1)   Denial and Isolation

2)   Anger

3)   Bargaining.

4)   Depression

5)   Acceptance

It is noted that she also has chapters on the fear of death, hope and attitudes about death. One problem with her work is that it has never really made it into clinical use. This may simply be because dying is such a personal and lonely enterprise. It may also be that despite her ground-breaking work we have not come very far since her writing. I have blindly given the case of Mr. P., which follows, to senior medical school students, and have received a cold response that I took, at times to be anger, when they are told the story is 30 years old. The case:

“Mr. P. was a fifty-one-year-old patient who was hospitalized with rapidly progressing amyotrophic lateral sclerosis with bulbar involvement. He was unable to breath without a respirator, had difficulties coughing up any sputum, and developed pneumonia and an infection at the site of his tracheotomy. Because of the latter he was also unable to speak; thus he would lie in bed, listening to the frightening sound of the respirator, unable to communicate to anybody his needs, thoughts, and feelings, We might have never called on this patient had it not been for one of the physicians who had the courage to ask for help for himself. One Friday evening he visited us and asked simply for some support, not for the patient primarily but for himself. While we sat and listened to him, we heard an account of feelings that are not often spoken about. The doctor was assigned to this patient on admission and was obviously impressed by this man’s suffering. His patient was relatively young and had a neurological disorder which required immense medical attention and nursing care in order to extend his life for a short while only. The patient’s wife had multiple sclerosis and had been paralyzed in all limbs for the past three years. The patient hoped to die during this admission as it was inconceivable for him to have two paralyzed people at home, each watching the other without the ability to care for the other. This double tragedy resulted in the physician’s anxiety and his overly vigorous efforts to save this man’s life “no matter in what condition” “ The doctor was quite aware that this was contrary to the patient’s wishes. His efforts continued successfully even after a coronary occlusion which complicated the picture. He fought it as successfully as he fought the pneumonia and infections. When the patient began to recover from all the complications, the question arose---”What now?” He could live only on the respirator with twenty-for-hour nursing care, unable to talk or move a finger, alive intellectually and fully aware of his predicament but otherwise unable to function. The doctor picked up implicit criticism of his attempts to save this man. He also elicited the patient’s anger and frustration at him. What was he supposed to do? Besides, it was too late to change matters. He had wished to do his best as a physician to prolong life and now that he had succeeded, he elicited nothing but criticism (real or unreal) and anger form the patient. We decided to attempt to solve the conflict in the patient’s presence since he was an important part of it. The patient looked interested when we told him of the reason for our visit. He was obviously satisfied that we had included him, thus regarding and treating him as a person in spite of his inability to communicate.  In introducing the problem I asked him to nod his head or to give us another signal if he did not want to discuss the matter. His eyes spoke more than words.  He obviously struggled to say more and we where looking for means of allowing him to take his part. The physician, relieved by sharing his burden, became quite inventive and deflated the respirator tube for a few minutes at a time which allowed the patient to speak a few words while exhaling. a flood of feelings when expressed in these interviews. He emphasized that he was not afraid to die, but was afraid to live. He also empathized with the physician but demanded of him “to help me live now that you so vigorously tried to pull me through.” The patient smiled and the physician smiled. There was a great relief of tension in the air when the two where able to talk to each other. I rephrased the doctor’s conflicts with which the patient sympathized. I asked him how we could be of the most help to him now. He described his increasing panic when he was unable to communicate by speaking, writing , or other means. he was grateful for those few minutes of joint effort and communication which made the next weeks much less painful. At a later session I observed with pleasure how the patient even, considered a possible discharge and planned on a transfer to the West Coast “if I can get the respirator and the nursing care there.”

In my personal experience I have seen little growth in the ability of physicians to confront death in a rational and caring manner. There are many reasons for this. One major one is a little noted fact that most physicians do not have all that much experience with death. For many death is a rare experience.  In the United States there are 828.4 deaths for each 100,000 people each year.  That is something over 2 million deaths a year. Gross division would show that is about 3 deaths per year per physician. The U.S. mortality rate from heart disease was 382 per 100,000 per year for men and 214 for women or a total of about 1.6 million due to heart disease. In other words out of the 2 million deaths per year 1.6 million are due to various consequences of heart disease or nearly 75 per cent of deaths and heart disease causes death in many forms, many of them sudden and unexpected. So many, many physicians will not experience any deaths in a given year and if so many of them will be sudden or, although in a medical setting, have no bearing on Dr. Ross’s book in that they will involve children, newborns and accidents. Medicine is, obviously, a very applied craft.  It is quite possible for a medical student to never experience a death during medical school and never experience a resuscitation. What meaning then does a curriculum on death have for them?

For the attending physician each death is peculiar to the patient. The admission comes unexpectedly. The physician is not prepared. The patient is not prepared.  The diagnosis is not secure. The focus is still on life and not death. The death this six months is a sudden MI in a 40 year old, the next is lost in an oncology referral, the next is an Alzheimer patient in a nursing home and only then might we come across a “classic case” admission, workup, fatal diagnosis and the process.

It is of interest that the first example of a doctor - patient encounter: that of Mr. P. is striking in that it is not about death at all but about life. The man does not die. One can take away from the story the horrible idea that the only thing killing the patient was the system. Only when the Dr. and the Patient understood what they felt and what their true interest should be did the problems resolve. It is extremely important here that she uses this example as she says that the doctor called the consult more for himself than for the patient.

So how can we pay homage it Kubler Ross and at the same time bring her insights into the 21^st century and make them applicable? I believe this can be done simply by introducing the concept of feeling hurt. So we start with what the reader might feel if they would have sudden knowledge of their impeding death ; we feel hurt. We can look at it in this fashion.

Going about my business ----------------> <----------something gets in my way.

 That something, of course, is the knowledge of my impeding death.  Least we not already forget the physician; he too has the same problem. He is going about his business and death knocks at his patient’s door. What does he do?

For the patient what will happen? Kubler Ross states, that if given the time and environment, we will, as dying patients, go through the following four steps:

Denial and Isolation

Anger

Bargaining

Depression

Acceptance.

I wish to suggest not a reordering but a clarification of these stages and a renaming.

Denial and Isolation for the moment will = Cognitive shock. Dr. Ross says:

“In summary, then, the patient’s first reaction may be a temporary state of shock from which he recuperates gradually. When his initial feeling of numbness begins to disappear and he can collect himself again, man’s usual response is “No, it cannot be me.”

What interests me is the “state of shock”. I hope to show that this state of shock is very different than Denial and Isolation . We might diagram this as:

Going about my business (desire to live) ----------------> < ------------- something gets in my way

(knowledge of my death) .

I

\I/

leads to a “state of shock”

2)   Anger will remain as Anger.

Again, Ross: “In contrast to the stage of denial, this stage of anger is very difficult to cope with from the point of view of family and staff. The reason for this is that this anger is displaced in all directions and projected onto the environment at times almost at random.” (p51) and “The tragedy is perhaps that we do not think of the reasons for the patients’ anger and take it personally, when it has originally nothing or little to do with the people who become the target of the anger. As the staff or family reacts personally to this anger, however, they respond with increasing anger on their part, only feeding into the patient’s hostile behavior. They may use avoidance and shorten the visits or the rounds or they may get into unnecessary argument by defending their stand, not knowing that the issues is often totally irrelevant.”(p52) Here it is very important, again, not to lose sight of the fact that everyone is going through a process; Family, friends, the physician and staff. Anger amplifies anger.

Going about my business (desire to live) ----------------> < -------------something gets in my way

(knowledge of my death).

I

\I/

Leads to a “state of shock”.

I

\I/

Leads to “anger”.

3)   Bargaining will become guilt

Dr. Ross: “Psychologically, promises may be associated with quiet guilt, and it would therefore be helpful if such remarks by patients where not just brushed aside by the staff. If an sensitive chaplain o physician elicits such statements, he may well wish to find out if the patient feels indeed guilty for not attending church more regularly if there are deeper unconscious hostile wishes which precipitated such guilt. “

Going about my business (desire to live) ----------------> < ------------- something gets in my way(knowledge of my death).

I

\I/

Leads to a “state of shock”.

I

\I/

Leads to “anger”.

I

\I/

Leads to “guilt”.

Here I diverge form Dr. Ross and will claim that her augment which is based on her invented quote of a patient: ‘”If God has decided to take us from this earth and he did not respond to my angry pleas, he may be more favorable if I ask nicely.”’ is faulty. She goes on to say that the patient then ‘bargains’ saying that “If you let me live I will be “good”. She points out that patients never keep their promises. Underlying this, but not stated, is the logical conclusion that if I am not “good” now I am “bad” or have been bad. On top of it I have just been bad by being “angry”. It is my belief, then, that the anger produces guilt that amplifies many past memories, of not so ideal behavior, for which we wish to atone and if we atone we should then be rewarded.

4)   Depression =A highly individual state based on real time stressors that elicit negative feelings added to any recalled memory that elicits negative feelings.

Depression is the most difficult to confront at this point for as you will see I also wish to look at depression in a new light; but for the moment let us say that this state is the individuals unique gestalt built on the now recalled memories and feelings of guilt. Along with the feeling of guilt, many memories are recalled that rekindle feelings of anger, distress, disgust and shame as well as fear. We then add the real time stresses of medical care, family concerns and financial concerns. The compilation of all of this is what I will call depression. I wish, then, to define the stage of depression as: A highly individual state based on real time stressors that ellicit negative feelings added to any recalled memory that elicits negative feelings.

Going about my business (desire to live) ----------------> < -------------something gets in my way(knowledge of my death).

I

\I/

Leads to a “state of shock”.

I

\I/

Leads to “anger”.

I

\I/

Leads to “guilt”.

I

\I/

leads to A highly individual state being based on real time stressors that

elicit negative feelings added to any recalled memory that elicit negative

feelings.

5)      Acceptance = The end stage brought on by the calming of the fourth stage.

Dr. Ross: “If a patient has had enough time, and has been given some help in working through the previously described stages, he will reach a stage during which he is neither depressed nor angry about his “fate.” He will have been able to express his previous feelings, his envy for the living and the healthy, his anger at those who do not have to face their end so soon. He will have mourned the impending loss of so many meaningful people and places and he will contemplate his coming end with a certain degree of quiet expectation. ... He will also have a need to doze off to sleep often and in brief intervals, which is different from the need to sleep during the times of depression. this is not a sleep of avoidance or a period of rest to get relief from pain, discomfort, or itching. It is a gradually increasing need to extend the hours of sleep very similar to that of the newborn child but in reverse order. .... Acceptance should not be mistaken for a happy stage. It is almost void of feelings.(p112) It is important to note that one needs time to go through the stages and that “death waits for no man”. But if one does have the time and the right history I believe that this state will only take place if the patient has had enough good experience in their life so that the emotion of interest will override the compilation of negative feelings that has followed. Certainly people can get stuck in any of these stages so no matter how much time one has they may not come to acceptance. To do so we had to have a lifetime of preparation. So too must the attending physician and the family have had a lifetime of preparation to let go.

Going about my business (desire to live) ----------------> < -------------something gets in my way

(knowledge of my death).

I

\I/

Leads to a “state of shock”.

I

\I/

Leads to “anger”.

I

\I/

Leads to “guilt”.

I

\I/

Leads to a The highly individual state of being based on real time stressors

that elicit negative feelings added to any recalled memory that elicit

negative feelings.

I

\I/

Leads to “acceptance”.

Why do I make these changes? I make them on the basis of a theory called Affect Theory developed by Silvan S. Tomkins and added to by Dr. Donald Nathanson. What I wish to now do is give a brief overview of that theory. I will then reinterpret the five stages showing how my initial reinterpretation is simply one of many profiles a patient might have.[ You may skip this summary of the theory if you wish altogether and go to the end of the paper where it says END OF SUMMARY or simply come back to this later. I put it here for those that might feel a need for some "grounding" for what I have so far said to this point.]

A SUMMARY OF AFFECT THEORY

There are said to be 9 human affects, which may be translated into 9 emotions, which are biological:

Joy

Interest “positive” affects

--------------

Surprise “neutral” affect

---------------

Anger

Fear

Distress

Disgust “negative” affects

Dismell

Shame

++++++++

These AFFECTS are biological.

ALL experience is FILTERED through these 9 emotions. There are no other options.

No one has more and no one has less options.

++++++++

The affects can be expanded in terms of definition as such:

interest-excitement

enjoyment-joy

surprise-startle

anger- rage

fear-terror

distress-anguish

dissmell

disgust

shame-humiliation

++++++++

Biology

These “affects” are templates through which we interpret the world. More specifically we are biological organism. If one video tapes the facial expressions of the human, it is said, per this theory, that we only have these responses. We have no say in the matter they are a biological response to environmental stimuli.

In basic biology one studies stimulus - response patterns

Basic High School biology teaches us :

stimulus-------> response ---------> to this point we are at the mercy of the world. Then:

-----------> AWARENESS

Only when we become aware of the affect can we take action on it.

stimulus ---------> response -------------> awareness ------------- ACTION

This action can be any learned behavior.

This is a continuous process as nearly every waking moment we are experiencing some affect.

--------> stimulus ------> physiologic response (affect)------>

cognitive awareness of the feeling of the affect-------> action

Nearly every moment of time we are experiencing some affect: being affected by the environment, responding physically to it, processing the feeling and , acting on the feeling.

So what is the “change”? It is instead of simply “stimulus-reponse” it is stimulus- one or more of our affects(feelings)-and then and only then a response.

++++++++++++

Our wish is to “accentuate the positive and eliminate the negative”

Maximize positive affect or feeling

Negative affect is, however, very powerful.

We have no choice but to experience negative affect. So to be accurate we cannot eliminate it. We want to minimize and mutualize it.

What we are feeling is not “me”. “Me” or “I” become aware of the affect. The self can be thought of as “me” minus affect, but I can only experience the world through affect. In any Marshall art or meditation what we are after is a state of readiness to respond. It seems to me that these systems, then, intuitively understood the biology of emotion. We can never be at zero (although this is debated within those that explore the theory) in all emotions but we can become hyper-aware of our emotions.

We do not all experience emotion in the same way. For example, anger. If we put all the 9 affects on a scale of 0-10 it seems to me that some people have a higher setting than others. Some people who get angry will almost never go past a “3” while others never enter the affect at less then 9. Can we reset our basic settings?

++++++++++++

Stimulus ------ >>> Response

What determines our response?: Our history. What determines our action? :

Scripts.

If nine people see a rat, we might think, from a cultural point of view, that the “Affect” that we would feel would be fear but from the list of affects it is apparent that all nine people might have nine different reactions..yes including Joy. Scripts come form our memory of what we felt and did in similar situations in the past. We build a “library” of scripts that are needed so that we may function moment by moment in space and time. ONLY animals have a developed consciousness. As we move around we need the resource library (automatic responses) in order to deal with continually new responses. Libraries allow us to categorize all stimuli. As we will see sometimes this can be good and sometimes not so good. If our scripts where determined by “bad” experiences the scripted response may be generalized in unhealthy ways and new non-toxic stimuli may be interpreted as toxic and a negative ladened script put into play.

++++++++++++++

Scripts are our history, our way to walk around and respond instantaneously to the environment. Stimuli: WALL, WALL, WALL : Response: don’t walk into wall.  This is very basic but say I see a rat in my office, how will I respond?? Off hand we would probably say with startle or fear. But to repeat for emphasis, it should be obvious by now that if we had the right 9 people in the room we could have all nine emotional responses. Someone might be joyful to see a rat as once they where drowning in a cave as rat showed them the way out. A scientist might be interested.. and on and on. Since it is my office I might go through several emotions: startle, disgust and then shame. Then suppose my father beat the crap out of me every time I said “can I”.... what then would be your script at a later time???

++++++++++

We can now think of SHAME as a BIOLOGICAL response to stimuli (weather internal or external)

There can be appropriate and non- appropriate responses to shame. The non- appropriate ones are nicely summarized in the COMPASS OF SHAME:

WITHDRAWAL

I

I

I

I

I

ATTACK OTHER<------------------------------->ATTACK SELF

I

I

I

I

AVOIDANCE

The shame response can be INTERNAL or EXTERNAL, It is biological... It is before

awareness and action .

A study was done of babies in which a light was put to one side, it was colorful and went on an off. The babies where taught to turn their heads three times for the lights to go on. Then the light did not go on and the babies had a biological response of shame-: head down and to the side, eyes averted. That is the expected response would be for the head to simply go back to a neutral position or for them to keep looking at the light, but since they where interested in the colored lights and now knew, or thought they had control over them they experienced shame when that control (and interest) was interrupted. I experienced this acutely the other day when talking to someone that means a great deal to me and I had to tell him I could not tell him something due to confidentiality; My head very forcibly turned down and away and I had to consciously force myself to look at him again. It is not bad or good it just is.

Shame is neutral it is simply the interruption of your interest. How you handle it, what you think about it, what feelings follow it depend on what you have learned about the feeling as you have grown. And, of course many of our experiences with the feeling of shame have not been good and have resulted in us learning to handle the feeling with actions that can be described in the

COMPASS OF SHAME:

WITHDRAWAL

( FROM TURNING YOUR ATTENTION AWAY FROM A GROUP TO LEAVING TOWN)

I

I

I

I

I

ATTACK OTHER)<--------------------------------> ATTACK SELF

( MILD DISGUST TO MURDER I ( SELF DEGRADATION “I AM DUMB” , TO CUTTING, TO

SUICIDE)

I

I

I

AVOIDANCE (DRUGS, ALCOHOL, SEX, WORK)

Shame HURTS, we do not want to suffer it so we will do most anything to avoid it. We do not recognize it. Shame has never been described as the lynch-pin as it is here. If you accept it as central to affective life it explains in great detail most human behavior whether it be positive or negative.

++++++++++++

SHAME is only elicited when there is an impediment to sustained interest or joy.[END OF SUMMARY]

1)   Involved in a good conversation and the phone rings. 2) A toddler with his mother: He sees you, you say “hi” he goes behind his mother’s leg and peeks at you: sustained interest while receiving a negative stimuli: your strangeness 3) The guy you are doing business with is not responding. 4) Your partner behaves continually in ways you do not understand: You are giving them “bad” vibes or they are carrying bad scripts that don’t fit yours.

INTEREST ++++++ +++++POSITIVE STIMULI

III

III

III

III

III

III

\/

SUSTAINED INTEREST============= > SHAME

/\ I

NEGATIVE STIMULI

SHAME LEADS TO:

WITHDRAWAL

I

I

I

I

I

ATTACK OTHER <-------------------------------> ATTACK SELF

I

I

I

AVOIDANCE

What we want to do is, in a sense, take the “hit”. We want to realize that this “hurt” or “shame” is first a physical feeling that is giving us information and that avoiding the hurt by doing one of the four things the Compass of Shame offers but will only make things worse. We need to look to why it hurt us and remove the impediment so we can renew our interest or get back to joy.  SHAME is only elicited when there is an impediment to sustained interest or joy.

+++++++++++++++++++++++++++++++++

 
Full length videos at home page. This video is a short review of some of the material you just read.

So let us revisit my reworking of the five stages:

Going about my business (desire to live) ----------------> < ------------- something gets in my way

(knowledge of my death)

I

\I/

Leads to a “state of shock”.

I

\I/

Leads to “anger”.

I

\I/

Leads to “guilt”.

I

\I/

Leads to a The highly individual state of being based on real time stressors that ellicit negative feelings added to any recalled memory that elicit negative feelings

I

\I/

Leads to “acceptance” This sequence can be broken down now into two sequences one being the affective sequence and the second being what we individually do when we experience affect.

The affective sequence:

Ongoing interest (desire to live) ----------------> < ------------- Impediment to that interest (knowledge of my death)

I

\I/

leads to a state of ‘cognitive shock’ or Shame,

I

\I/

Leads to, for the most part, anger but other ‘negative’ (fear, distress,

disgust, dissmell, renewed shame) affects are certainly called into play and in

an infinite number of combinations and intensities,

I

\I/

Leads to “guilt” which then may elicit more negative affect. But guilt is by no means necessary as it is not an innate affect but a ‘scripted’ behavior.

I

\I/

Leads to a highly individual state of being based on real time stressors that

elicit negative feelings added to any recalled memory that elicit negative

feelings.

I

\I/

Leads to interest in internal life that leads to a calming of negative affect which permits me to be interested in the time I have left.

The scripted sequence:

Anytime I experience “shame” I then might follow that feeling with any other affect. We then DO SOMETHING. We withdraw, attach other, attack self or avoid.  In Dr. Ross’s experience the primary response was Denial- Isolation or withdrawal and avoidance.

The second stage of Anger is played out in general by Attacking Others but if one thinks a moment we might turn that anger on ourselves or continue to feel anger but stay in the state of Isolation and or Avoidance or Denial. I feel shock, become angry, and remove myself from others, increase my drinking or any number of combinations. The scripted response is then what I DO with this anger.

The third stage is of Guilt it is, again, a highly individual scripted stage.  One may or may not have guilt. If one does it will elicit more negative affect and a sustained feedback loop may be set up. Guilt engenders more shame, shame more anger, anger more shame or any number of responses. Each will be married to a scripted response in the world of withdrawal, attack other, attack self or avoidance.

The fourth stage of “Depression” then, is simply a continuation of the first three. If it is the same why is it expressed as a different stage? I think it is because the patient ‘acts’ definitely. Things become overwhelming. The internal storm is peaking and the initial actions (scripted behavior) by the patient to ward off the inevitable are not working.  The knowledge of the ineffectiveness of these actions actually brings on new shame and a new cycle of shame, negative affect, memory and guilt but now the options on how to act are limited. We have gone around the circle. We have withdrawn, we have attacked ourselves and others and we have avoided. There is only one thing left to do and that is to accept.  To accept in this situation takes on new meaning. Here we cannot remove the impediment so that our interests may continue. Surprise, anger, fear, disgust, dissmell and shame abandon us as useful informative tools. Interest, the ace in the hole, that has always pulled us out of the rut before abandons us. What then can we do? To me this is still a mystery. We are left with a self: As Ross says  “Acceptance should not be mistaken for a happy stage. It is almost void of feelings. “Throughout this exercise reason has been mute. Affect Theory shows us that emotion is king and will do what it will do unless we take special pains to understand it. It seems to me that those that die in peace have in some sense triumphed over emotion either by a belief in an after life that, after whatever negative affect they have suffered has subsided, will produce a calming of the brain that will produce a sense of joy or we have come to simply a reasoned end (although to use reason, we must couple it with the emotion of interest) using the uniquely human ability to dominate emotion at crucial times and ironically well expressed in this poem:

THE LAST DECISION

by Maya Angelou

The print is too small, distressing me.

Wavering black things on the page.

Wriggling polliwogs all about.

I know it’s my age.

”ll have to give up reading.

The food is too rich, revolting me.

I swallow it hot or force it down cold,

and wait all day as it sits in my throat.

Tired as I am, I know I’ve grown old.

I’ll have to give up eating.

My children’s concerns are tiring me.

They stand at my bed and move their lips,

and I cannot hear one single word.

I’d rather give up listening.

Life is too busy, wearying me.

Questions and answers and heavy thought.

I’ve subtracted and added and multiplied,

and all my figuring has come to naught.

Today I’ll give up living

No where are we saying that the scripted behavior that follows shame cannot lead to some positive outcome. Shame may lead me to scripted behavior that will in effect, allow me to disavow and deny in such a fashion that I do not accept the diagnosis or that it is fatal and I search for support in attacking the problem in “making sure” I am right. This may serendipitously prove me right. The occasion of the information might lead me to criticize my behavior in such a way that it will lead me to resolve some old problems. This is all well and good.  However insofar as the whole sequence started with an impediment to our interest in life causing shame it is thought that the real resolution lies in paying strict attention to the impediment, to renew ones interest as quickly as possible. This is the best of all possible worlds for if we look the diagnosis in the eye we may indeed get so interested that we will look for alternatives, we will go on a Priticken diet that no one suggested and or no one believed we could do and we end up extending our life. If we do this through avoidance we run the risk of only shaming ourselves again if we fail. If we confront our mortality directly we will prepare ourselves for failure at the same time as we look for solutions.

+++++++++++++++++++++++++++ ++++++++

Likewise the physician does well to shift interest to death instead of life. But this is almost more difficult for him. Is not this his job to sustain life? How does one know when to stop? If we do not communicate with the patient we are as stuck as they are. The Doctor of Mr. P. was stable enough to know that something was wrong and was lucky enough to have Dr. Kubler Ross at hand to help him understand his own shame response. If not he might well have killed the patient trying to save him.

A few years ago there was a large multi-hospital study called the Support study to determine if the actions of physicians and patients in regard to such things as DNR status and Advanced Directives could be influenced by a specific program of action. The end result was surprising to all in that it seemed to have changed nothing, just as Kubler Ross’s book seems to have changed little. It is my contention that this status quo will continue as long as we continue to trap ourselves in the, now, age old mind-body split.

Death and dying is not a medical procedure. It, like birth, that is often criticized as being too medicalized, is not a medical event. It is a community event. It is the failure of medicine and its triumph if only it can come to accept it. The title of Dr. Ross’s book is not “On Death and Dying In the Hospital Attended By A Physician”. It is on death. If we are to continue her work we need to see it as a community project. It must involve, schools, churches, doctors, and social workers. But to do that we must first confront the fear she so eloquently speaks of in the first chapter. If we do not we will continue to persist in a mind - body split that has its origins rooted in thought 2500 years old and will continue to produce patients and physicians that will live their lives in the avoidance poll, not a good place to start if we are to know death.