Death in a Cancer Ward

There is no grimmer duty in a hospital than working in a cancer ward full of dying patients. As custodians of terminal cases, nurses bear particularly heavy emotional burdens. The girls show a tough and cold exterior--an attitude quickly acquired in hospital service. But often it cloaks deep feelings of anger and frustration at their inability to slow the inevitable or at least relieve their patients' pain. The patients, in turn, become even more despondent. Confronted by apparently diffident nurses, they begin to complain that they are lied to about their condition, treated with contempt and given inadequate attention.

New York Psychiatrist Samuel Klagsbrun, 36, believes that the atmosphere in a death ward can be made at least reasonably tolerable. He tested his thesis in a 21-year demonstration project at Yale New Haven Hospital in Connecticut, where he was consulting psychiatrist in a small cancer-research unit filled with terminal cases. When he arrived, he found the morale of both staff and patients abysmal. The doctors and nurses considered the patients "walking dead"; the patients grumbled constantly about "uncaring" doctors, "unavailable" nurses, and experimental drugs that they thought were being used on them as if they were guinea pigs.

No China Vase. Klagsbrun decided first to minister to the psychological needs of the unit as a whole rather than any individual. He did this by giving particularly careful attention to the nurses, since their influence on the patients was pervasive. In a series of group discussions, he was able to make the nurses believe that, despite their feelings of futility, they were performing a crucial if difficult duty. Most important of all, Klagsbrun encouraged the nurses to look upon the patients in a more realistic and candid way. Death, he insisted, should not be treated like a delicate china vase; nor, he adds, should patients be considered as all that fragile, even though death hangs over them.

His program to "revolutionize ward culture" had an unmistakable impact. Told to deal more firmly with whimsical requests, which are actually signs of anxiety, the nurses talked bluntly to troublesome patients. "Mrs. Jones," a nurse would say, "you really don't need that bedpan again, do you?" The free-and-easy approach had its understanding and mellow side. Sensing that a patient was particularly troubled, a nurse would ask if she could help, even if her charge had not rung for aid.

As it happened, the spirit of open communication in the ward created a new problem: the patients started asking "Am I going to die?" Klagsbrun's recommendation: each patient should be handled in a straightforward manner, but one that he could most easily accept. Often the patient himself provided the clue as to how the question should be answered. When one told Klagsbrun, "Doc, I've never felt better," the psychiatrist knew that the man needed to delude himself about the true nature of his condition and could not cope with the truth. On the other hand, Klagsbrun felt that if the patient talked objectively about his pain, he was craving for honesty and could be told about the inevitability of death.

More Activity. As the spirit in the unit improved, the nurses began to prod the patients into greater activity. Many of them, it turned out, were well enough to do little chores for the nurses, socialize with one another, stroll to other parts of the hospital. In at least one instance, the unit's new joie de vivre exceeded all expectations. Walking into the room of a 39-year-old man, a nurse was amused to find that he had invited his wife to join him in bed.

Klagsbrun concedes that his upbeat approach, which has been adopted as a regular part of the hospital's procedures, does not satisfactorily deal with the agonizing time immediately before death. "This period," he says, "is still an unknown entity from the psychological point of view." Even so, he may have made some unexpected progress. With life rapidly slipping from her, an old Italian woman called to a nurse one day. "It is the end, isn't it?" she asked. The nurse nodded, sat next to the old woman and held her hand. "I don't want to die alone," the old woman said. "You won't be alone," the nurse replied. Ten minutes later, the old woman's labored breathing stopped, with the nurse still holding her hand.

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