At Dying Beds

At dying beds I’ve experienced a lot of silence – which felt at times good, at times disturbing. Dying people will be almost always be in coma in their last hours (and, mostly, days). What hinders us from speaking with the dying?

  • As family members, we may be in a shock state, frozen or confused.
  • We may be insecure if they hear and understand us.
  • We may be insecure what is relevant and helpful for them.
  • We may feel insecure what the staff thinks of us if we behave unconventional.
But surely, if we find out what hinders us from speaking and acting, this can free us and widen the range of our possibilities, to the benefit of both ourselves and the patient.

Sometimes it’s extremely difficult to notice and interpret any nonverbal reactions of coma patients. In other cases we need to sharpen our senses. With no other body reactions left, often there are still reactions on our words, or on caressing, in the patients’ changing his of breath style and rhythm (unless on a breathing machine).
If we do find tiny nonverbal reactions or changes of the way of breathing, the questions are:

  • Does the patient show this behavior repeatedly (every time) when we bring up a certain topic or do something particular (or when a certain person is arriving or leaving or being mentioned)?
  • Do we rather see the reaction as one of stress or relief?

I would like to summarize a few things that I have learned from the Encounters I had with dying people.
1. Treat dying people as living people.                                                                              2. At a dying bed, get aware of what hinders you from acting and speaking free. Free yourself to get flexible.
3. Observe which tiny reactions (movements, mimics, breath) the dying person shows repeatedly on certain key words, persons, behavior. Are they reacions of stress, relief or interest? Which are the triggers?
4. Dying patients may be in coma, but they’re usually not deaf. Choose your words well. No catastrophic medical descriptions or burial talk.
5. Create rapport. Introduce yourself and tell your aim shortly. Use body contact, use your voice and breath pacing.
6. See a coma patient as someone who is already in trance. Create rapport. Interventions can start right away, without induction
7. The subconscious responds strongly to imagery. Speak in a dream language. Use metaphors, avoid abstract words.
8. Breath pacing and leading can regulate pain or breath problems (and can regulate breath down till it almost stops).
9. Breath, blood pressure and heart rate can also be regulated by metaphors (f. e. of a flying eagle, a pulsating jellyfish or a manta ray).
10. Speak about emotional content rather than about facts.
11. Express in metaphors or more directly that it is possible and good to let go – of live, of psychological problems of body problems.
12. Use metaphoric terms to speak about the good future.
13. Introduce thoughts like “You can love them from the other side”, “things will change, relations go on”.
14. Use negative terms only with a good reason. Except for pacing strong pain, don’t mention “pain” but “body sensations”. Teach this to the relatives.
15. People will rather die when they’re ready to go. What may help: Rituals, a bye-bye from family members, messages of “letting go”.

The Good Shepherd

I would like to say something about breath pacing, and about texts that we can recite to a dying Person.
I knew Mrs. Seiberth, and we had liked each other. I knew that she was a religious woman and that she wished that her son would come and see her. Asked why he doesn’t come she said: “He’s living far away. – But also, he is afraid of seeing me so sick.” When I was visiting her now she was in coma. She looked into an empty space. With every breath she made a coughing sound. I put my hands on her arm. Calm and slowly, with long pauses in the pace of her breath I recited the psalm of the good shepherd. Her breath went calmer and the coughing noise went silent. But at the words “thy rod and staff they comfort me” the coughing came back. Maybe they reminded her of something that made her sad? The concept of systematic desensitation of fears came to my mind. So I repeated these very words so often in a very calm and friendly tone till the coughing disappeared again. Then I continued. At the words “in the presence of my enemies” the coughing came back. I did the same procedure of repeating the words in a friendly tone till the coughing was gone and she was breathing calmly. At the words “Goodness and mercy will follow me all my life” her breath got even calmer. So I repeated these words many times till it got even calmer. I finished the Psalm and said “I would like to say bye-bye now.” Immediately the coughing noise came back and continued with every breath. “I will come back, I will come back, I will come back…” I said, and the noise disappeared. The next day I visited her I read the same psalm to her. Her breath was calm and silent all the time. Only when I said that now I would leave the coughing noise came back. “I come again, I come again, I come again…” I said till it was calm again. The next day I was about ninety minutes later than on the previous days. Entering her room I saw a man who introduced himself as her son. “She’s died an hour ago.” He said. „Was she still alive when you came?“ „Yes“, he said. (Stefan Hammel, Handbook of Therapeutic Storytelling, Karnac, London 2017/18)

The Cloak Room

Noticing that the man I mentioned yesterday died so soon after my visit I got curious about the effectivity of the cloak room metaphor.

I remember I was called to the bed of a dying woman. When I arrived she was breathing about once per minute. I didn’t know that a person could breathe so little and still be alive. Her daughter and her son in law were there. I asked if it were appropriate to speak a prayer, to which they said “Yes”. After telling the dying woman that her daughter and son in law were there, who I was and what I was going to do I put my hand on her arm and spoke a prayer. Then I said to her: “I would like to tell you something, Mrs. S. I imagine there’s a door. When it will be the right time for you, you can go through that door. Next to the door there’s a cloak room. There’s someone who can have an eye on your things so they’re safe. It’s a special wardrobe. You can had in anything that’s a burden to you.
If you’re afraid – take it off. You don’t need any fear over there.
If you’re sad – hand it in. For what? You don’t have any use for that now.
If you bear a grudge or haven’t forgiven someone – hang it on the big wardrobe.
If you feel obliged to anything – take it off.
If you think you need to stay – there’s nothing you need to! If you want, give it to the one who’s standing there for guarding it.
If you think there’s still something left to do or that there’s anything missing – hand it in to the one who will guard it for you.
If there’s anything unpleasant in your body – give it to him as well.
If there’s any problem with breathing – give it to him as well.
If there’s anything else you would like to give to him – hand in anything that you don’t need any more.
Give him anything that has become a burden for you. Take it off. You don’t need it any more. And when you notice that it’s time for you, go through the door.” I finished with a blessing.
During the prayer the breath frequency of the woman had gon up to about six breaths per minutes, and thus it stayed for a while. Her daughter and son-in-law were observing her breath silently. The silence felt somewhat heavy for me and I had the imagination it could be the same for the dying woman. So I asked: “Can you tell me what happened so your mother got in this state?” The daughter said a few sentences. Her mother’s breath got very slow again. After five breaths there was a very tiny one. Then everything was still. (Stefan Hammel, Loslassen und leben. Impress, Mainz 2016)
I’ve used this metaphor a number of times now. Often the effect seemed to be very strong. The structure is thus: There’s door and a cloak room and an attendant next to it. You say: Whatever burdens you concerning the past: Hand it in. This can be specified as a bad conscience or anger against someone else or sadness about something that happened. Whatever burdens you concerning the future: Hand it in. This could be specified as worries about the relatives or about what comes after death. Whatever burdens you concerning the present, hand it in. This could for example be specified as a discomfort of the body (pain) or breathing problems.

You Can Love Me from the Other Side

Having learnt that dying people may well notice when their relatives decide to let go of them and, if you will, allow them to go, I more and more integrated the theme of „letting go“ in my work with dying people.

I remember being at the dying bed of a man. His wife was next to him. They knew each other only since two years and had been very happy with each other. He had been inspired by her Christian faith and had adapted more and more of it for himself. I had met him in a clear state some days ago. Now he was in coma. I told him about about a coat rack for his troubles… that he could imagine the cloak room of God where he could lay down anything that would burden him. He could take off any fear or grieve and it would be taken care of. After that his wife said that he could let go and that she could let go and that he could express his love to her also when he is on the other side and that he could care for her from over there. A quarter of an hour later he died without struggle.
I kept her intervention in mind which is summarized: “You can love me and care for me from the other side”. Sometimes I say to people: “What is going to come is just the invisible second part of your live together.” The difference which this makes both for the ones who leave and for those who stay is remarkable.

Letting Go of Life

From my experience as a chaplain I see a lot of evidence that the ears of the dying are open till the last seconds. They may not be conscious. Maybe they’re like dreaming. But certainly they hear us and it makes a lot of difference what we say to them.
I remember being at the dying bed of a man. All the members of his family were assembled: His wife, his children and children in law, his brothers and sisters and grandchildren. Some of them were crying strongly. The man was breathing in short, quick, strong inhalations with long pauses between each breath and the next. I was wondering what he could understand of what was going on. He looked as if he were sleeping. Probably he was under a high dose of Morphine. I couldn’t detect any reaction in his face. When I prayed for him at the side of the dying bed I included a prayer that God may give both him and his family the ability of letting go while being aware of all the good that would rest with them. After the prayer there was a little silence. Then his daughter said: “Letting go is so hard. But I have heard that only when you let go of what you love it will really belong to you.” Then she looked over to her father and said: “He’s not breathing any more.” (Stefan Hammel, Loslassen und leben. Impress, Mainz 2016)

On the Effects of Last Rites

In my work as a chaplain I have been at many dying beds. I find it notable that people don’t want to call the pastor unless their Family member is really dying. Maybe they think that when the pastor’s been there, there’s no way back. You could take that as a superstition. But there’s some evidence that they may be right. I’ve seen people survive when the medical staff said they would die in the next few hours. I’ve seen one person survive for three days after the doctor told the relatives that according to brain death diagnostics the patient is already dead. I have not seen a single person survive after the pastor was there for a last prayer. I remember saying to a colleague: “I’ve always got a bad conscience. I feel as if I’m killing these people with my prayers. They all die within hours after I’ve been there.” He replied: “Oh, you as well?”
I remember being at a dying bed of an old woman. She was in coma, had an oxigene mask but still had trouble breating. There were about eight relatives around her bed, a tight-knit family clan. I spoke with them and I did a little ceremony. When I spoke the Lord’s prayer everyone spoke it with me real loud. It was quite a powerful experience. After I left the room one of the relatives said to me: “Did you see? When you came her heart rate was at 90 but during the Lord’s prayer it was at 140.” The nurse said: “It can take hours or days, we don’t know.” I remember answering: “It’s a strange thing. Mostly people die within hours after these prayers.” She left that uncommented. 15 min later I got a phone call that the lady had died and the relatives wanted to see me once again. The same nurse opened the door. “I had to think of your words”, she said.

La flor en la isla

En una pequeña isla en medio del océano extenso crecía una hermosa flor amarilla de oro. Nadie sabía cómo había llegado allí, porque en esta isla no había ninguna flor aparte de ella. Las gaviotas venían volando para contemplar este milagro con asombro. “Es linda como el sol”, decían. Los peces venían nadando. Levantaban las cabezas encima del agua para admirarla. “Es linda como un coral”, decían. Un cangrejo salió a la tierra para mirarla. “Es linda como una perla en el suelo del mar”, dijo. Y todos venían casi cada día para admirar esta flor.

Un día, cuando volvieron para contemplar la flor, se encontraron con que los pétalos dorados de la flor se habían vuelto marones y secos. “Ay de nosotros”, dijeron las gaviotas, los peces y el cangrejo. “El sol quemó nuestra flor. ¿Quién ahora nos refrescará el corazón?”. Y todos se pusieron tristes.

Pero algunos días más tarde apareció en lugar de la flor una maravillosa bola de color blanco tierno. “¿Qué es eso?”, preguntaron los animales. “Es tan blando como una nube”, dijeron las gaviotas. “Es tan ligero como la espuma de las olas”, dijeron los peces. “Es tan fino como el resplandor del sol en la arena”, dijo el cangrejo. Y todos los animales se alegraron.

En este momento un golpe de viento barrió la isla y sopló este milagro blanco dispersándolo por ella en miles de copos. “Ay de nosotros”, hablaron las gaviotas, los peces y el cangrejo. “El viento ha dispersado nuestra bola. ¿Qué alegrará nuestro ánimo ahora?” Y todos estaban tristes entonces.

Un día por la mañana, al levantarse el sol sobre la mar, allí en la luz dorada matinal relucieron cientos y cientos de hermosas flores color amarillo de oro. Entonces bailaron las gaviotas en el cielo y los peces en el agua, y el cangrejo bailó con sus amigos una danza de rueda en medio de las flores, y todos se alegraron.

(Por Stefan Hammel, traducción: Bettina Betz)

The Balloon

A therapeutic story by Katharina Lamprecht, with whom, along with our Swiss friends Adrian Hürzeler and Martin Niedermann, I have written the book “Wie das Krokodil zum Fliegen kam” (How the crocodile learned to fly)…

No one in the community knew, when exactly the festivity would take place. But that it would happen, everyone was sure of it.

When the day came, they all gathered at the meadow near the village. So many people. Not only from the village but also wanderer, passing by accidentally, stopped and many shared the moment. In the middle of the meadow was a booth where everyone could choose and take a balloon filled with helium. There were red, green, blue, yellow and purple ones. Some had faces on them, some stripes or dots. It was all very colorful.

One after the other the people let go of their balloons. And up they rose into the blue-grey sky. And what a beautiful sight it was. At the beginning they all stayed together, a colorful bunch of balloons, like grapes on a grapevine. But after a while, some of them got loose, they peeled away and began their very own journey.

And one of them, I don´t recall whether it was the red one or the green one or perhaps the one with the little dots, this one made its way calmly and silently to a place where the others didn´t go and he got lost in the vastness of the sky, to fly far far away. Perhaps even to the stars.

¿Dónde están las estrellas durante el día?

Ella tiene dos años y muchas preguntas. “¿Dónde están las estrellas durante el día?”, por ejemplo le pregunta a su padre.
“En el cielo”, contesta este, “así como por la noche.”
“¿Entonces están apagadas? Es que no brillan para nada.”
“¡Claro que sí! Siguen brillando. Pero el sol es tan luminoso que ya no se ve la pequeña luz de las estrellas. Es como cuando ya no oyes música baja si de repente alguien pone en marcha una máquina ruidosa. La música baja todavía está, solo ya no se la percibe. La música está acallada y las estrellas están deslumbradas.”
Ella piensa un momento y dice: “Ahora sé también donde están mis sueños durante el día cuando estoy despierta.”

(Por Stefan Hammel, traduccíon: Bettina Betz)

L’interrupteur d’arrêt d’urgence

« Vous travaillez avec la méthode de l’hypnose ? », m’a demandé l’homme. « Alors vous pourriez tout simplement enlever-hypnotiser mon problème ». Il rigolait. Sa femme l’avait amené, il n’avait pas une grande envie de faire une thérapie. Je lui ai demandé « Quelle est votre problème ? ». « Il m’a frappé » a répondu la femme qui était assise à côté de lui. « En plus à ce moment-là j’avais notre fils sur les bras. » « C’était comme si quelqu’un avait appuyé sur l’interrupteur d’arrêt d’urgence » a-t-il dit. « Ca a été une réaction automatique. Cela n’aurait jamais dû arriver ». « Vous n’avez pas besoin d’être hypnotisé » ai-je répondu. « Vous pouvez faire ça vous-même. Est-ce que vous connaissez ces boîtes en verre rouges qui pendent dans les hôpitaux et les édifices publics avec un interrupteur qui déclenche une alerte incendie ? » « Bien sûr » a dit l’homme. « « Pourquoi y-a-t-il un verre devant ? « « Pour qu’on ne la déclenche pas par erreur ». « Et si on prenait une vitre très fine comme une lame porte-objet pour un microscope ? » « Elle casse quand on se cale contre ». « Qu’en est-il du verre blindé ? » « C’est trop épais. » « Réfléchissez à l’épaisseur pour que votre femme ne puisse pas la défoncer. Regardez cette vitre et mettez-la en place. »