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.

Le myome

J’ai dit à l’amie « quand tu te réveilleras cette après-midi » l’opération sera passée et le myome sera parti. Tu t’es demandé s’il y a eu un élément déclencheur pour son origine. En fait peu importe ce qu’il y avait à l’origine. Ce que tu peux faire c’est la chose suivante : Rappelle-toi des expériences accablantes et peut-être traumatisantes et d’autres choses que tu veux lâcher et dont tu veux te débarrasser. En pensée, mets tout ce dont tu n’as plus besoin dans le myome. Et quand tu te réveilleras cette après-midi tu les auras toutes envoyées sur le chemin. » L’amie a déclaré plus tard qu’elle avait réalisé la proposition et avait transféré dans le myome ses réactions aux différentes expériences accablantes de son passé. Elle a vécu cette approche comme libératrice. Après l’opération elle s’est vite remise et s’est sentie plus forte et plus active que dans les mois précédents.

Pour cette intervention thérapeutique il y a beaucoup de variations dependant sur la situation unique d’une traitement : On peut mettre le trauma en cas de gastro ou de boulimie dans le contenu de l’estomac, en cas de chimio dans les cheveux, le libérer pendant le passage aux toilettes …

His Last Day

“That’s that”, said my neighbour when I visited him on his birthday. “Next year we won’t see each other any more”. I was shocked. I didn’t know how to answer. “Don’t worry”, his wife explained to me. “He says that every year. For twenty years now he has been saying to me again and again: “Today is my last day.”

Everything Else

In a land in our time there lived a man, who read a book and found lots of wonderful stories therein. There were true and invented stories, experienced and pensive, enjoyable and painful stories. There were stories which contained stories, and such which were actually not stories. For every story he read, there occurred to him nearly five which he had either experienced or thought up himself. So the thought came to him, that a lot in the world was a story which could be healing for himself and others; he only needed to absorb the healing stories well and to forget the terrible ones immediately. Then he would learn which story he had used when and for what. So he organised his own stories which he knew, and which had become a help to himself and others, or could become so. Sometimes he noted it down when a new story came to his ears and sometimes when a helpful story occurred to him, he memorised it.

Then he saw before him in a picture the storystories of this life arranged in long shelves, as in a large pharmacy. And behind the counter there sat a man who had learnt to listen to himself and others. He was a master of his subjectspecialty. His talent was that he understood how to tell the right thing at the right time to himself and to those who visited him.

Mary

“I won’t die before Mary is in her place again!” It sounded quiet and sure from Erna’s mouth. It was autumn. The pneumatic drills hammered on the street and a sweet, biting smell of tar lay in the air. This was the house of Erna’s parents. She had lived here since she was a small child. She could still remember this place when the horses and carts used to be the mode of transport and then, later the first trams! She hung on to this place which was filled with memories.

But mostly she loved the fountain in the centre, the fountain with the statue of the Virgin Mary. The marketplace had been extensively pulled up. The workers had carried the fountain away. Experts had first carefully marked each stone so as to be able to rebuild it exactly as it was. When the new year came, the square was newly plastered. And finally the fountain with the statue of the Virgin Mary also returned to its place.

For a couple of days Erna enjoyed the new and yet long-familiar view. Then she was ready.