beliefs. The great religions are all intimately concerned with matters of life and death. Usually, this implies something of what death means, both to the individual and for all humanity, and also makes comment on what follows death. For this reason, when the process of dying has been observed in committed believers, it has been possible to see their calm conviction that they are moving on to something else and not just to oblivion.

Some people who have come close to death have reported a profound experience in which they believed that they had left their physical bodies and transcended the normal boundaries of time and space (Greyson, 2000). This gives an opportunity to explore the links between the spiritual and the psychological in the context of death and dying. Unfortunately, in medical investigations of this phenomenon, there has often been a failure to record the religious beliefs of those reporting near-death experiences, and so this opportunity has been missed.

It is self-evident that the psychiatrist should not try to impose his or her beliefs on the patient. Neither, however, should the psychiatrist ignore and exclude areas from discussion that may be of crucial concern to the patient. A psychiatrist once said, ‘Patients never talk about religion to me’. He had not considered whether he was seeing a selected group of patients who had no interest in religion or, alternatively, that his patients knew what sort of response they would get if they volunteered any sort of religious interest. Patients can benefit considerably when the psychiatrist encourages them to use their own religious beliefs to help them through the difficult life crises associated with death and dying in the same way that they are helped to use other resources of their individual personality in therapy.

When individuals know that they are dying or are faced with the risk of death, they will almost inevitably consider their spiritual situation; this is universal human experience. Psychiatrists pride themselves on their holistic approach to illness; disease is seen as not solely a biochemical upset in a localised organ or system within the body. This concentration of attention on all aspects of the person – body, mind and spirit – becomes acutely relevant when concerned with death. The hospice movement originally arose out of spiritual concerns for the dying patient.

Literature sometimes helps people to resolve the spiritual issues of death. It can be both objective and personal and it can give inspiration. Reading how someone else did or did not cope with this, the ultimate life crisis, helps us to order our thoughts, refine our beliefs and decide for ourselves where we can place our trust for the future. When I was faced with quite a high risk of death within the next few hours, it was the reassuring cadences of the 23rd Psalm that gave me strength through the long hours of the night: ‘Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me’.

Some writing is of value in objectifying and articulating our thoughts and feelings. This is particularly true when our patients are concerned with matters of life and death. If the psychiatrist's concern and tolerance for the patient's spiritual and religious position is added to this, the usefulness of literature is given another dimension. We all, ultimately, have to face our own death and the process leading to it. Whatever spiritual resources we have, that is when we will call upon them. Eventually, we all become patients. Much in literature helps us and our patients prepare for and integrate our thinking about the deaths of those close to us and of ourselves.