AWARENESS OF DTHING -CA SA MP OA

Awareness of Dying Glaser and Strauss (1967) describe types of awareness of dying. In closed awareness, the patient is unaware of impending death while the staff and/or family engage in tactics to avoid disclosure. This occurs when the patient does not recognize the signs, the physician avoids the subject, the family guards the secret, and the entire staff keeps the conversation focused on a superficial level. Closed awareness prevents any choice or end-of-life planning for the patient and makes reconciliation with friends and family impossible. In many traditional cultures, speaking of death is believed to do more harm than good. For instance, Greek physicians and nurses fear that revealing the truth to patients will provoke unhealthy emotions (Georgaki, Kalaidopoulou, Liarmakopoulos, and Mystakidou, 2002). Only 11% of Greek physicians disclose the diagnosis of cancer to all their patients and 66% of nurses find it difficult to speak openly to a patient about death. In suspicion awareness, the patient suspects his prognosis but the family and staff do not confirm this, and continue to use tactics to avoid the subject. This occurs because of fear that troubling emotions will be expressed. If the situation is not acknowledged, feelings are avoided. In mutual pretense, all parties are aware of dying but agree to act as if the person is going to live. Neither wants to disturb the other with discomforting news. Tact and silence dominate the environment. Rituals focusing on wellness continue and discussion is about safe subjects. If a nurse or family member witnesses the person crying, he or she will avoid calling attention to the situation and attempt to change the subject. Many cultures, particularly nonWestern cultures, place a high value on avoiding the awareness that death is coming closer. In 1886, Leo Tolstoy (1981, pp. 102–103) wrote about the lies required to maintain mutual pretense: Ivan Ilyich suffered most of all from the lie, the lie which, for some reason, everyone accepted: that he was not dying but simply ill, and that if he stayed calm and underwent treatment he could expect good results. Yet he knew that regardless of what was done, all he could expect was more agonizing suffering and death. And he was tortured by this lie, tortured by the fact that they refused to acknowledge what he and everyone else knew, that they wanted to lie about his horrible condition and to force him to become a party to that lie. This lie, a lie perpetrated on the eve of his death, a lie that was bound to degrade the awesome, solemn act of his dying to the level of their social calls. . . . He saw that no one pitied him because no one even cared to understand his situation.  Finally, open awareness occurs when both staff/family and patient acknowledge dying. The patient then has the opportunity to bring closure to his life, say good-bye, say, “I’m sorry,” and state final wishes. Open awareness invites closure not only for the patient, but for loved ones as well.