ALDACTONEO(spironolactone)

Composition:Each uncoated, scored, light tan tablet con-tains spironolactone, 25 mg.Aldactone offers an entirely new approach tothe treatment of essential hypertension, edemaand ascites, including resistant states. Aldac-tone specifically blocks the effects on thekidneys of mineralocorticoids and antagonizesthe sodium retaining and water retaining effectsof aidosterone which is important in the pro-duction of edema.

Indications:Aldactone is indicated in the treatment ofedema and ascites of congestive heart failure,hepatic cirrhosis, the nephrotic syndrome, andidiopathic edema as well as that due to malig-nant effusions especially if not responding wellto conventional diuretics.Aldactone is also indicated for lowering bloodpressure in essential hypertension, correctinghypokalemic alkalosis in severe hypertensionand in the treatment of myasthenia gravis.

Dosage:Edema: the initial recommended adult dose isone 25 mg. tablet four times daily. Rarely apatient may require up to 300 mg. per day andothers as little as 75 mg. per day. If adequatediuresis with Aldactone is not obtained withinfive days, Aldactazide should be substituted inits-usual dosage to obtain the synergistic effectof the spironolactone and the thiazide com-ponents. In an occasional patient with severe,resistant edema, it may be necessary to add aglucocorticoid to this combined therapy.In children a dosage providing 1.5 mg. ofAldactone per pound of body weight should beemployed.Essential hypertension: One tablet four timesa day, treatment should be continued at leasttwo weeks.

Precautions:Other than acute renal insufficiency there areno known contraindications to Aldactone. Itshould be used judiciously in patients withhyponatremia or hyperkalemia.

Side Effects:Side effects are mild and infrequent; drowsi-ness, mental confusion and maculopapular orerythematous eruptions have occurred rarely,subsiding within forty-eight hours on discon-tinuation of the drug. Gynecomastia and mildandrogenic manifestations have also beenreported in a few patients.

Toxicity:No reports of fatal overdosage in man. Noadverse effects from high dosage in chronicanimal studies.Symptoms of Overdosage: True toxicity hasnot been reported; drowiness, mental con-fusion or a maculopapular or erythematousrash has occurred rarely. These manifestationsdisappear promptly on discontinuance of med-ication. Hyperkalemia may be exacerbated.Treatment: No specific antidote. No true tox-icity has occurred or is expected. Appearanceof effects described above require only discon-tinuance of the drug. For hyperkalemia, reducepotassium intake, administer potassium-excreting diuretics, intravenous glucose withregular insulin or oral ion exchange resins.

Supply:Bottles of 100 and 500 tablets.

G. D. Searle Company of Canada Limited,Oakville, Ontario.

cert avec cette modification, unepression negative peut devoir etreinstauree pendant 1'expiration. Endehors des changements physiologi-ques qui surviennent dans l'orga-nisme, les risques provenant dedefectuosites de I'appareil ou de sonemploi errone peuvent etre catastro-phiques.

References1. MUSHIN WW, RENDELL-BAKER L,

THOMPSON PW: Chapter I, in AutomaticVentilation of the Lungs (second ed).Philadelphia, F. A. Davis, 1969

2. MORGAN BC, MARTIN WE, HORNBEINTF, et al: Hemodynamic effects of inter-mittent positive pressure respiration.Anesthesiology 27: 584, 1966

3. COURNAND A, MOTLEY HL, WERKO L, etal: Physiological studies of effects of inter-mittent positive pressure breathing on car-diac output in man. Am JPhysiol 152: 162,1948

4. CAMPBELL EJ, NUNN JF, PECKETT BW: A

comparison of artificial ventilation andspontaneous respiration with particular re-ference to ventilation-bloodflow relation-ships. BrJ A naesth 30: 166, 1958

5. WOLLMAN H, ALEXANDER C, COHEN PJ,et al: Cerebral circulation during generalanesthesia and hyperventilation in man:thiopental induction to nitrous oxide andd-tubocurarine. Anesthesiology 26: 329,1965

6. SULLIVAN SF, PATTERSON RW: Posthy-perventilation hypoxia: theoretical consi-derations in man. Anesthesiology 29: 981,1968

7. NORRY HM: Personal communication8. DEAN HN, PARSONS DE, RAPHAELY RC:

Case report: bilateral tension pneumo-thorax from mechanical failure of anes-thesia machine due to misplaced expira-tory valve. Anesth Anaig (Cleve) 50: 195,1971

9. FAIRLEY HB, HUNTER DD: Mechanicalventilators: an assessment of two new ma-chines for use in the operating room. CanAnaesth Soc J 10: 364, 1963

10. PETERS RM, HUTCHIN P: Adequacy ofavailable respirators to their tasks. AnnThorac Surg 3: 414, 1967

A clinical perspective on dyingRobert G. Janes, M.D., Stanford, California, U.S.A.

Summary: There is continuing needfor dissemination of alreadyavailable, clinically useful knowledgeconcerning the psychological needsof the seriously ill and dying.Against the changing social contextof dying, some of our erroneousassumptions about these patientsare explored and the genuine fearsand personal needs are discussed.The implications of this knowledgefor medical education are recognized.

Too little currently available infor-mation concerning the problems ofseriously ill and dying patients isreaching primary care physicians.These patients constitute a largelyneglected social group in an eraotherwise characterized by intenseinterest in social minorities. Thedying, for obvious reasons, are not avocal minority. Death will never be

ROBERT G. JANES, M.D., Chief Resident andActing Instructor, Department of Psychiatry,Stanford University Hospital,Stanford, California.Reprint request to: Dr. Robert G. Janes,Department of Psychiatry,Stanford University School of Medicine,Stanford, California 94305.

fashionable. None the less the subjecthas received increasing attention re-cently by health planners, economistsand sociologists.14 Rarely does thisimportant literature focus on theprincipal object of these concerns,the experience of the seriously ill anddying person himself. It is as if it ismore comfortable to speak of deathrates and social rituals than aboutthe very real and immediate existen-tial dilemma of dying itself. Deathremains a taboo topic that seems toexceed even sex in provoking a liter-ature that tends to obscure personalissues and events. One can too easilylapse into metaphysics and popularreligious cliches. Kubler-Ross andothers have taken a patient-centredapproach, much more useful in thetense, emotionally charged atmos-phere surrounding the dying.59

In my effort to highlight some ofthe available useful clinical knowl-edge on this subject I will initially ex-amine the changing social context ofdying. Against this background wecan explore some of our erroneousassumptions about the seriously illand, one may hope, reveal their genu-ine concerns, fears and personal

C.M.A. JOURNAL/SEPTEMBER 9, 1972/VOL. 107 425

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needs. Finally I will comment on theimplications of such knowledge formedical education.

The changing context of dyingWith the advent of technologicalmedicine since 1900, fewer and fewerindividuals die in familiar surround-ings, on their own turf as it were, insight of family relics and in reachof the ministrations of family andfriends. Less than one-third of thenearly two million deaths in the U.S.this year will occur outside institu¬tions.10 This transition from home toinstitutional atmosphere rudely di-vests the process of dying of its per¬sonal, evocative and historical ele¬ments elaborated over generations ofbereaved families struggling to copewith impending loss. Further, thephenomenal treatment advances inmedicine have largely reduced theimpact of sudden or premature deathonly to produce a population payingfor its longevity through the chronici¬ty of its ailments. In our modern dayparable, Lazarus appears not at themouth of the grave but through thedoor of the intensive c&re unit. Adeath in the family today is more

likely to provoke litigation than a re-

ligious justifying of the ways of Godto man. "Nothing happens by itselfanymore, there are no acts of God.Man is to blame for almost every-thing."11

Assumptions about the seriously illand dyingThe first assumption is provoked bythe very diagnosis of serious illness.For example, the word cancer in theminds of laity and professionals alikeoften elicits the unconscious equa-tion: cancer = terminal disease. Theimplication is an early, perhaps gris-ly, demise. That this is untrue shouldbe obvious. Many cancers are curableand we all rationally know this. Butcertain diagnoses (e.g. leukemia,cancer) evoke a kind of primitivefear in all of us that can paralyze rea¬

sonable action. Even in the most so¬

phisticated medical communities ex-

traordinarily primitive beliefs aboutcancer thrive. Several years ago Iparticipated in a training workshopat Stanford for nurses and nurses'aides concerning the psychologicalcare of cancer patients. Among theseveral hundred participants thegreatest concern centred about thechance of "catching" cancer whileworking on the wards! It is hard to

426 C.M.A. JOURNAL/SEPTEMBER 9, 1972/VOL. 107

imagine effectively caring for suchpatients in an atmosphere of sus¬

pected contagion.Even physicians in varying degrees

display their frequently unwarrantedpessimism. Everyone knows of so-called "hopeless" cases which re-

sponded to the attentions of a partic¬ularly persevering physician who val-ued remission equally as cure. Fami¬lies, too, occasionally sense a doc¬tor's defeatist attitude and, if strongenough, place their kin in anothermore therapeutically optimistic at¬mosphere. This is a seldom mention¬ed aspect of so-called "doctor shop-ping" in the face of critical illness.Not all such families are searchingfor a magical cure but rather are re-

sponding to a kind of hopelessnessthey detect in the physician's de-meanour.

A second assumption finds ex¬

pression in the prevalent belief thatmedicine and nursing have little tooffer the incurable or terminally illpatient except drugs to decrease painand other kinds of discomfort. Forsome physicians the point at whichthey say, "I've done everything Ican" is reached when the armamen-tarium of technical procedures is ex-

hausted. At this juncture the patientis suddenly redefined from curable toincurable. Again another uncon¬scious equation is evoked: incurable= beyond help. There are somesubtle and not so subtle indicators ofthis transition. The code, DNR (DoNot Resuscitate), may be inscribedon the nurses' medicine sheet. Astime wears on there is a reluctance tomake rounds on the dying patient.Generally he is moved to a privateroom or the drapes about his bed re¬main closed. Visiting privileges forfamily and fellow patients may becurtailed for the specious reason thathe is too ill to tolerate their presence.As his seclusion increases his sense ofisolation and worthlessness grows.This phase may be only days or

might stretch for weeks. The physi¬cian may eventually receive onlyverbal reports from the nurse withoutactually seeing the patient.The explanation for this retreat

lies in the natural emotional resis¬tance to contact with the dying en¬countered in medical staff and fami¬ly alike. The anxiety provoked in theobservers gains support from allquarters. The physician is confrontedwith his own helplessness and impo-tence in the face of inexorably pro¬

gressive disease. The family mem¬

bers, perhaps having mixed feelingsof guilt and unmanageable grief to¬ward the dying person, may uncon-

sciously avoid the sickbed. Underthe guise of not upsetting the patientthey escape their own discomfort.The timing and pattern of profes¬

sional retreat are variable. In a

teaching centre the appeal of a dis¬ease process seems important. Apatient with a truly exotic, even iffatal, malignant growth may haverounds conducted on him to the lastminute and physicians can take ref-uge in intellectual bedside disserta-tions a form of preoccupationwith pathology in lieu of person.Doctors are frequently heard to saythings like, "this is a beautiful exam¬ple" of such and such a tumour withthe emphasis on the word beautiful.

In sum, these powerful feelingsprovoked by proximity to the dyingcreate an atmosphere of patient iso¬lation and professional nihilism. Thisprevents us from encountering thedying patient on a personal level thatwill allow us to see what more we

might have to offer besides drugs todecrease the important, but not soledistress of dying.A final assumption we need to ex¬

amine is the prevalent notion thatoffering truth to the dying only in¬creases suffering, promotes depres¬sion and abolishes hope. Some evenfear the risk of an unmanageable or

perhaps suicidal patient. The equa¬tion here is: truth = suffering. Itleads to the demeaning conclusionthat a human being is unable to copewith the knowledge that he is aboutto die. It is no secret that personswith serious illness commit suicide.What is not clear is whether or not theknowledge of their disease is reallyan important factor in the suicidedecision.12 Typically the informationis confided only to some select fami¬ly member. A survey of physicianattitudes revealed that 88% of doc¬tors generally don't tell the patientthe potential outcome of his illness.Yet 60% of these same doctors re-

sponded that they would want thisinformation themselves if in a simi¬lar position.13 It would be valuableto speculate on the meaning of thisdiscrepancy, but the consequencesfor the patient are more important.Bland reassurances and half-truthsmore designed to reduce the anxietyof the giver than the receiver becomethe patient's fare. He learns not that

he has cancer but "just a small le¬sion", "a minor tumour" or a

"bowel condition".In a sense this is what the patient,

when first confronted with the badnews, will hear anyway no matterhow explicit is his doctor. The uni¬versal phenomenon of denial imme¬diately becomes operative. This is thepsychological mechanism wherebyintolerable reality issues are pushedfrom awareness. The reactions ofcancer patients on being told theirdiagnosis have been studied. Of 231patients who were told explicitly theyhad cancer, 19% subsequently deniedreceiving such information. It ismore encouraging that two-thirdswere grateful to know the truth. Only7% resented the frankness.14 Intruth, most patients suspect veryearly in their illness that there maybe a fatal outcome and their inabilityto get accurate information abouttheir status can lead to frighteningand embarrassing circumstances. Astheir illness progresses, denial weak-ens and the patient without adequateknowledge is left free to speculateabout all sorts of frightening possi-bilities in an atmosphere of cloudedcommunication.Not only does the patient deny,

but, as previously suggested, doctors,nurses and paramedical personnelalso protect themselves from the dis-couraging and even distasteful expo¬sure to death and dying by this phe¬nomenon of denial. Furthermore, a

patient is quick to sense the denyingdoctor. A mutual pretense springsup in which both parties have theknowledge of probable outcome butthe patient does not share his feelingsfor fear of offending or making un-comfortable his physician. I recallone outspoken patient with carci¬noma who, after enduring a longcourse of surgical and irradiationtherapy, bitterly accused his chroni¬cally platitudinous doctor of notbeing able to recognize a dying man.

All this foregoing is evasion of thequestion, to tell or not to tell. Onecannot answer this question unless itsform is changed, as Kubler-Ross sug¬gests, to "How can I best share thisknowledge with my patient."15 Thetruth has many forms and the patientrelies on his physician to present thenews in an acceptable manner. Thereis no general formula. Much de¬pends on a sensitive perception ofpatient needs and the doctor's per¬sonal verbal style. The worst possible

C.M.A. JOURNAL/SEPTEMBER 9, 1972/VOL. 107 427

response is a concrete prognosis interms of time (which after all it isimpossible for the physician to know)with explicit details as to the course.Patients' reactions to such news,however presented, is highly variableranging from brute stoicism accom-

panied by practical business-like ar¬

rangements of important final mat¬ters to complete social paralysisand despondency. More commonly,though, the patient will want to thinkand then at a time of his choosing(not yours) talk, for you will havegiven him the opportunity to sharehis deepest thoughts.

Concerns and fearsIt is at this time that the alert physi¬cian, nurse or aide, having escapedsome of these self-protective assump-tions about the dying, can listen andlearn from the dying themselves thereal nature of their concerns andfears.

Chief among these is not the fearof death itself, but of the process ofdying, of anticipated pain and dis¬comfort. This is much greater thanthe fear of impending extinction.

Closely allied to this is the fear ofprogressive destruction of the bodyego, a particularly frightening pros-pect if a cosmetically important areais involved. This is a fear of becom¬ing ugly and therefore unlovable andperhaps deserted while still alive.We have mentioned the features of

progressive isolation .as the livingprematurely retreat from the dying.The patient is acutely sensitive tothis event. Dying is terribly lonelyonly closeness and warmth help.

For some patients whose previouslife styles showed great independenceand self-control over their own lives,the worst feature of dying is loss ofcontrol, loss of personal mastery inthe futile struggle against disease.

Inevitable, too, are the feelings ofgreat personal loss, loss of life op¬portunities and life plans. This seems

especially poignant for younger pa¬tients deprived of being able to re¬flect on a long and varied existence.Such a deep sense of deprivationmay be disguised. Initially the keenlyfelt disappointment is projected tofamily and staff in angry outburstsalternating with depressive episodes.All this is an expression of sorrownot over the death to come, but forchildren, career aspirations, plansand possessions left behind.

NeedsGiven these kinds of concerns on thepart of the dying patient, concernswhich can only be elicited by avail¬able persons in a setting of sharedmutual knowledge, let us look nowat what this dying human, in his finallife crisis, really needs.

Foremost he needs to recognizethe fact of serious illness or impend¬ing death but be given the opportu¬nity to regulate the amount of re-

vealing that is done, to be respectedin his simultaneous need to knowand need to deny and not to be cutoff with reassuring platitudes or tobe told in explicit disquieting termsthe details of his situation. The pa¬tient always allows for hope evenwhen the doctor does not. It is acommon clinical experience thatwhen the patient gives up, deathsoon follows.16He needs to have his seemingly

trivial daily concerns attended to de¬spite the larger reality of his diagno¬sis. For the dying, since the future isuncertain, the present assumes enor-mous importance. A patient withterminal illness might complainabout ill-fitting false teeth and re¬

quest a new set that would requiresix weeks labour. This is a way notonly of avoiding thoughts of deathbut of dealing with the only concep-tualizable realities he has. Hence theimportance of the daily rituals ofliving: the morning newspaper, a spe¬cial meal, the opportunity to liveuntil you die.He needs to feel he is the object of

honest and ongoing importance onthe part of family and professionalstaff, to feel that there is alwayssomething to be done, to receive an

expression from his caretakers of a"we're in this together" attitude. Itis great comfort to the patient toknow his physician is in league withhim against whatever manner of dif¬ficulty he might encounter.He needs to have the opportunity

to use the time left to him for resolu¬tion of important life issues. Thismay be the drawing up of a will,custody of children or reunions andleave-takings. Also important is theopportunity to discuss unresolvedemotional conflicts peculiar to theindividual. Obviously none of this ispossible in an uninformed patientwhose physician has not been ablegently to communicate the meaningof his illness.He needs to be allowed to grieve.

While the bereaved family after thepatient's death may eventually beable to re-invest themselves in lifetasks (the theme of "life goes on"),the dying patient needs to divest him¬self of life's objects. This is a periodof anticipatory grieving for the com-

ing loss of objects and endeavours.This emotional preparation will cul-minate in the final stages when thepatient, appearing depressed, is infact void of feeling, without depres¬sion or pain. In this, penultimatestage of the dying process silence,but not isolation, is indicated in thesickroom. The quiet human presenceof family and friends is enough.Some patients express a wish to

leave behind, if possible, a gift, per¬haps a piece ofjewelry or a favouritebook, with some significant person.This is a symbolic measure of thesearch for continuity, perhaps im-mortality. It is the leaving of a partof the dying with the living. Dyingpatients may bestow such tokens ontheir nurses and physicians and theknowledge of their meaning turnsthe acceptance into a healing eventof great comfort. I have on my deska favourite coffee cup from one suchpatient as a reminder of this wish.

Finally, I would suggest a majorneed of any dying patient is to findan acceptable answer to the question"Why me?" For those who are elderlyor with firm religious beliefs the an¬swer is less difficult. Some find com¬fort in feeling that their illness hasbeen given meaning by participationin medical research. My experiencehas been that this finding of meaningis actually a greater problem forfamily or spouse than patient.Implications for medical educationI have not mentioned here the im¬portant problems of dying children,the pyschological dilemma of the be¬reaved family or the circumstancesof serious illness and death in thespecial setting of an intensive careunit or research centre. Each areahas its own useful literature.17"21Despite the ready availability of suchinformation there continues to be in-sufficient infusion of this knowledgeinto the medical and nursing cur-ricula. One cannot overemphasizethe importance of introducing thesecharged issues early in training be¬fore students retreat behind the ar-mour of technical medicine. Only ahandful of teaching centres offermore than a cursory exposure tothese problems. Yet the situation of

C.M.A. JOURNAL/SEPTEMBER 9, 1972/VOL. 107 429

the seriously ill and dying patientoffers rich opportunity for the intro-duction of students to the humanisticelements of medicine. Here one canredefine the role of physician as notjust curing illness but helping the pa-tient come to terms with his own life.It is an ideal forum for learning howmajor clinical and life decisions aremade in concert with patient, familyand life goals.Some doctors today still bristle

at such suggestions, fearing exten-sion of their responsibility and in-volvement beyond the "scientific"aspects of patient care. However in-

congruous it may seem, today's phy-sician, by virtue of his therapeuticprowess, the hospital setting of deathand the increasing secularization ofsociety, is viewed by many of his pa-tients as both technical and emotion-al adviser. Dying is the important lastlife crisis that demands its own solu-tion for doctor, patient and familyalike. In helping to orchestrate anacceptable denouement the physicianparticipates in a process which en-hances his contribution as practition-er of both the scientific and humanis-tic aspects of medicine.

ResumeLa perspection de la mort en cliniqueII importe de continuer a repandrenos connaissances actuelles, clini-quement utiles, sur les besoins psy-chologiques du moribond. Nousavons cru utile de confronter cer-taines de nos hypotheses erroneessur ces malades avec les realites so-ciales changeantes de la mort et demieux comprendre les veritablescraintes et les besoins personnels deces malades. Nous nous rendons par-faitement compte du r6le que doi-vent jouer ces notions dans l'ensei-gnement medical.

References1. GLASER BG, STRAUSS AL: Awareness of

Dying. Chicago, Aldine Publishing Co.,1965

2. Glaser BG, Strauss AL: Time for Dying.Chicago, Aldine Publishing Co., 1968

3. FEIFEL H (ed): Meaning of Death. NewYork, McGraw-Hill, 1959

4. BRIM OG JR, et al (eds): The Dying Pa-tient. New York, Russell Sage Founda-tion, 1970

5. KUBLER-ROSS E: On Death and Dying,New York, The MacMillan Co., 1969

6. HINTON JM: Dying. Baltimore, PenguinBooks, 1967

7. HACKETT TP, WEISMAN A: The treatmentof the dying, in Current Psychiatric Thera-pies, edited by Masserman, J, New YorkGrune and Stratton, 1962

8. PATTISON EM: The experience of dying.Am JPsychother21: 32-43, 1967

9. ROTHENBERG A: Psychological problemsin terminal cancer management. J AmCancer 14: 1063-73, 1961

10. LERNER M: When, why and where peopledie, in The Dying Patient, edited by BRIMO G JR, et al, New York, Russell SageFoundation, 1970, p20

11. MORISON RS: Preface, in The DyingPatient, edited by BRIM OG JR, et al, NewYork, Russell Sage Foundation, 1970

12. HINTON JM: Facing death. J PsychosomRes 10: 22-8,1966

13. OKEN D: What to tell cancer patients. Astudy of medical attitudes. JAMA 175:1120-28, 1961

14. AITKEN-SWAN J, EASSON EC: Reactionsof cancer patients on being told their diag-nosis. Br MedJ 1: 779-83, 1959

15. KUBLER-ROSS, E: On Death and Dying.New York, The MacMillan Co., 1969

16. WEISMAN AD, HACKETT TP: Predilectionto death. Death and dying as a psychi-atric problem. Psychosom Med 23: 232-56,1961

17. EASSON WM: Care of the young patientwho is dying. JAMA 205: 203-7, 1968

18. FRIEDMAN SB, CHODOFF P, MASON JW, etal: Behavioral observations on parents an-ticipating the death of a child. Pediatrics32: 610-25, 1963

19. GROLLJMAN EA (ed): Explaining Death toChildren. Boston, Beacon Press, 1967

20. KOUMANS AJ: Psychiatric consultation inan intensive care unit. JAMA 194: 633-7,1965

21. JANES RG, WEISZ AE: Psychiatric liaisonwith a cancer research centre. Compr Psy-chiatry 11: 336-345, 1970

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430 C.M.A. JOURNAL/SEPTEMBER 9, 1972/VOL. 107