Abstract
In this chapter, definitions of beginnings and endings of pre-exital dying in contemporary Germany are discussed, and vague elements in these definitions are highlighted. By referring to dying persons’ narratives of how their dying processes started, the initiation into dying is sketched. The role of the doctor as initiating expert, and common proceedings of initiating discussions between the doctor and the person about to die are presented. When a person is informed by a physician that she is dying, crucial presuppositions which are decisive for her identity conceptualization change (Whyte 2009): Most apparently, she has to imagine a future without herself, and herself without a future.
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Notes
- 1.
For an overview of diverging and complex definition models of defining dying in Germany see e.g. Schmied (1985), Wittkowski & Strenge (2011), Bormann & Borasio (2012), Becker & Xander (2012).
- 2.
This is also true for people who are regarded as already dead as a person though they are physically alive, or at least qualified as likely never to become alive and conscious again. Permanently comatose or severely brain-injured people are usually not seen as actually alive by their families once it becomes apparent they will no longer act, talk, and think like an ordinary person: Due to a biomedical diagnosis combined with a non-lively appearance, they can even be seen as pre-exitally dead, not as pre-exitally dying. Sometimes the decision is made to allow severely brain-injured persons without consciousness to die at a certain point, through the withdrawal of biomedical equipment that was keeping their bodies alive. The ambiguities that severely brain-injured patients evoke in their being neither dead nor alive are discussed elsewhere (Kitzinger & Kitzinger 2014).
- 3.
While the German culture relies on physicians as experts, the authority who qualifies a person as dying does not necessarily have to be a physician in every culture (Esho 1986).
- 4.
Intensive use of medical equipment and curative therapies is seen as hindering a bearable dying, reflected in palliative care guidelines that mention dying persons’ “wish to ‘be allowed’ to die without hi-tech medicine” (Seeger 2007: 9).
- 5.
For an overview of the economic dimensions and arrangements of dying in Germany, see Marckmann et al. (2012).
- 6.
For accounts of how extensive palliative treatment options are regarding shortness of breath or pain, see e.g. Bausewein (2012), Gravou-Apostolatou & Sittl (2012).
- 7.
Contrastingly, communicating a terminal diagnosis directly to a patient is often regarded as cruel and rather pointless in South China, as I witnessed during my contrast research in the Pearl River Delta. Doctors tend not to reveal diagnoses of this kind, and certainly do not interpret it as their duty to inform a person about her limited time span. If a Chinese doctor ever drops a hint that an illness might be incurable, she will rather tell close family members, not the person concerned. Instead of informing a dying person about her condition, a physician’s aim is rather preventing a dying person from hopelessness and despair. Furthermore, biomedical diagnostics and treatment options in South China are not as reliable as they are in Germany – at least for low- and middle-income families. A terminal diagnosis which is openly communicated, in the Pearl River Delta, rather points at a variety of possible hidden reasons than actually meaning what it says: Confronting a family or patient with an incurable condition may mean that a certain doctor simply does not know anything about treatment options for a particular disease; that a doctor misinterpreted measurement results of any kind; that essential medicine for treatment is not available; or that a doctor wants to press a patient’s family for money, giving a more favorable diagnosis with treatment options if she receives bribes.
- 8.
For more information on interpretations of suicidal desires and actions in various cultural contexts, see Broz & Münster (2015).
- 9.
See e.g. Kränzle (2007: 4).
- 10.
Such a situation happened, e.g., to the author, as discussed in subchapter 2.4.
- 11.
See e.g. Kränzle & May (2007).
- 12.
For a description of what counts as ideal communication of a terminal diagnosis in Germany, see Roller (2015: 20; 33-35; 40).
- 13.
In the setting described here, “dying starts with recognizing the facts” (Schmied 1985: 13, transl.by the author; see also Wittkowski 2011: 64).
- 14.
Patients are no longer prohibited from receiving high-potential morphine, for example, but instead are suddenly in a position to decide on their own doses. The aims of treatment concerning terminal patients are not cure, but “relief of suffering” (Wiesing 2012: 146; see also Müller-Busch 2012; Bausewein et al. 2015).
- 15.
The Aufklärungspflicht or Mitteilungspflicht [legal duty to inform a patient] can only be suspended if a diagnosis is likely to shorten a patient’s life: For example if she is already suicidal, or if it is very likely that she will become suicidal when receiving a terminal diagnosis. If a patient is not able to understand the content and consequences of a diagnosis properly, then a doctor will inform the closest relatives or legal guardian instead. However, the Mitteilungspflicht is rarely sued for retrospectively (Prof. Höfling, Department for Constitutional Law, University of Cologne, personal communication, August 2013). The Mitteilungspflicht is rather interpreted as a positive duty, as Volkenandt explains (transl.): “a human being [about to die] must not be bilked out of this conscience [of being dying]” (Volkenandt 2012: 111).
- 16.
For reflections on the extent to which phrases that include excusing remarks, like “I am sorry”, may be unfavorable, see Volkenandt (2012: 112).
- 17.
For contributions focusing on the doctor-patient-talk communicating terminal diseases, and its implicit and explicit messages, see Volkenandt (2012), Lutfey & Maynard (1998). Doctors usually know about that and refer to it saying e.g. that “patients only hear what they want to hear”, “she didn’t listen”, “you always have to take into account that they don’t hear what you say” (quotes from fieldnotes).
- 18.
For a critical review of stage models of dying, see Wittkowski & Strenge (2011).
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Menzfeld, M. (2018). Becoming dying. In: Anthropology of Dying. Springer VS, Wiesbaden. https://doi.org/10.1007/978-3-658-19826-8_3
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DOI: https://doi.org/10.1007/978-3-658-19826-8_3
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