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Alan T. Bates, MD, PhD, FRCPC Addressing existential suffering Physicians can feel better equipped to deal with a dying patient’s emotional experience by considering some relevant contributions of existential philosophers and being aware of possible interventions, including manualized therapies. ABSTRACT: Existential distress is “ t feels as though I’m traveling fur­ not really understand what it means. often present in terminal illness and ther and further into a cave that’s It sounds like something we might may be associated with syndromes Igetting darker and narrower, and have studied at university if we had such as depression, anxiety, and de- there’s no way to go back.” not been so busy taking all the medi­ sire for hastened death. Physicians Patients with terminal illness ex­ cal school prerequisites. Fortunately, with expertise in managing physi- press existential suffering and spiri­ a physician does not need to be a cal pain may feel unequipped to tual distress in a number of different philosophy major to understand the address social, psychological, and ways. Hearing a patient say the words core concepts of existentialism and spiritual aspects of pain. Through a above, a physician may feel paralyzed use that understanding in the care of brief exploration of the foundations or poorly equipped to respond. What patients. of existentialism and existential psy- can you really say when a patient has Clearly, talking to patients about chotherapy, this article aims to de- a progressive terminal illness? There death is key to helping them cope with mystify existentialism and provide is no denying the illness, and no de­ anxiety about it. By taking something practical tips for addressing exis- nying the patient’s experience of it. as nebulous as death and discussing tential suffering, even in parents However, the feelings of dread, pow­ it in more concrete terms in regular and children with terminal illness. erlessness, and loss of control that a conversation, we can make death less Formalized interventions that as- physician may experience on hearing frightening and unpredictable for our sist patients with existential issues these words can be used to help the patients. And in that same spirit, by are recommended. Physicians are patient. Experiencing these emotions considering some relevant contribu­ encouraged to get support in ex- shows our capacity to understand or tions from a few existential philoso­ ploring domains that they may feel perceive some of what our suffering phers and thinkers, we can feel better are outside their scope of practice, patients are feeling. Though initially equipped to do this. such as spirituality, and encouraged difficult for us to experience, these to adjust boundaries in the doctor- feelings can become a guide to what a Kierkegaard patient relationship in palliative care patient needs help with. Søren Kierkegaard is widely regard­ settings. With the aid of a physician ed as the father of existential philoso­ who addresses existential suffering, Foundations of existentialism it is possible for patients to transi- and existential psychotherapy Dr Bates is a provincial practice leader for tion from feeling hopeless to feeling Existentialism is something we have psychiatry with the BC Cancer Agency and more alive than ever. usually heard of, but few of us know a clinical assistant professor in the Depart­ much about. And lots of us feel intim­ ment of Psychiatry at the University of Brit­ This article has been peer reviewed. idated by the term because we do ish Columbia. 268 BC MEDICAL JOURNAL VOL. 58 NO. 5, JUNE 2016 bcmj.org Addressing existential suffering phy.1 His work often focused on per­ Nietzsche sciousness”7 in order to discover what sonal choice and commitment, and Friedrich Nietzsche is intimately is really important in life, and patients how everyone lives as a “single indi­ associated with the concept of nihil­ sometimes describe this as a kind of vidual.”2 Kierkegaard also explored ism, which in turn is related to exis­ “silver lining” to being terminally ill. the emotions of people making sig­ tential nihilism—the idea that life has Unfortunately, this can also be expe­ nificant life decisions, and certainly no meaning or purpose. Patients at the rienced as a terrible realization that there can be often a number of these end of life may experience a kind of much of life was not spent on what the to make at the end of life in a modern existential nihilism and say that their patient now views as most important. medical system. existence has been meaningless or Martin Heidegger extended Kier­ that there is no longer any point in Frankl kegaard’s idea of living as a single in­ being alive. Nietzsche argued that our Viktor Frankl was an Austrian psy­ dividual to dying as a single individu­ primary driving force is not mean­ chiatrist who spent 3 years in Nazi al, proposing that death is an entirely ing or happiness, but rather the “will concentration camps. In contrast to personal experience that must be taken to power” or pursuit of high achieve­ Nietzsche’s “will to power,” Frankl on alone.3 Patients do sometimes ex­ ment and reaching the best possible maintained that “will to meaning” is perience a new and distressing sense position in life.5 If this is our primary the primary driving force of human of aloneness at the end of life, know­ driving force, it is understandable that behavior. His experiences in the con­ ing that nobody is going to share this patients who have had great success in centration camps are described in his specific experience with them. The their careers or other pursuits may feel book Man’s Search for Meaning,8 feeling of being the only one who can there is no longer any purpose to their which confirms his belief that mean­ make choices about how to live out fi­ existence once they are seriously ill. ing can be found in any situation, nal days can be overwhelming. Although it may be a manifesta­ even in great suffering. He theorized While some at the end of life take tion of depression or some other mod­ that finding meaning in difficult situ­ great comfort from their faith, oth­ ifiable condition, existential nihilism ations gives us the will to continue ers may find their unfortunate cir­ is a concept that great minds have living through the worst of circum­ cumstance cause them to question it. either supported or struggled with, stances. Frankl’s ideas are now being Kierkegaard theorized that there is no and one that is not easy to dismiss out applied in modern evidence­based faith without uncertainty or doubt.4 of hand. However, there are certainly psychiatric interventions for patients He described how faith is not required alternate views that may facilitate a with advanced cancer as meaning­ to believe in something tangible like patient’s leap of faith to a more com­ centred psychotherapy.9,10 a chair, but is necessary to believe fortable opinion. in something for which there is little Yalom or no evidence. In other words, faith Sartre Irvin Yalom has written extensively is required when there is significant Jean­Paul Sartre argued that “exis­ on existential psychotherapy,11 where uncertainty or doubt, and without tence precedes essence”6 and that it is psychiatric symptoms or inner con­ uncertainty or doubt there may be not until we have engaged with life flicts are viewed as the result of dif­ little role for faith. The concept of a and done things that we can look back ficulties in facing what he describes as “leap of faith” originates in Kierkeg­ and see our “essence” reflected in the four “givens” of human existence: aard’s writings, although he does not what we have done. At the end of life, mortality, meaninglessness, isolation, use this exact phrase. One can suggest patients may feel they are returning to and freedom. Existential psychother­ to a patient that fear centred on uncer­ mere existence. Sartre even suggested apy focuses on identifying which of tainty surrounding death is common that death results in us existing only these existential givens patients are and that the doubt they are feeling may to the outside world, leaving evidence struggling with and helping them to actually be an opportunity to strength­ of a uniquely individual experience respond in positive ways. Certainly, en their faith rather than to abandon it. of existence that is no longer pres­ acute appreciation of one’s mortality, While not directly related to Kierkeg­ ent. The thought of retreating from disconnection from meaning, feelings aard’s ideas, another potentially com­ essence to existence only to others of isolation, and uncomfortable free­ forting aspect of uncertainty is that it could certainly be a frightening one. dom in making difficult choices can means you have wiggle room or flex­ In contrast, Sartre also wrote about all play a significant role in existential ibility and that nothing is set in stone. needing to experience “death con­ suffering at the end of life. BC MEDICAL JOURNAL VOL. 58 NO. 5, JUNE 2016 bcmj.org 269 Addressing existential suffering What is existential of a frustrating day). It is also wrong patient’s spiritual beliefs are, and suffering? to imagine we can treat any of these questions based on the FICA spiritual If you are still not sure how to define spheres in isolation. Opiate medica­ history tool17,18 can help you do this existential suffering, you are not alone. tions for physical suffering, for ex­ (see the Table ). In a review of existential suffering ample, have significant psychological Although one could argue it is a in the palliative care setting, Boston effects.

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