Predilection to Death: Death and Dying as a Psychiatric Problem
Predilection to Death: Death and Dying as a Psychiatric Problem
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对死亡的偏好：死亡和临终是一种精神问题
DOI：
10.1097/00006842-196105000-00005
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发表时间：
1961
影响因子：
3.3
通讯作者：
T. Hackett
中科院分区：
文献类型：
--
作者：
A. Weisman;T. Hackett
报道了一系列5例罕见的外科患者，其中死亡倾向是临床图像中突出的一部分。这些偏爱患者的共同特征是，每个人在入院时都预料到自己的死亡。除了患有精神疾病的女性外，她们既没有焦虑，也没有明显的抑郁。所有人都表示相信死亡将在短时间内发生，除了一个年轻女孩平静地期待死亡而没有公开提及死亡。对死亡的定罪总是伴随着被另一个人杀害的预期。倾向患者可以很容易地与术前高度预期焦虑的患者、抑郁患者、自杀患者以及那些正确预测自己的死亡并且在尸检中没有显示明显病变的罕见患者区分开来。两名男子在康复过程中意外死亡。三名女性患者不仅预计会死亡，而且预计会死于恶性疾病。然而，在一名妇女中，这种疾病显然已经被控制了28年。直到一名患有相同疾病的年轻人死亡后，另一名患者才出现复发和转移。第三名女性同时患有严重的精神疾病和无法治愈的癌症，在死亡前不久，当一种姑息手术威胁要延长她不愉快的生命时，她变得警觉起来。死亡比生命对这些患者更有吸引力，因为它承诺要么与失去的爱团聚，要么解决长期的冲突，要么从痛苦中得到喘息。在最后一次入院期间，每个患者的情绪都被隔离了。她们的“孤独”有几种不同的类型：一名男子是半流浪汉，从未经历过情感上的亲密；另一名男子流放了自己，离开了家人；一名女子的丈夫和家庭成员相继死亡；另一名女子一生中背弃了除最正式的关系之外的所有关系；一名年轻女孩不仅因死亡失去了一位亲密的朋友，而且被她的医生和家人遗弃，他们如此担心，以至于不能接受她肯定会死。对偏爱患者的研究导致了对临终患者护理的总体评估，特别是从传统上假定的对死亡的矛盾态度的角度。心理动力学原理在死亡概念和死亡过程中的应用是建立在适当死亡假设的基础上的。恰当的死亡是一种承认个人死亡的必然性作为生命的实现的死亡。它满足四个条件：减少冲突，与自我理想相容；与活人和已经死亡的人保持个人关系的连续性；以及幻象的完善。简而言之，适当死亡的情况与患者自杀的情况相反。适当死亡的条件是从非人身性死亡、人际死亡和个人内死亡之间的区别得出的。对死亡的恐惧与对死亡的恐惧是不同的。死亡过程在心理上与最初的焦虑、即将解体的感觉和对死亡的恐惧相对应。事实证明，这是一种死亡恐惧症，间接与“理性”恐惧有关。适当的死亡是安乐死的一个方面--对于即将死亡的患者来说，没有痛苦地死亡。然而，安乐死的传统概念是加速不治之症患者的死亡，这与精神干预倡导的正确对待死亡的态度是相反的。在传统的安乐死中，忽视了患者的个性；在治疗患者与疾病分离的建议中，增强了人格的独特尊严。提出了实施适当死亡的各种实用建议，但如果不坦率地与患者一起面对死亡的迫在眉睫，就不可能进行干预。已有证据表明，医生通常比病人更难做到这一点。心照不宣地把沉默、否认、欺骗和孤立强加给垂死的病人本身可能会造成痛苦，并导致垂死的人失去亲人，一种生前的孤独、情感上的遗弃和幸存者强加给垂死的人的丧失兴趣的状态。书中列举了一些例子，在这些例子中，改变的人际关系提供了接近死亡的前兆。医生不会认为死亡是一种超越他能力范围的失败，而是可以延长他的护理时间，帮助他的临终病人实现一个合适的情感世界，在其中死亡。
&NA; A series of five unusual surgical patients is reported in which “predilection” to death was a prominent part of the clinical picture. The common characteristic of these predilection patients is that each anticipated his death at the time of admission. With the exception of a mentally ill woman, they were neither anxious nor significantly depressed. All expressed the conviction that death would occur within a short time, except for a young girl who serenely anticipated death without openly referring to it. The conviction of death was invariably accompanied by an expectation of being killed by another. Predilection patients may be readily distinguished from preoperative patients with high anticipatory anxiety, depressed patients, suicidal patients, and those rare patients who correctly prognosticate their own deaths and demonstrate no significant lesions at autopsy. Two men died unexpectedly in the course of convalescence. Three women patients were not only expecting to die but were expected to die because of malignant disease. However, in one woman, the disease had apparently been arrested for 28 yr. Relapse and metastatic lesions did not occur in another patient until after a young man with the same disease had succumbed. A third woman, suffering both from severe mental illness and incurable cancer, became alarmed shortly before death when a palliative procedure threatened to prolong her unhappy life. Death held more appeal for these patients than did life because it promised either reunion with lost love, resolution of long conflict, or respite from anguish. Each patient was emotionally isolated during the final admission. Their “loneliness” was of several different kinds; one man was a semi‐vagrant who had never known emotional intimacy; another man had exiled himself from his family; one woman had suffered successive deaths of her husband and members of her family; another woman had repudiated all but the most formal relationships throughout her life; a young girl had not only lost a close friend by death but was deserted by her physicians and family, who were so concerned that they could not come to terms with her certain death. Study of the predilection patients has led to an evaluation of the care of the dying patient in general, particularly from the viewpoint of the paradoxical attitudes towards death that are conventionally assumed. The application of psychodynamic principles to the concept of death and the process of dying is based on the hypothesis of the appropriate death. An appropriate death is one that recognizes the inevitability of personal death as a fulfillment of life. It satisfies four conditions: conflict reduction, compatibility with ego ideals; continuity of personal relations with the living and the already dead; and consummation of phantasies. In short, the circumstances of an appropriate death are the opposite of those in which a patient would commit suicide. The conditions of an appropriate death have been derived from the distinction between impersonal, interpersonal, and intrapersonal death. The fear of dying is not the same as the fear of death. The dying process has psychological counterparts in primary anxiety, the sense of imminent disintegration; the fear of death. it has been shown, is a death phobia, indirectly related to “rational” fears. Appropriate death is an aspect of euthanasia‐‐death without suffering‐‐for patients whose death is imminent. However, the conventional concept of euthanasia as the hastening of the death of incurably ill patients is the antithesis of the appropriate attitude towards death which psychiatric intervention advocates. In conventional euthanasia, the patient's personality is ignored; in the proposal of therapeutic dissociation of the patient from the disease, the personality in its unique dignity is enhanced. Various practical recommendations for implementing the appropriate death are presented, but no intervention is possible without frankly facing the imminence of death with the patient. Evidence has been presented to indicate that this is usually more difficult for the doctor than for the patient. Tacitly to impose silence, denial, deception, and isolation upon the dying patient may itself cause suffering and bring about bereavement of the dying, a state of premortem loneliness, emotional abandonment, and withdrawn interest that the survivors impose upon the dying. Examples are cited in which altered interpersonal relationships provide the prodromal intimations of approaching death. Instead of viewing death as a failure beyond his competence, the physician can extend his care and help his dying patient to achieve an appropriate emotional world in which to die.