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Running head: FINAL EXIT: DISAPPEARING BEHIND THE CURTAIN
Final Exit: Disappearing Behind the Curtain
Thursday, February 28, 2008
Professor Nicholas D. Carros
GPY 584N: Life-Span Counseling
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The essence of Goodness is: Preserve life, promote life, help life achieve its highest
Final Exit: Disappearing Behind the Curtain
From an early use of the term “euthanasia” by Francis Bacon to the first modern
discussion of medical euthanasia in 1826 by the German physician Carl F. H. Marx, in his search
for a contrivance for the care of the dying, the alleviation of pain and suffering became a central
concern for the treatment of the dying (Lavi, 2005). With the discovery of morphine in 1806 and
the discovery of ether and chloroform in the 1840’s, the new medical hope for a potentially
painless death became an alternative the well known religious art of dying, ars moriendi, which
placed hope in the redeeming power of pain (Lavi). Williams (1997, p.123) provides a brief
modern definition of the Greek word combination - eu (good) thanatos (death): “Euthanasia is an
action or omission which is intended to bring about the death of a seriously ill person, in
accordance with the expressed wish and/or for the good of the person.”
Beyond this simple definition things begin to get complicated. For example, claiming to
present pro and con aspects of euthanasia using diverse sources, the authors of Euthanasia
ProCon (www.euthanasiaprocon.org) break down the definition of euthanasia into three
categories: voluntary active euthanasia (a competent person makes a voluntary request to be
helped to die), passive euthanasia (withdrawing of treatment), and non-voluntary euthanasia
(cases where persons are unable to make a decision or make their wishes known). This last
group, non-voluntary euthanasia might include: Babies, comatose persons, persons with severely
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impaired mental functioning, and persons deemed so impaired that they need to be protected
from themselves- in sum persons who cannot or have not requested euthanasia.
Another form of euthanasia, which has escaped undue scrutiny by both the legal and
medical establishment, is known as lethal dosing (LD). This practice, first discussed in 1936
during a session of the British House of Lords to repudiate proponents of a euthanasia bill, was
considered an alternative route making euthanasia unnecessary (Lavi). LD has since become a
regular practice in hospices and hospitals, openly recognized and recommended by medical
professionals; the AMA, Supreme Court and the Vatican under Pope Pius XII are some of the
heavy weights supporting LD (Lavi). LD is the “sublegal “ practice of administering medication
necessary to relieve the pain of terminally ill patients even if the effect of the medication may
shorten life (Lavi). Euthanasia is understood as an attempt to relieve the dying of suffering the
effects of their illness by the use of the advancing technology of medicine. In most cases
discussion of euthanasia is tacitly understood as voluntary active euthanasia.
While advance directives have been around since the late 1960’s they have become more
important because of advances in medical technology and the ability to sustain life for longer
periods of time through terminal illness. Advance directives are directives or treatment
preferences provided in advance by a person in the case of incapacitance; a substitute decision
maker or agent is usually designated as part of the directive to act on behalf of the person.
Advance directives usually have three parts: (1) living will: specifies the kind of treatment a
person wants if she or he becomes incapacitated (2) power of attorney: allows another to legally
act on behalf of another who becomes incapacitated and (3) health care proxy: an individual is
designated to make medical decisions on behalf of another who is incapacitated as if she or he
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were that person (Hecht & Shiel, 2008). A key factor in advance directives is that patients have
the right to refuse medical treatment, reject life-sustaining measures even if this leads to death.
The autonomy of the persons’ will is upheld even against medical advice to sustain life.
Any one of the ten leading cases of death in the Unites States could account for a critical
or terminal illness and would have a significant psychological impact on a person’s well being.1
In recent years large quantities of experimental data and knowledge have been publicized to help
provide effective counseling for those suffering from critical and terminal illness. However,
much of the training in psychology programs focuses on topics, models, and clinical assessment
of mental illness- its treatment and prevention of relapse. Most of the models seem to lack focus
on the special mental health needs of those who are critically or terminally ill. The model
paradigm was not designed to meet the needs of the critical or terminally ill patient. There are
multiple factors, themes, meta-themes, processes, triads, symptom clusters, and challenges faced
by critically and terminally ill persons that make their treatment by counselors and psychologists
a challenging and daunting matter. There are also major spiritual issues and concerns that also
factor in these situations. As technology in medicine increases the capability of the critically
and terminally ill to sustain life for longer periods of time, counselors may find more clients with
critical and terminal illness in their office. As the population continues to grow and people live
longer, critical and terminal illness becomes a major issue in counseling and mental health.
Psychologists may feel poorly trained and ill equipped to meet the demands of multiple,
unpredictable and changing circumstances of people with serious illness (Chesney, 2002).
Understanding, mitigating and alleviating the mental, social and spiritual concerns of those
The leading causes of death in the U.S. in descending order are: (1) Heart disease (2) cancer (3)
cerebrovascular disease (4) chronic lower respiratory disease (5) accident (6) diabetes (7) influenza &
pneumonia (8) Alzheimer’s disease (9) kidney disease (10) blood poisoning (Durand & Barlow, 2006).
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suffering from critical and terminal illness has been the special purview of the specialized field
of health psychology.
In the 1950’s the theory of psychosomatic medicine was introduced- the study of how
psychological factors affect somatic processes. Psychophysiological disorder became a popular
label in use during the early stages of the development of health psychology in the 1970’s
(Durand & Barlow, 2006). The early focus on psychosomatic medicine although helpful was
misleading because it overemphasized blending the disciplines of medicine and psychology.
The two disciplines have very unique perspectives on health and wellness and very different
models from which those perspectives are derived. During the early 1970’s, health psychology
proponents grappled with the confluence of behavioral, biological and social factors with health
and a new model was developed -the biopsychosocial model (Durand, 2006). Health psychology
eventually became part of the APA under division 38. Since January of 1996, a bi-monthly
journal has been published; The Journal of Health Psychology. The APA defines the special
discipline of health psychology as:
“…understanding the etiology and promotion and maintenance of health, the prevention,
diagnosis, treatment and rehabilitation of physical and mental illness, the study of psychological,
social, emotional, and behavioral factors in physical and mental illness, the improvement of the
health care system, and formulation of health policy.” (APA, Division 38, Health Psychology)
Critical illness presents special challenges to those who become critically and terminally ill as
well as the health-care providers and family.
Pain and Stress
A perception of pain, discomfort, and unease is usually accompanied by disruption of
bodily functions as the consequence of critical and terminal illness. Three distinct processes are
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part of the “pain” experience of illness: Physical pain or discomfort, cognitive recognition of
physical symptoms of the illness, and an emotional response of concern (Weiss & Lonnquist,
1997). Pain becomes part of a complex of physical and psychological processes associated with
illness. In a recent study Reyes-Gibbs, Aday, Anderson, Mendoza, and Cleeland (2006),
reported that chronic pain was implicated as part of a triad of symptom clusters (pain-depression-
fatigue) with cancer patients: physical (pain, shortness of breath), cognitive (delirium, memory
loss, concentration problems) and affective (depression and anxiety).
Critically and terminally ill patients often experience various degrees of pain, but a
common feature is that pain is enduring; it seldom fades away (Lair, 1996). Pain can be so
severe that the main motivating factor of hospice care is to provide relief from pain during the
final stages of life (Lair). Besides the pain associated with the illness, there may also be pain and
discomfort coupled with the treatment of illness such as surgery, chemotherapy, dialysis, etc.
How a person responds to pain is dependent upon a number of factors. Weiss (1997) lists ten,
however, four are directly related to symptoms of pain and a person’s tolerance levels: (1) The
perceptual intensity of symptoms (sharp pain, high fever, intense headache), (2) disruptive
symptoms- the extent to which the symptoms disrupt social and occupational functioning, (3) a
person’s tolerance threshold and his or her values about stoicism and independence, and (4) the
frequency and persistence of symptoms. Furthermore, pain is not a condition that manifests
itself alone, Lair (p. 92) states “pain gives rise to anxiety and depression, especially in persons
who are dying. Besides these and other related symptoms the pain may become manifest as
spiritual concerns. A terminal diagnosis is often felt as an “existential slap” threatening the very
meaning and being of a person’s existence. An existential slap is understood as the moment of
realization of the immanence of death (Coyle, 2006).
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Themes, Metathemes and Subthemes
The physical, psychological, social and spiritual dimensions of a person seem to converge
and deepen in the face of critical or terminal illness. Coyle (2006) identified four tasks (or
themes) related to these dimensions that the dying patient needs to engage in: Physical tasks
(meeting the body’s needs and minimizing physical distress), psychological tasks (emphasizing
security, autonomy and richness in living), social tasks (social attachments to groups and
individuals and spiritual tasks (meaningfulness, connectedness, transcendence and hope). He
noticed in his study that these tasks became “had work” for the participants because they were in
a weakened state.
This is an unfortunate circumstance given that a person suffering critical or terminal
illness may face increasing pressure and demands to, return to normal functioning, be less of a
burden on caregivers, and resolve personal, social, and spiritual ambiguities. Coyle (2006)
suggested that four meta-themes emerged from the research: Relationship of the patient to the
healthcare system, relationship to a changing self, relationship to pain or other distressing
symptoms, and relationship to the existential slap. The difficulty of the sufferer to work through
these and aforementioned issues is compounded by the struggle to live while at the same time
preparing for death. Supportive counseling efforts need to be focused on recognizing the various
concerns and difficulties associated with suffering. Coyle mentions three other subthemes which
would be an excellent place for counselors to start to provide support, sufferers try to: (1) orient
to the disease and maintain control, (2) search for and create a system of support and safety, and
(3) struggle to find meaning and create a legacy. In the struggle to find meaning, patients begin
to enter into dialogue with their spiritual concerns. Spirituality, as defined by Kai-Kuen, Tai-
Yuan & Ching-Yu (2006, p.450), quoting Muldoon & King (1995) “…is a universal connection
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to the transcendent and the search fro meaning in life that may or may no be linked to a divine
Boston & Mount (2006) discuss existential and spiritual distress as important aspects of
quality of life for end-stage terminally ill patients. Their research focused on the beneficial
impact of meeting the spiritual concerns of patients in palliative care settings and on the negative
impact of not addressing these concerns on patients as well as their primary caregivers. They
identified six concepts of spirituality (Ibid, p.16):
• Relationship with a higher power
• Sense of connection with self, family & community
• Sense of transcendence through personal suffering and healing
• Sense of “alignment”
• Sense of purpose
Boston & Mount (p. 24) concluded that while there is a paucity of research on caregiver
conceptualizations of spiritual concerns and on how the suffering of patients impacts the spiritual
well being of caregivers, “Spiritual/existential concerns are important determinants of enhanced
quality of life…They thus warrant the attention to detail paid to other aspects of palliative
diagnosis and therapeutics.” By placing the spiritual care and concerns on par with other
therapeutics, they are pointing out a much-needed addition to the common paradigmatic model
of healing in health psychology which deals only with psychological, social, emotional, and
behavioral factors. Admittedly, incorporating spiritual concerns into new treatment paradigms
will require much research and study.
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In the United States the first law to permit euthanasia, the Oregon Death With
Dignity Act of 1997 was voted on and passed in 1994. The law took effect three years later on
October 27, 1997 because of legal issues and by 2004, 208 Oregon patients took lethal doses of
medication: 80 had cancer and most chose to die at home (Bell, 2006). Several other countries
have begun to struggle with the issue (German & Italy) while others have already passed them
(Netherlands and Holland). It is my opinion that euthanasia is a subject that should not only be
left to the legal system to debate and decide. Given some of the issues presented in this paper,
euthanasia is an issue that needs a great deal of research, debate and study done from a
multidisciplinary perspective including especially the spiritual perspective. On an issue this
important and with so much potential for wrongdoing I tend to lean in the direction of not
supporting the legislation. I would demand that unequivacable sound and valid proof, evidence,
research, testimony and debate be brought to bear on this subject before moving forward. As of
this time, I am agnostic with a predisposition to not support this legislation. At this time I am
convinced that we have available very good palliative care (even though it could be vastly
improved judging from some of the research findings already mentioned) and LD to aid persons
in their dying.
Imagine watching a favorite new television show and then during commercial time
“heavenly” music plays and chimes ring, images of dazzling lights and “angels” dressed in
flowing robes appear heralding a message that begins with an advertisement by Blissful Endings,
a company that specializes in euthanasia. The company, with music playing and angels floating
and swaying recommends it’s expert services such as: suggesting for you or a loved one nearing
the end of life special clinics and centers which offer a consummate, effortless and most
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gratifying transition to the other world; their experts will calculate the “best” time to end a
terminal illness blissfully; the ad shows helpful thanatologists dressed in pleasant flowing
“spiritual” robes with “cherub” faces offering discounted prices to those who call (within the
next 24 hours): Spiritual counselors are standing by to answer all their questions to make the
transition so that your or that special loved on can make the conversion with absolutely no
anxiety or pain. For an added special fee this can all be coordinated with your healthcare plan,
life insurance provider, estate planners, undertaker and local minister or psycho-pomp shaman.
Imagine this! By the way, the favorite show you happen to have been watching is titled… Final
Exit: Disappearing Behind The Curtain, with host Fenton Moonlight, real life scenes of beautiful
passages; people and their loved ones share with you the final moments of their earthly
existence…just imagine that this can actually happen!
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APA, Author. Health Psychology (2006) Division 38. Retrieved November 27, 2006 from:
Bell, A., (01-18-06), PBS, News Hour Extra, Retrieved February 27, 2008, from:
Boston, P. H., & Mount, B. M. (2006). The Caregiver’s Perspective on Existential and Spiritual
Distress in Palliative Care. Journal of Pain and Symptom Management, 32, 1, 13-26.
Chesney, M. A., & Antoni, M. H. (Eds.). (2002). Innovative approaches to health psychology.
Mahwah, NJ: Lawrence Erlbaum Associate, Publishers.
Coyle, N. (2006). The Hard Work of Living in the Face of Death. Journal of Pain and Symptom
Management, 32, 3, 266-274.
Durand, M. V., & Barlow, D. H. (2006). Essentials of abnormal psychology (4th ed.). Belmont,
CA: Thompson Wadsworth, Inc.
Kai-Kuen, L., Tai-Yuan, C., & Ching-Yu, C. (2006). The Influence of Awareness of Terminal
Condition on Spiritual Well-Being in Terminal Cancer Patients. Journal of Pain and
Symptom Management, 31, 5, 449-456.
Lair, G. S. (1996). Counseling the terminally ill: Sharing the journey. Washington, DC: Taylor
Lavi, S.J. (2005). The modern art of dying: A history of euthanasia in the United States.
Princeton, NJ: Princeton University Press.
Muldoon, M., & King, N. (1995). Spirituality, health care, and bioethics. Journal of Religion &
Weiss, G. L. & Lonnquist, L. E. (1997). The sociology of health, healing and illness (2nd ed.).
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Upper Saddle River, NJ: Prentice Hall.
Williams, J.R. (1997). Christian perspectives on bioethics: Religious values and public policy in
a pluralistic society. Ontario, Canada: Novalis.