MEDICAL MATTERS: Too often, the doctor is a distant figure, not trained to hold the patient's hand - only to evade his half-hearted probing. At worst, this can culminate in the patient being pushed off to an acute hospital ward to die - "unprepossessing and unprepossessed".
I wrote these words in 1984 as a final-year medical student. They were part of an essay which won the Sheppard Memorial Prize of the Royal College of General Practitioners. Written partly in response to my professional experience on the wards and partly as a reaction to the death at home of an aunt from cancer of the kidney, the essay also marked the first time I was influenced by the work of Dr Elizabeth Kubler-Ross, who died last month.
Kubler-Ross, a Swiss-born psychiatrist, was one of the world's foremost authorities on the psychological aspects of dying. After an unhappy childhood - her father refused to allow her study medicine - she worked in a Zurich laboratory. Eventually, she entered the medical school in Zurich, graduating in 1957.
She met her husband, Dr Emmanuel Ross, there and they moved to New York where she completed her psychiatric training. In 1965, she became an assistant professor of psychiatry at the University of Chicago Medical School. She initiated a series of conversations with dying patients for her students.
Other doctors objected to her teaching programme, arguing that patients should be shielded from thoughts of death. "Take your medicine and you'll get well," was a typical comment, Kubler-Ross wrote in her seminal book, On Death and Dying.
From her patient interviews, she identified the now established five stages that many patients go through in confronting their deaths: denial, anger, bargaining, depression and acceptance.
Denial is a natural first reaction to having bad news. However, as their condition worsens, a patient naturally feels angry. A period of bargaining follows, when the person may say "yes, I'm going to die, but if I pray hard, maybe I will get a few more years". When bargaining brings about no improvement, depression usually sets in. Finally, acceptance comesand the patient is ready to let go.
Not all dying patients follow the same progression, Kubler-Ross said, but most experience two or more stages. She also concluded that acceptance of death comes more easily for people who could look back and feel they had not wasted their lives.
Others have built on her work and expanded on the stages of dying. Dr Rob Buckman, a cancer specialist and author, says: "In my view, Dr Ross has described types of reaction and not stages.
" I find that there are many kinds of reaction other than those five, including fear, anxiety, hope and guilt. Some kinds of reaction are more common near the beginning, some are more common near the end. Many people are, for example, angry and depressed [at the same time\] at the beginning and become more accepting near the end."
But, as a medical student about to qualify, I found her book very helpful. It at least gave me a map with which to navigate the potential minefield that is communicating with the dying patient. And when you add relatives to the equation, who are going through the same reactions, it's an area in which doctors and healthcare professionals need good training.
One of the key things you learn in practice is that the five stages or reactions do not affect everyone the same way. Sometimes, the dying person will switch between stages. Some people experience only a few of the stages.
You also learn not to take it personally, if the patient or a family member gets angry. You learn that a relative and a patient may exhibit completely contrary emotions within hours of what may have seemed like a very good discussion.
After years of teaching and practising medicine, I am convinced there are some people for whom the term "constructive denial" best describes their reaction. Despite being given every opportunity to discuss their illness and its poor prognosis, they choose not to discuss either openly. But both you and those around the patient have a strong instinct that they are comfortable with this; after they have died, families express a satisfaction that although it was never discussed the person knew they were dying.
Partially paralysed after a series of strokes nine years ago, Kubler-Ross said in 2000: "I told God last night he is a damned procrastinator." She eventually died at a home for the elderly in Scottsdale, Arizona.
Elizabeth Kubler-Ross, thanatologist, born July 8th, 1926; died August 24th, 2004
Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.