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By Rob George

Q: How do you break the news to someone that they�re going to die?

A: When people are dying, most people actually know it�deep inside. The starting point is really where a person is in their mind: psychologically, emotionally. The important thing really is to gauge where somebody is coming from in terms of the thoughts they are having, the anxieties that they�ve got, and then out of that, make a decision about whether you tell them straight away, whether you lead into it, or whether you end up giving them permission to tell you. And actually that�s the best way of doing it.

Q: Is there a standard grief process? A set of stages people tend to experience?

A: If you try and classify how someone is likely to handle the dying process, there are some models which say: "abcde." I think they are na�ve because they go in funny orders and people always break the rules. I think the general message that I communicate when I�m teaching people to talk about death and dying is to say: "This is unwelcome news." You will always do it badly. You will probably have to do it many times. And anger, guilt, frustration, denial, all of these things are part and parcel of the process of coming to accept reality. Although of course, some people will never accept that reality.

Q: How can a caregiver, family member, or friend help a dying loved one cope?

A: There are three areas that are important in caring for people. There are obviously the physical issues around their illness: their symptom control, their pain management. There are the psychological things to do with the family and the way they communicate and what�s going on there. But one of the areas that�s most difficult to manage is the business of a person�s sense of meaning: who they are and the resolutions that they come to - in other words, the spiritual domain of care. And that�s often badly managed. It�s often ignored or it is systematized in a religious way when actually it�s not about religion. It�s about meaning and it�s about a sense of self and a sense of future.

Q: How do you broach the subject of a patient�s religious framework?

A: I tend to ask them very broad openers. I may say: "Are you the praying kind?" I may say: "Tell me: what beliefs or what structure do you function out of? Do you believe that there is something beyond the grave? Do you believe that there is an alternative reality? Or are you one of these people who lives for material things and for the moment?" The essential thing really is to check with a person that you are using the framework that is familiar to them. But also within a framework of religion that you give that person an opportunity to experience or to engage the spiritual rather than engaging the religious. And that�s a very important distinction to make.

If we�re looking at helping people with spirituality, we have to be clear. "Spirituality" is a very fashionable term - and it hides a whole load of nothing in many respects. So there has to be some structure to it. But then we have to distinguish that from religion. So for example, someone who comes from a very orthodox Islamic or Jewish faith structure will operate by rules and regulations and often won�t even think about the implication or the meaning of what�s going on. And they find it very, very difficult to do that. Alternatively, someone who has a sense that there is something beyond themselves, a view of the transcendent, may be so amorphous in the way that they are thinking that they actually need some structures. I think when we think about people�s spiritual journey: there are those who have religion and there are those who have faith. And sometimes the two overlap - but often one is surprised. You know the image in the Bible when Jesus says that: "There are some that I�ll say: �I never knew you.�"? Equally, I think there are a lot He�ll welcome as old friends who never really took the conventional journey of Christian faith. People who have faith, people who understand the uncertainty but understand that questioning is acceptable and part of the dialogue of relationship will do well.

Q: What is a "healthy death?"

A: If you imagine that a birth for a baby is a pretty traumatic thing. Parents and everybody else sitting on this side of the birth canal receive that child with joy and excitement and the pain is immediately gone. If you think about death, I think we�re looking from the other end. That�s where we�re looking, as it were, from the uterus. We�re looking from the womb out towards whatever lies beyond. And necessarily a pressure is required for that to come about. For that to be a productive and a meaningful thing is what I mean by a healthy death.

Q: Is there a difference in the coping mechanisms between a long, prolonged death process versus a sudden death?

A: When death is expected, in other words, where the illness we know is going to lead to that death over weeks or months, then we�re in a position to make preparations. If, however, a person has a complication that leads to a death before that, that can almost be more traumatic or as traumatic as a sudden death. Essentially, people have not had the chance to reconcile and resolve. And dealing with sudden removals of a person from the world often leads to a lot more recrimination and guilt and remorse amongst the people who are left. Because they have nothing with which to engage to address the difficulties that they perhaps had in that relationship.

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