Exkarnieren Anhang 2
Vergleich: Siehe: Anhang + Anhang 3 (Interview mit Rosina Sonnenschmidt) + Anhang 4 (Paolo Bavastro/Aktive Sterbehilfe) + Tod Repertorium: (Mirilli) + Anhang 5 (Birgitt Bahlmann/)
+ Anhang
6 (‡ Floris Reitsma ‡/Boudewijn/Chabo) + Anhang 7 (Christian Schüle - aus
"Christ & Welt") + Anhang 8 (Elisabeth Kubler-Ross/Lia
Bello/‡ M.Girke ‡) + Anhang 9 Sterbebegleitung (Jakob Simmank) + Organspende (Rosina
Sonnanschmidt/‡ Hinrich
Baumgart ‡)
+ Psychopomp/https://hpathy.com/homeopathy-papers/death-final-frontier/
Angst vor dem Tode: Acon. Alum. ARS. Carc.
Cocc. Cupr-met. LAT-M. Plb-met. Puls. Rhus-t.
TARENT. Tarent-c. Verat.
[Johannes W. Schneider]
A new field of research developed in medicine and psychology during the
second half of this century is thanatology, the study of the dying process.
This concerns not the moment of death but a process that often takes a long
time. Previously, death was only seen in negative terms, as the extinction of
life. Now people are asking if there are characteristic stages which form a
distinct entity and which have to be understood not only in the light of
preceding life but also of impending death.
Phases in the process
Dr. Elisabeth Kubler-Ross's book On Death and Dying was a pioneering
effort in this direction. She found the dying process to be in five typical
stages.
1. the sick individual is for the first time, seriously considering that
death may be the outcome of his illness. The idea may still be suppressed, but
deep down the individual knows what is coming.
2. knowledge of approaching death can no longer be suppressed but keeps
coming to conscious awareness. The dying person then wants to prove to himself
and others that
he still exists. He tyrannizes family and nursing staff and refuses to
see visitors.
3. the individual realizes that he must die - but not yet. He begins to
negotiate with his physician, with God. Yes, he has not lived a good life until
now, but if he could only
be given a few more months he would make better use of them.
4. it becomes clear that death is approaching not just in general terms,
but now. This causes depression, and self-reproach until,
5. the sick individual fully accepts death. He grows peaceful and may
even be able to comfort those who must remain behind.
Evidently the five stages will not be equally well developed in every
case, and patients may even go back to an earlier stage if their condition
improves. The above progression is, however, typical, and experience shows it
to be so, with many variations.
Elisabeth Kubler-Ross made careful observations not only of the symptoms
of dying but of the dying individual himself. It is most fortunate that the
beginning of modern research into dying was marked not by cool, objective
interest in the subject but a caring attitude toward the human being. Concepts
developed in the human sciences are only in accord with reality if they come
from such a caring attitude.
Modern research into dying has another important precondition. To understand
dying, we must think in terms of processes. It is not enough to describe facts,
but we must see them as steps along a road. The scientist must follow the road
taken by the dying individual with understanding. It is a great help to the
dying individual if a caregiver understands the dying process. Then he does not
feel left on his own. The dying individual is not the object of pity but is
accompanied with insight and understanding.
Finally, there is a third precondition for the study of the dying process.
It is that the evolution has to be considered in light of its ultimate goal,
which is death. Death influences and shapes the final part of life. The
depression seen in the fourth stage of dying can thus be seen as a preparation
for the approaching separation. Coming closer
to the threshold of death the sick individual abandons his egotistical
attitude and gradually develops a new, sovereign view of the value of life. It
is part of the characteristic nature of human development that new capabilities
often appear first as their negative counter image. Values that have applied
until now are destroyed, making room for a
new stage in individual development. Just as the independent thinking
and insight which develops in our young years tends to present first as the
negative counter image of
a critical attitude to society, so the peace of dying first shows itself
as depressed feelings about the life lived so far. This depression can only be
understood if we know it will be followed by the stage when life coming to its
close is contemplated in peace.
Elisabeth Kubler-Ross distinguishes five stages in the dying process,
noting above all the changes in the dying individual's relation to the world
around him. If we consider the changes in conscious awareness, four stages may
be discerned in the process.
1st may be characteristic dreams as the individual approaches
the threshold of death. The dream images will rarely show openly what they
imply: a funeral, a coffin, a grave stone, or seeing one's own dead body. (It
may be noted in passing that images of death in dreams do not usually refer to
actual death but more often to the dreamer's state
of exhaustion or separation from someone near and dear.) A student
dreams he is walking through the local cemetery and looking at the beautiful
grave stones.
He is about to turn and leave when his eye catches a stone with his own
name; the date of birth is correctly stated, the date of death partly obscured
by some moss covering
the last digit for the year. Wanting to scrape off the moss, the dreamer
wakes up in a state of agitation but, in the process of waking up, has the
feeling that it is the current year. These are two of the themes that come in
genuine death dreams. The dreamer wants to escape before the essential theme of
the dream, his own grave stone, appears and yet feels drawn to this dream
content. He also wants to know the year of his death, but the dream stops, and
on waking up the student merely has a feeling that it is the current year. The
other typical feature of a genuine death dream is that it casts a veil over an
essential element which the dreamer would really like to know once he has
awakened.
It would be tremendously important to him to know the year and day of
his death.
3rd did not appear in this dream: knowledge of one's own
death brings peace and, sometimes, even happiness.
Generally speaking, however, the theme of death is hidden, presenting in
symbolic form. The 19th Century German dramatist, Friedrich Hebbel,
described a dream dreamt of
a friend, von Engelhofen, an official at the imperial court in Vienna.
He was walking through a landscape he had never seen before, finally coming to
a large river, the opposite bank of which was shrouded in mist. He offered
money to a ferryman to take him across but was refused. The dream returned for
eight more nights. The ninth night, however, the dreamer was allowed to enter
the boat and was taken across the river "swiftly as an arrow". There
he saw a palace, and his father (who had died earlier) standing in front
of it to welcome him. Mr. von Engelhofen knew his dream to have been a
true one when he awoke but interpreted it as predicting a diplomatic mission to
be undertaken that might earn him an decoration or promotion. We note that
wishful thinking came in, drowning out the subtle language of the dream. The
river is the image of the border between the realm of the living and the dead
not only in dreams but also in mythology. The dead father represented the world
beyond the threshold of death which awaited the dreamer. Symbolic dreams of
death almost always leave the individual free to interpret them in another way
and so may easily be misinterpreted.
When we are close to death, symbolic images appear not only in our
dreams but also in waking consciousness, interspersed with the images we gain
from sensory perception. The inner image will often fill the center of our
field of perception, with optical perceptions remaining in the margins. The
dying individual sees himself in a dark, damp cave. A crevice appears in the
rock, opening out onto a magnificent wide landscape in bright sunlight. The eye
is drawn to the rich green of the meadows. The dark cave is clearly one's own
sick body; the landscape outside is the world after death which seeks to draw
the dying individual to it. The fact that the eye is drawn to the landscape
indicates that an activity is already coming in from outside.
The same theme may appear in a completely different image. The dying
individual may feel himself to be sitting in a train that is rushing faster and
faster through a tunnel.
The light illumining the landscape outside is already visible on the
tunnel walls. The tunnel corresponds to the cave in the other dream, the light
to the green landscape, and
the accelerating speed of the train to the eye being drawn from outside.
For the dying individual, the inner image often has the same inner
reality as the optical perception. Together they are the reality in which he
lives. Thus a dying man might ask the niece sitting at his bedside: "Where
did you get on, and where are you going?" The niece, having no idea of
train or tunnel, sees this as the beginning of the mental confusion that is
often said to precede death. But the dying individual knows very well that his
niece arrived yesterday to nurse him and has asked neighbours to look after
her two children. He merely does not realize that the tunnel and the
train are inner images that others do not share. Thinking based on memory is
quite intact but grows uncertain when it comes to observation of natural laws.
The person fails to realize that a rock will not open up to reveal a landscape.
During this first stage of changing consciousness, thinking begins to
let go of its bonds with the physical world (which also happens in the
transition to dreaming) but does not abandon the logical sequence of life's
memories, whereas dreams may link different remembered elements in a quite
arbitrary way. The individual continues to identify with
his physical body, remaining in the cave, but a view opens up on
existence outside the physical body. The inner image is already more powerful
than the optical image, pushing it aside and taking up the center itself.
The individual is beginning to let go of the body; the endeavor to do so
is apparent in the behavior of a dying person. He'll kick the bedclothes aside
or want to leave the room, perhaps even by the window. Yet it is not really the
room he wants to leave but his body. He still experiences himself in his body
but this has become a burden. If the patient still has sufficient physical
energy, he has to be watched at this stage, for he distinguishes as little
between the soul leaving the body behind and getting out of bed as he does
between inner and outer image.
A second stage in the change of consciousness begins when the dying
individual no longer identifies with his body but sees it from outside. In a
car crash, the passenger is thrown out into the road where he lies motionless
and seemingly unconscious. He is looking at his own body from a point about two
meters above his neck. He knows himself to be severely injured but not dead. He
sees other cars stopping, people standing around him, and hears one of them
say: "He's dead." The "unconscious" person is afraid that
people will not consider his injuries but treat the body as a corpse. Incidents
such as this show how much unconscious or dying people take in of what happens
around them.
I know a physician who always tells an unconscious patient what he is
doing: "I am giving you an injection. I am taking your temperature.
.." This shows great wisdom in caring. Maybe those words do not reach the
unconscious mind, but they may equally well help the patient not to become
estranged from his body as he lies unconscious.
In any case, the physician is taking him seriously as a human being, and
this in itself is sufficient justification.
In the accident case just mentioned, the injured individual experiences
himself at a particular point in space that remains the same, close to his
body. The conscious mind has separated from the body, but the familiar,
point-centered concentration of the conscious mind continues. Separation
progresses when the feeling of being close to the body ceases and the dying
individual feels himself to be sitting in a plane, for instance, looking down
at his home town. Now the point in space is in motion, and attention is no
longer focused only on the body but on the whole life sphere. It is still
focused on a particular point on earth, however. This final limitation of the
conscious mind disappears when the dying individual feels himself to be
floating freely in cosmic space, now fully free of the burden of body and
earth. Now, the content of consciousness is no longer determined by the
physical body but by the buoyancy of the excarnating human being.
Growing beyond the confines of the body may also be experienced in
another form that is less buoyant. It is the experience of getting bigger. Even
an overtired person may feel the head growing larger than the skull. The familiar
experience of one's physical form is overlaid with perception of the life
organism, with the physical body no longer
able to keep it within its boundaries. Close to death the experience may
grow stronger and extend to the whole body.
There is another way of experiencing the body from outside that belongs
to the same stage. The dying person thinks he hears a cracking, crashing or
groaning sound, either from unknown far away places or, if it is localized,
usually from below. He will say the people in the flat below are hammering or
that a bed spring must have creaked. These sound images reflect him bumping
into his own body, touching it from outside. Optically, this may take the form
of a dark shadow suddenly cast on a beautiful landscape prospect. This image
also occurs in dreams, shortly before waking up.
In the two above stages, the dying person's conscious mind is still
directed to the world he is about to leave. In the third phase, the earthly
world has vanished, and he meets figures from another world. The simplest way
in which this may happen is that the individual feels called by name. It may be
the voice of his mother or some other familiar person, but it may also be a
chorus of voices. Nor does it have to be his name; it may be something like
"Come and join us". The experience may condense into the vision of
a loved person who has died; the eyes of that person make the strongest
impression with a seeking, asking look that draws the other to it.
A young child comes to be at home on earth on eye contact with its
mother. In the same way the dying individual finds his new home as he feels
someone is looking at him. This theme also comes in dreams when someone is
close to death. The individual is walking through a beautiful meadow where the
plants have eyes instead of flowers, big eyes that look at him unblinkingly,
hundreds of eyes. Or the individual is in a domed hall, the vault above him a
blue mosaic. The keystone is a huge eye looking down on
him. Or he is walking in a misty park and sees a rock in the distance;
as he comes closer this assumes the form of someone dear to him who has died
and now gives him
a penetrating look.
Close to the threshold of death the perception of being looked at also
occurs in waking consciousness. The 19th Century Swiss poet and
novelist, Gottfried Keller, said the night before his death that he saw two
knights in golden armor next to a cupboard in his room who looked at him
unwaveringly for a long time. The eyes do not merely rest
on the dying individual but enter deeply into him. They do not look but
see through the person and judge him. Not the way one person might look at
another and form a judgment, but in such a way that the look already is the
judgment. There is nothing alien about this judgment, however, and the dying
individual feels: if I were completely honest with myself, I would have to feel
the way those eyes do.
The strangest experience of this kind is the appearance of the
"Mongolian" who comes to the dying individual as a totally alien
figure, his features immobile, giving no indication of a particular age. This
unapproachable expression is in striking contrast to the look in the eyes which
is like the dying individual meeting himself, reflecting his
own judgment on himself. Keller's two golden knights showed, in an
almost mythical way, that they did not belong to the earth world - we don't
wear armor any more, and only heavenly beings wear garments of gold - but with
the "Mongolian" the supernatural character is almost hidden. The
strangeness and unapproachability show that on and beyond the threshold the
human being no longer sees himself the way he does in life. We are often quite
surprised to find out what others think of us. This might, of course,
be because they do not judge us rightly. We can evade this. But the
experience on the threshold of death is inexorable, with all self-justification
dying on our lips.
The human being comes to see: This is I.
People who are dead may also appear, and the dying person may have a
conversation with them; or figures of pure light appear, their glory drawing
the dying individual to them. Dying people often give a name to those figures
of light, calling them Christ or angels. Caution is indicated here, for they
often merely indicate that the dying person always imagined Christ or an angel
to look like the figure he now meets. The one thing that is certain is that
this is not one of the dead but a more-than-human spirit.
This will usually be all one is able to find out. If the dying
individual returns once more to a quiet reflective mood, he may get a feeling
for whether this figure of light came
to meet him as a very personal gesture related to his own inherent
nature, perhaps protectively enveloping him in light, which would suggest an
angelic encounter; or, if the gesture is more than personal, addressing his
human nature and he was simply being received as a human being in the throes of
death, which suggests one of the less frequent Christ encounters. We should not
always think immediately of the most sublime that may happen to man.
These encounters show characteristic differences in dying children
compared to older people. Even when long illness or advanced age has made the
individual's thoughts turn to death for some time, perception of the figure of light
comes as a surprise. The contrast to life on earth is clearly felt, and yet
this new experience is usually taken as a matter of fact, confirming something
the individual has always known deep down, even if it went against accepted
opinion. When an older person who is dying is finding his way into this world
of light, the eyes often show a delicate luster which is perceived by those
around him. The other world does not come as a surprise to dying children.
For them, it is like returning to a familiar home from a journey.
Knowledge of the spiritual reality does not come from the depths but is like
something not far away that is remembered and will provide immediate
orientation.
In the 4. stage of changing consciousness, the dying individual already
feels at home in the new world. Not only does he grow calm but he is able to
radiate peace and calm, and to comfort or bless those around him. It used to be
very important to people to reach a deathbed in time to receive the dying
person's blessing. Why is it that the power
of this is so rarely experienced today? Is this only due to the dying
person or perhaps also those who have to stay behind and do not dare face the
reality of death?
The individual gesture of dying
The four stages of changing consciousness were described as part of a
typical dying process, as were Elisabeth Kubler Ross's stages. Typical does not
mean that every individual has all the experiences. Some stages may be
particularly marked, others only hinted at or not even percephble. The time sequence
of the steps is typical.
Every human life shows the typical stages of development and also a
highly individual form of biography. This also holds true for dying. There is
an ancient saying that
we really only know someone if we know how he died. This individual note
cannot be described as a process, a sequence in time; it is a gesture revealing
the person's individual nature.
The gesture of dying may be wholly in accord with the gesture of the
biography or it may give new emphasis to something. Social individuals may die
in isolation.
Recluses may gather their friends around their deathbed, perhaps even
reconciling them. Some depart suddenly in the midst of an active life; others
gradually prepare themselves and their families for the parting. A man in his
late eighties, fit and always active, is working in his beloved garden when he
suddenly feels weak and sits down
for a moment, never to get up again. Death coming swiftly is not
bringing a new note to the biography in this case but is letting the person die
the way he lived, performing
the work he has been given.
Another, also in his late eighties, has never been seriously ill, except
for being wounded in the war. Having to depend on others was not a feature in
his biography.
He suffers a myocardial infarction and is taken to an intensive care
unit, where death is imminent a few days later. The machines have been turned
off, a "Do not disturb" sign hangs on the door, and the family is
quietly waiting for what has to come. Suddenly, the patient feels better, wants
to eat something, and has two more weeks during which
he experiences the dying of his body very consciously; previously
irritated at any medical intervention, he now shows great patience as he allows
himself to be nursed and treated. Something has been added to a life that had
run its full course, something he can take with him.
Not a ripe fruit, but a seed for future development.
Another aspect of the individual gesture of dying is the ordering of
one's affairs. Before a sudden and unexpected death, one makes arrangements to
make life secure for the family or for the dying person himself the sense of
which only shows itself later. A woman in an old people's home wanted to visit
a friend. She canceled her meals, said good-bye to everyone in the home, and
asked the caretaker to repair a lamp in her room while she was away. No one
noticed that no taxi arrived to collect her. When the caretaker had repaired
the lamp the next day and was about to leave the flat, he got a feeling that
something was not right in the bathroom. He opened the door and saw the dead
woman lying there. Here, we see quite clearly a woman unknowingly seeking
solitude to die unobtrusively - also making sure that she will be found.
A physician had an incurable disease for a long time. He continued his
medical practice in his flat, though with some effort, feeling responsible for
his patients. Shortly before his death, he went into his consulting room where
he sat quietly at his desk for some time; he then went to his wife and
children, looking at them long and hard before withdrawing to his waiting room
where he sat down in a chair and died. Saying goodbye to something that meant
much is a common element in the gesture of dying, especially the deep gaze, as
though to take it in once more, lest one forget.
Of course, people are not usually aware of this individual gesture of
dying, and we only perceive it in looking back. Characteristically, those who
are left behind will hardly note these images or forget them, only realizing
their significance when death has ensued. This applies particularly to acts
that are like symbols of making farewells, a few hours before his death, a man
who had had many appointments in his life and had to organize his time most carefully,
took off the watch he had so often looked at. A member of the family reached
out quickly to prevent it falling to the floor and put it on the table. When
the room was tidied after the man died, the watch was seen lying there.
Suddenly it became clear that the symbolic gesture intended to say: time has
come to an end - no more appointments.
Acts such as these, indicating a farewell to life, may sometimes be
observed quite a long time before death. For many years my father and I had
given lecture courses during the summer holidays.
I was only there for some of the time when my father was lecturing,
leaving early to go on holiday. Planning the program for the following year, my
father unexpectedly and for no apparent reason asked: "Will you be there
the whole time?" Taken aback, I felt for a moment that there was more
behind those words than appeared. I planned a shorter holiday but forgot those
words again.
The next year, my father had a stroke the day after his first lecture.
The 86-year-old, fit and active until then, went down rapidly and died within a
few months. It was only after he had his stroke that I remembered his earlier
words.
In the encounter with people who will soon be dying one often has
extraordinary premonitions of death. I remember visiting a friend. We said
good-bye at the door of his flat, and as I walked down the stairs I suddenly
asked myself: could this have been our last parting? I rejected the idea
immediately, for neither of us was old, and we were both fit. I did not think
of the situation again until the news of his sudden and unexpected death
reached me a few days later.
When the threshold of death is nearing people often feel the need to
speak of death and what comes after it. They will sometimes initiate the
subject themselves, perhaps in very general terms.
We always feel our way at first, to see if the other person is ready to
talk about the subject. We also know very well whom we can talk to and whom
not. We may feel we'd rather leave it to someone else, who may know better how
to handle it if we are thus approached, but we must not evade it for it is
addressed to us. Someone who is close to death is not usually looking for new
knowledge concerning death but for assurance concerning something he has
"known" for a long time. Of course, we really only know things from
direct experience. We shall only know death for what it is when it reaches out
for us. Then, however, it will no longer be a question of knowing about death,
but
of knowing its reality. The latest scientific discoveries will,
therefore, be of little use to a dying person, he does not need expert opinions
but what the person he has asked truly believes. We are addressed as human
beings here, not as people with special knowledge.
The question concerning death is often not put in words but asked with
the eyes. We enter the room of someone who is dying and become aware of an
expectant look. Will you also say: "You'll be all right", which is
what my physician, my colleague and my niece have said, or will you admit to something
you know, something I also know? Are you going to chat, to meet your own need,
or will you talk to me, the person I am now? Not only old people may look for
such openness, but children, too. Someone who has been touched by approaching
death no longer needs to be diverted, entertained, the daily routine; he is
asking about something that really matters.
People who have as yet no awareness of the approaching threshold, even
though close to death, usually also have no desire to talk about death. The thought
of what is to come is then not truth to set them free but an alien power that
may even destroy their last vital resources. It does not matter at all if that
person has said at some earlier time that he would want to know when the end
was coming, wanting to die in full conscious awareness. The thought of distant
death and the reality of approaching death are two very different things.
Letting go of life
A man of advanced age who had been expected to die any moment for two
weeks, was taking difficult breaths; it was as though he was already far away
from his body.
A member of the family sitting beside him and holding his hand addressed
him by name. The dying man was all there again at that moment, turning his eyes
to those he was leaving behind - eyes from which spoke profound knowledge of
the world after death - and he closed his eyes forever. Destiny is favoring
someone by enabling them to die like this. To lay the body aside in full
conscious awareness, inwardly accepting the end of life on earth and turning to
a new world.
A woman of advanced age who had already got in step with the world on
the other side of the threshold was able to say calmly and as a matter of fact,
as though to reaffirm the facts for herself: "Now I die." In her last
hour her thoughts went once more to what had been the essence of her life.
For many who die peacefully it is nevertheless important to hold the
hand of someone near to them. Often with quite unexpected strength. For the
moment the body slips away from the dying individual he feels himself to be
above an abyss that separates him from the world after death. At that moment
the clasp of a hand is a kind of substitute for living experience of one's own
body which had given experience of self until now. Holding the hand of a dying
person is often the last act of love we can perform for them. For those of us
who remain behind, it is a tangible experience of the reality of death.
People find it easier to let go of life if they feel it has been
fulfilled. It is, therefore, a help for the dying to be told once more what
they have meant to others. Fulsome phrases won't serve the purpose, but a
simple thank-you does. People often will not have achieved what they had
originally thought life should be. It is all the more important then to be
assured that much has been achieved that may not have been originally intended,
life simply demanding that it be done. Many a task has remained half done, and
it is a relief to know that others will take it on. This applies above all to a
dying mother who is concerned for her children's future. A single sentence
making things clear can mean
a great deal to her.
Those who are close to death will sometimes be afraid that people will
forget them. This is not as surprising as it may seem at first. For as the
physical body increasingly becomes less significant for experience of self,
memory content and, therefore, being remembered by others gains in importance.
The reassuring words, "We'll never forget you, gran", do not help
much when death is near.
Only experiences of reality will serve. Someone about to die knows
whether and how the family has so far remembered others who have gone before,
on the day of their death, at the grave or in daily conversation. This, we
hope, makes the dying individual feel sure that he, too, will be one of those
remembered. The "month of the dead" was
an old tradition; it came in the Fall in some countries and in Winter in
others. People believed or felt that the dead took part in the life of those
left behind during those weeks. Some would set a place at table for them, and
care would be taken to avoid noise, lest they be frightened. Thrashing of grain
and the big family wash day would have to wait until the dead had returned to
their own world. In the Swedish calendar, 12 January was called the "day
of the angels' departure" well into this century, the "angels"
being the dead who had visited their old abode from 13 December.
It is advisable to put down in writing at an early stage who should have
the few things with which one has a special inner connection such a piece of
jewelry, the handsome vase that was a wedding present, the family Bible, etc.
after one's death. Objects that are not really general goods and chattels but
like a piece of oneself can become something of a bridge when those who are
left behind and to whom they have been given pick them up. Knowledge of such
provisions can give a feeling of security when words no longer have much
effect. The dying individual likes to think of being remembered in very real terms.
A key element in letting go of the body is the question: has life been
fulfilled? We might say that every human being has the arc of his life span as
part of himself, and some are sensitively aware of this. Younger people in particular
will often have a sense for whether they are going to grow old or die young.
This deep-down knowledge may emerge clearly at special movements. The German
poet, Ernst Arndt, was asked by a friend if he had considered his age when he
started on a major project at age 86. Amdt told him of a dream he had had 20
years earlier. Walking through a cemetery he had seen his grave stone. It did
not give the date of death but clearly stated "at the age of 91." He
therefore said he had another 5 years to go, and this proved to be true.
You would think that someone dying at the age of 91 would have satisfied
his longing for life on earth to the full. That may be so. Quite a few people,
however, will say as death approaches: "Surely that can't be it. I had
imagined life to be something else." Or: "I have not really lived my
life." This does not mean they have not enjoyed life to the full. A life
may have been hard and yet the individual may feel it was his very own. People
may have lived only for others and yet, or perhaps exactly because of this,
feel their own life to have been truly fulfilled.
What about those who die young? Can a life be meaningful and fulfilled
if it ends in childhood or youth? Looking back, one will often find that such
individuals had a real hunger for experiences, as if they "knew" that
they had not much time on this earth. Sometimes a strange melancholy clouds
such children's experience of the world, or their remarkably active will
matures. I remember a pupil of mine who died a violent death before reaching
the age of 14. She had a mature, serious facial expression through which a
bright pleasure in life would also show again and again. After the long
holidays she always made one big effort and quickly caught up in any subject
where she was weak; this was done with a persistence one normally would expect
to see only in an adult who is really working on herself. We might say that, in
her case, biographic elements that normally come later in life appeared in
childhood. She lived life in condensed form.
When life has been fulfilled and death is part of destiny, is there any
justification in medical intervention - using all means at our disposal? Every
human being has the right to live and to shape his own life. Does he not also
have the right to die? This question often leads to demands that incurably sick
or extremely old people should be given the freedom to choose active assistance
with death, that is, an injection that will quickly and painlessly terminate
life. People who think like this fail to consider how easily seriously ill or
very old people's will to live is influenced by others around them. Many simply
no longer want to live because they feel they are a burden to others. If
justification should ever be found for the termination of unwanted life this
would open the floodgates, undermining respect for life altogether. It will
then be necessary for governments to establish "objective" standards
for the value of a life. We know this has happened before. It is a complete
illusion to think people who are in such borderline situations can freely
decide for life or death, quite apart from the question of whether we actually
have the right to decide. It would be brutal to make someone who is
discouraged, hopeless, isolated and despairing make the decision over life or
death. It would be a mockery of freedom and self-determination, not respect.
The lethal injection would deprive the person of the individual gesture of
dying; death would not be his own but something imposed by the will of the family,
physicians, or another.
A totally different question is whether life should be maintained at all
costs. A physician is obliged to do everything in his power for his patients,
including those terminally ill, and it is right to call him to account if he fails
to meet his obligations for the patient is the weaker one in this case, is at
his mercy, and has to be protected. The question is, what does
"everything" in his power mean? Knowing that he may be called to
account, the physician must secure himself. Because of this, means are
sometimes used which the physician really no longer considers appropriate, not
in the patient's interest, but to meet legal requirements. This is not
individual, and cannot be so, but takes account of general regulations in clinical
medicine. The doctor-patient relationship is, however, a personal one, or
should be. As a patient, I claim the right to chose my own physician and the
medical approach he uses. The more effective and real the relationship, the
greater the individual and therefore human nature of healing - and of dying.
The more sophisticated medical technology becomes, the more sensitive must we
be to the individual character of disease and of dying. Medicine clearly needs
reform in this respect, and this calls for initiative not only from physicians
but also from patients.
Is it intervention in destiny to extend life with an organ transplant?
Undoubtedly. This applies even to blood transfusions. It is also destiny to
live in the 20th Century when such aid is available. When people
such as Jehovah's Witnesses refuse a blood transfusion and prefer to face death
instead, this is a personal decision and physicians usually respect it. The
problem is that the decision
is made in advance, the person concerned (understandably) wanting to
make sure his wishes are met even when he is no longer able to decide for
himself. It is a decision
one does not like to leave to others because it is so very important.
Yet in the face of death the situation often looks very different and it may be
that a completely different decision is made (not only from fear). If there is
a possibility of being unable to decide at a later point, it is generally
advisable to ask someone one trusts - his physician or perhaps a member of the
family - to take the responsibility. It is far from easy to be involved in
deciding on the life or death of someone close to you, but it is one of the
responsibilities one has to accept.
What is the situation regarding resuscitation? It is justifiable to
fetch someone back across the threshold of death? Isn't it that a decision has
been made which the family
has to accept, however hard this may be? Looking at the life people have
had after resuscitation, one finds again and again that it held important
elements which one would not like to see missing from the biography, and that
these people really wanted to live, to work on themselves and on the world,
something only made possible by the difficult intervention by the physician.
An extreme example is the following. I knew a child who had been in a
coma for nine months after a road accident. The child had been clinically dead
and resuscitated ten times. When I was told this before seeing the child I
thought: surely this child wanted to die and has been prevented from doing so. Yet
the impression I gained from observing the child at play was different. The
child was still somewhat hesitant and, indeed, clumsy in its movements, but had
a marked will to be creative in its play. It was actively making itself part of
the world. Seeing this, I have become very cautious in saying that even
repeated clinical death is a definite statement on the part of the human
I that it wants to leave the earthly world.
Another child was taken to hospital after an accident. The physician
later said to the parents: "The injuries were severe but need not have
been fatal. The child did not give us time, however." These words, spoken
by a sensitive individual, show that the child wanted to depart and did not
want treatment. Considering the circumstances attending the accident, it is
remarkable that the mother, who always took such great care, was not on the
spot at just that moment but was as if tied to her housework, which created the
space for the accident to happen. Even during her pregnancy the mother had had
a strong feeling that this child would need special care and attention. Talking
to her, one felt she had had a premonition of the child's early death.
With children who have died, one often has the impression that they have
taken the world in deeply and intensely. Looking back one gets the feeling that
the purpose of this life had been to experience the world with great intensity.
Other children's fates cannot be understood at all unless one looks at their
environment. They may have been quiet, perhaps attracting no particular
attention, but achieved much with their short life and especially their death.
They transformed the people among whom they lived. Close observation may show
that these children remain close to their families, that they are waiting. If
their families do not drown themselves in pain but let the pain be a gate
opening up to deeper insight into the world, the dead children are happy, for
their waiting has not been in vain. Their life gains meaning after death.
Death may come early or late, suddenly or after long preparation, due to
illness or accident, but it may be that "the time has come". Looking
back on the last weeks or months of a life that ended unexpectedly you often
recall words or acts that clearly announced the coming departure, though this
was not understood at the time. One often finds that important affairs are put
in order or a relationship put to rights. Often a word is said, quite casually,
that will only later prove vital in understanding that individual's life.
The interesting thing is that such words and acts will effortlessly come
to mind after the individual's death and then appear highly significant. It
seems incredible that no note was taken of them at the time, for seen in
retrospect they are so obvious.
Clearly, death does not always come when a life span has reached
completion, and "the time has come." An early Christian prayer carved
over the gate to the city of Miletus addressed seven archangels, asking them to
protect the city and its inhabitants from an "untimely death" - not
death as such for that is part of human existence, and even angels cannot
change this. However, they may be able to avert a danger when life has not yet
run its course.
It is quite unthinkable that millions of people actually sought an early
and violent death in concentration camps or from starvation. As 20th
Century people we cannot reject our share of responsibility that easily. Those
terrible events show that human beings can powerfully intervene in destiny,
both their own and that of others. Human beings depend on one another today
across all borders. The individual is more and more becoming a member of the
human race, and this determines destiny in a way that goes beyond the intention
brought with us at birth.
People who feel their life has run its course often feel that others are
waiting for them beyond the threshold of death. They may speak frequently of
long-dead friends.
This is entirely natural in the old, for they often live more intensely
in their memories than in the here and now. Their memories are an important
affirmation of self for them when the capacities grow less. Relationships with
the living may become fewer, and those to the dead grow more important and
real.
Living one's memories may condense to a feeling that some of the dead
are expecting one. There is a popular tradition that someone who has recently
died draws someone
who has been close after him. Married people often follow each other
quickly. But the simpler and more obvious explanation for this is probably that
the one left behind has lost a major purpose in life and may, indeed, long for
death, and this loosens the bonds with life on earth. This is not what we are
speaking of, however. We are concerned with people who died long ago and come
back to mind again as the individual approaches the threshold of death.
When the dead actually "appear in person" to the inner eye,
how can we tell if these are memory pictures or a present encounter? Memory
pictures take us back into a familiar world, perhaps our childhood or youth.
Being thus familiar, they give security, self-affirmation and orientation in a
world that may have grown alien. Old people are, above all, happy in their
memories. Images reflecting a present encounter with the dead almost always
come as a surprise. The dead do not look the way one last knew them but have
changed, usually being younger and inwardly illumined. People who speak of such
experiences are often unable to say what clothes the dead person wore, even if
they have had him clearly before the inner eye for a long time. The question
is, what made them recognize him? This is the wrong question to ask, for in a
real encounter we do not recognize the dead by something (which is the case
with memories), but we know inwardly who it is. Similarly, we may wake still
hearing words we know for sure were spoken by someone dead, perhaps even
knowing exactly who it was, though actual sound was not involved. This
certainty is an unmistakable characteristic of present encounters with the
dead. Any doubts as to the reality of the event vanish in the face of that
certainty, just as there is no doubt as to the reality of the event when we
perceive someone clearly with the senses.
In earlier centuries, death was still experienced within a wider
context. In medieval times and the early part of our present age, believers
knew they had come from the hand
of God to enter into life on earth and would return to God on their
death. The term "blessed" was used as an attribute in some languages
to indicate that the individual continued to exist and was experiencing a
happier existence, unless he had committed grievous sins. It is understandable
that in recent centuries, when certainty of life after death had vanished,
people wanted to banish the image of death from their lives. This, however,
increased the feeling of death's alien and, indeed, sinister nature.
Death was made into a nothing, and so were the dead. They would, of
course, be remembered and honored; the question is why, since they no longer
existed? Probably because this enabled people to do justice to a deep, inner
knowledge of the reality of the world after death without getting into conflict
with materialistic ways of thinking.
Modern people are more aware again that birth and death are not absolute
boundaries to existence. Wanting to understand their true nature, to express in
thoughts what they know deep down in their hearts, they have to take account in
a new way of the reality of existence before birth and after death, not with
theories or creeds, but from experience. Attention and understanding must be
given not only to the dying individual but also to the dead. It is true,
however, that the further away they go in dying and death, the more subtle and
intimate their observation has to be if it is still to reach them. Fixed habits
of thinking must not impose themselves on observation, and the observer must
grow increasingly still. Active stillness is a faculty of the soul that allows
access to the intimate experiences we have spoken of in this chapter.
If birth and death are no longer absolute boundaries to existence, the
unborn and the dead become real to us. They are part of humanity just as much
as the living are.
The living shape the world and carry responsibility today. But those who
are waiting to enter into life have their eye on them. Raphael showed this in
his Sistine Madonna.
The clouds behind Mary condense into heads, into the unborn, whose eyes
follow the one who has now found his mother. In the same way the eyes of the
dead are on those who approach the gate of death. To think in truly human terms
we have to include all human beings, those who are visible and those not
visible to the eye.
ZEIT ONLINE
Gesundheit
Sterbebegleitung "Liebevolles Unterlassen fällt Ärzten schwer"
Ein Gespräch mit dem Arzt und Autor Gian Domenico Borasio über die richtige Begleitung Sterbender
DIE ZEIT: Ihr neues Sachbuch trägt den Titel Über das Sterben. Klingt nicht gerade nach einem Bestseller...
Borasio: Warten wir’s ab. Es ist als eine Hilfsschrift gedacht und behandelt Fragen, mit denen sich jeder irgendwann auseinandersetzen muss. Zum Beispiel Familien, die
einen sterbenden Angehörigen begleiten, das sind immerhin zu jedem gegebenen Zeitpunkt weit über eine Million Familien hierzulande. Ich verbinde besonders eine Hoffnung mit diesem Buch: nämlich die bei uns in Deutschland weitverbreitete Angst vor dem Lebensende ein paar Millimeter herunterzubringen.
ZEIT: Wie stellen Sie sich das vor? Die Angst vor dem Sterben ist doch etwas vollkommen Kreatürliches.
Borasio: Selbstverständlich. Hinzu kommt aber vor allem die Angst davor, ausgeliefert zu sein, und vor qualvollen Symptomen in der Sterbephase. Das Buch versucht, diese Ängste durch Informationen und praktische Tipps zu reduzieren.
ZEIT: Was sind Ihrer Meinung nach denn die schlimmsten Fehler in der Behandlung Sterbender?
Borasio: Ein einfaches Beispiel ist, dass Sterbenden reflexhaft Flüssigkeit und Sauerstoff gegeben werden, um zu verhindern, dass sie »verdursten und ersticken«, wie es heißt. Falsch! Dabei wird genau das Gegenteil erreicht. Stellen Sie sich einen Augenblick lang einen im Bett liegenden Sterbenden vor, der nicht mehr kommunizieren kann. Wie liegt er da?
ZEIT: Wahrscheinlich steht sein Mund offen.
Borasio: Genau. Und der Sauerstoff, über eine Nasenbrille verabreicht, geht aus dem Mund wieder heraus. Das trocknet die Mundschleimhäute aus und verursacht Durstgefühl. Das lässt sich aber zum Beispiel mit konsequenter Mundpflege oder auch kleinen Eiswürfeln gut beheben. Die künstlich zugeführte Flüssigkeit hingegen kann in der Sterbephase nicht ausgeschieden werden, weil die Nieren ihre Funktion einschränken. Dann lagert sich die Flüssigkeit in der Lunge ein und verursacht Atemnot.
ZEIT: Weshalb wird die Atemnot so gefürchtet?
Borasio: Es ist dasjenige Symptom, das schwerste existenzielle Ängste auslöst, und diese Angst verstärkt noch die Atemnot, wodurch sich wiederum die Angst vergrößert – ein Teufelskreis. Das wirksamste Medikament dagegen ist das Morphin. Davor haben aber Ärzte Angst, wegen der atemdämpfenden Wirkung von Morphin, obwohl wir seit 1993 wissen, dass Morphin das beste und sicherste Medikament bei Atemnot ist. Angesichts der vorhandenen Daten stellt die Nichtbehandlung einer terminalen Atemnot mit Morphin eindeutig einen Kunstfehler dar.
ZEIT: Abgesehen von Atemnot haben die meisten von uns aber wohl die größte Angst vor Schmerzen.
Borasio: Schmerz macht etwa nur 1/3 der physischen Symptome am Lebensende aus, und sie sind in der Regel beherrschbar. Die Symptomkontrolle in der modernen Palliativmedizin ist inzwischen so weit ausgereift, dass die Menschen keine Angst mehr haben müssen, aufgrund von nicht therapierbaren Symptomen qualvoll zu sterben. Die Sorge, dass die Gabe von Morphin oder verwandten Medikamenten bei Schwerstkranken Sucht auslösen oder den Tod beschleunigen könnte, ist längst von der Wissenschaft widerlegt.
ZEIT: Haben Ärzte verlernt, hochbetagte Menschen auf natürliche Weise sterben zu lassen, wie es früher doch offenbar die Regel war?
Borasio: In den vergangenen Jahrzehnten wurden Ärzte zunehmend in einer Weise sozialisiert, die es ihnen schwer macht, das durchzuführen, was ich das liebevolle Unterlassen am Lebensende nenne. Dazu gehört manchmal auch Mut, dazu müssen innere Schranken überwunden werden. Denn wenn der Arzt handeln kann, fühlt er sich wohler, er tut ja etwas. Inzwischen regen sich allerdings zunehmend Zweifel, ob das alles so richtig ist. Denn beim Sterben ist es wie bei der Geburt: In den meisten Fällen läuft es am besten ab, wenn es nicht von außen gestört wird.
ZEIT: Sicher haben Ärzte immer wieder auch die Sorge vor rechtlichen Konsequenzen, wenn sie nicht handeln.
Borasio: Maßnahmen, die für den Patienten in seiner aktuellen Situation wirkungslos oder sogar schädlich wären, wie die oben erwähnten, dürfen vom Arzt nicht angeordnet werden. Das ist keine passive Sterbehilfe, sondern nur gute Medizin. Der Bundesgerichtshof hat 2010 im Fall Putz im Übrigen eindeutig festgestellt, dass das Unterlassen oder Beenden einer begonnenen Behandlung gerechtfertigt ist, wenn dies dem Patientenwillen entspricht.
Pallativmedizin ist mehr als Schmerztherapie
ZEIT: Haben viele Ärzte womöglich selbst Angst vor dem Sterben?
Borasio: Natürlich, auch wenn das vielfach unbewusste Ängste sind. Ein guter Arzt muss sich mit der eigenen Endlichkeit auseinandergesetzt haben. Dazu haben wir ein Seminar »Leben im Angesicht des Todes« angeboten: Studenten sind zu Sterbenden nach Hause gegangen, nur mit der Aufgabe, diese Situation auf sich wirken zu lassen.
Ein Student schrieb uns danach: »Das war zweifellos die sinnvollste Erfahrung in meinem Studium«.
ZEIT: Inzwischen gehört die Palliativmedizin als Pflichtfach zum Medizinstudium. Aber sie hat dennoch häufig das Image der Händchenhalter oder einfach der Schmerzlinderer.
Borasio: Palliativmedizin mit Schmerztherapie gleichzusetzen greift viel zu kurz. Die Schmerzbehandlung stellt nur 16% der Palliativbetreuung dar. Es geht vielmehr darum, wie die Palliativ-Pionierin Cicely Saunders gesagt hat, im umfassenden Sinn einen Raum zu schaffen, um jedem Menschen die Möglichkeit zu geben, seinen eigenen Tod zu sterben. Dazu versuchen wir, Hindernisse zu beseitigen, seien sie physischer, psychosozialer oder spiritueller Natur, und Ressourcen zu aktivieren. Palliativmedizin ist eine Fachdisziplin mit wissenschaftlich gesichertem Know-how und liefert hochprofessionelle Leistungen. Allerdings sollten wir uns zurückhalten mit der Vorstellung vom »guten Tod«, die wir Patienten vorgeben. Das wäre eine Selbstüberhöhung der Therapeuten.
ZEIT: Die meisten Menschen wünschen sich, zu Hause in ihrer vertrauten Umgebung für immer die Augen zu schließen. Das gelingt aber nur etwa jedem Vierten. Kann die Palliativmedizin dazu beitragen, dass es mehr werden?
Borasio: Ja, das kann sie sogar sehr gut – wobei aber die Frage, wo ein Mensch stirbt, nicht im Vordergrund steht. Wichtig ist, wo und wie die Menschen leben, bevor sie sterben. Es ist nicht besonders schwierig, die letzten 24 Stunden im Leben eines Menschen friedlich und würdig zu gestalten. Schwierig und aufwendig ist, die letzten 24 Monate eines Lebens lebenswert und beschwerdefrei zu gestalten. Das ist der Maßstab, und damit ist klar, dass es um alle Ärzte geht, alle Pflegenden, alle im Gesundheitswesen Tätigen.
ZEIT: Lässt sich dieser Zeitpunkt denn genau bestimmen?
Borasio: Man kann es jedenfalls besser, als es heute häufig geschieht. Ein Beispiel: Parkinson-Patienten, die Schluckbeschwerden bekommen, haben eine Lebenserwartung von 2 Jahren. Damit sind sie ohne Zweifel Palliativpatienten! Hilfreich ist auch die sogenannte Überraschungsfrage. Man fragt dabei die Ärzte nicht: Wie lange wird dieser Patient noch leben?, sondern: Wären Sie überrascht, wenn dieser Patient innerhalb der nächsten zwei Jahre verstirbt? Das ergibt realitätsnahe Zahlen, die sich hinterher als richtig erweisen.
Wir müssen einfach mehr
Forschung betreiben, was die Prognostik betrifft, denn wie viel Zeit ihnen noch bleibt, das wollen die meisten Patienten eben wissen.
ZEIT: Inzwischen gibt es ja einen Anspruch auf Hilfe durch die Spezialisierte Ambulante Palliativversorgung, die SAPV. Gibt es Ihrer Meinung nach genug dieser Beratungsteams?
Borasio: Noch nicht. Es gibt einerseits einen Anspruch auf diese Versorgung, andererseits aber mauern die Krankenkassen und stellen Teams vor überhöhte Anforderungen, was die
Dokumentation der Fälle betrifft. Palliativteams, die gute Arbeit leisten, fühlen sich dadurch geknebelt und haben weniger Zeit für den Patienten und seine Angehörigen.
ZEIT: Werden Patientenverfügungen seit der gesetzlichen Änderung 2009 besser beachtet?
Borasio: Ja, das Gesetz hat für mehr Rechtssicherheit gesorgt. Inzwischen wird allgemein anerkannt, dass man an einer Patientenverfügung nicht vorbeikommt.
ZEIT: Sie raten, ein Hausarzt solle die Patientenverfügung mitunterschreiben. Das ist meist nicht der Fall. Warum ist das wichtig?
Borasio: Weil es beweist, dass ein Dialog zwischen Hausarzt und Patient stattgefunden hat. Außerdem wird durch die Unterschrift des Arztes bestätigt, dass der Patient einwilligungsfähig war, und damit sind letzte Zweifel an der Wirksamkeit der Patientenverfügung beseitigt.
ZEIT: Professor Borasio, Ihr Fach hat ja häufig noch die Aura der »Todesengel«. Was haben Sie dem entgegenzuhalten?
Borasio: Palliativmedizin schafft Raum für die individuelle Entwicklung am Lebensende. Wie überraschend das wirken kann, hat eben eine bahnbrechende Studie belegt, die 2010 im New England Journal of Medicine erschien. Verglichen wurden zwei Gruppen von Patienten mit fortgeschrittenem Lungenkrebs. Die erste bekam die übliche Therapie – Chemotherapie, Bestrahlung und so weiter. Bei der zweiten Gruppe wurde frühzeitig die Palliativmedizin in die Betreuung integriert. Das Ergebnis: Die Patienten der Gruppe mit Palliativbetreuung hatten eine bessere Lebensqualität, zeigten seltener depressive Symptome und bekamen weniger aggressive Therapien am Lebensende. Und nun die große Überraschung: Die Patienten der Palliativgruppe lebten nicht nur besser, sondern fast drei Monate länger als die in der Kontrollgruppe. Das würde in der Pharmabranche als wegweisender Therapieerfolg gelten. Dieses Ergebnis sollte allen Akteuren im Gesundheitswesen zu denken geben.
ZEIT ONLINE
Wissen
[Christoph Drösser]
Stimmt’s? Der Film des Lebens
Sehen Menschen unmittelbar vor ihrem Tod noch einmal ihr bisheriges Leben im Zeitraffer vorüberziehen? Klaus Schanne, Kirchheim
Was Menschen unmittelbar vor dem Tod erleben, darüber gibt es naturgemäß keine Berichte. Allerdings erzählt etwa ein Drittel der Menschen, die dem Tod sozusagen in letzter Minute von der Schippe gesprungen sind, von so genannten Nahtod-Erfahrungen. Und dabei gibt es einige Elemente, die immer wieder auftauchen: der Blick durch einen Tunnel, an dessen Ende ein helles Licht leuchtet; das Gefühl, den eigenen Körper zu verlassen und von außen zu betrachten; und eben auch der »Film des Lebens«, der im Zeitraffer vor dem inneren Auge abläuft.
In jüngster Zeit haben Forscher begonnen, solche Nahtod-Erlebnisse systematisch zu analysieren. Der Psychiater Michael Schröter-Kunhardt etwa hat 230 Fälle untersucht, darunter auch viele, in denen die Menschen einen »Lebensfilm« sahen – der übrigens mal vorwärts abläuft und mal rückwärts. Der Neurologe Detlef Linke glaubt sogar, die Quelle für die Erinnerungsflut gefunden zu haben:
Gewisse Rezeptoren im Hirn reagieren auf Sauerstoffmangel verstärkt und werfen das Retrokino an.
ZEIT ONLINE
[Christian Schüle]
Umgang mit dem Tod Der Tod kehrt ins Leben zurück
Lange haben wir den Tod verdrängt. Nun kehrt er ins Leben zurück. Ein Essay
Ein Wandel hat die Republik erfasst: Der Tod kehrt ins Leben zurück. Die Gesellschaft formuliert bisher ungewohnte Aussagen über Leid, Schmerz und Trauer und entwirft neue Bilder und Begriffe vom Leben und Sterben. Allgemeinverbindliche Regelungen gibt es nicht mehr, Weltanschauungen spielen dabei kaum noch eine Rolle. An diesem gewandelten Umgang mit dem Skandal der Sterblichkeit kann man ein verändertes Menschenbild ablesen: Der Mensch von heute lässt sich seinen Tod nicht mehr aus der Hand nehmen. Kulturhistorisch betrachtet, ist in Deutschland eine kleine Revolution im Gange.
Als äußeres Spiegelbild soziokultureller Veränderungen in der deutschen Gesellschaft kann auf ideale Weise der Hamburger Friedhof Ohlsdorf dienen. Er ist kein Friedhof im klassischen Sinn, kein christlich umflorter Gottesacker. Er ist ein Parkfriedhof, ein Naturpark mit Toten, der nun der Pluralisierung und Partikularisierung der Gesellschaft Rechnung trägt. Da gibt es einen Bereich für totgeborene Kinder, eine Rasenfläche für anonyme Beisetzungen, einen urwaldartigen Ruheforst mit Urnengräbern um Stieleichen, Rotbuchen und Waldkiefern. Da gibt es das erste Gemeinschaftsgrabfeld von Aids-Toten genauso wie den von einem privaten Verein betriebenen »Garten der Frauen« im Geiste der Frauenbewegung, in dem prominente und nicht prominente Damen ruhen und in dem Muße, Poesie und die Ästhetik des Arrangements das Gefühl einer postmortalen Heimat hervorrufen. Während Einzel- wie Familiengräber an Bedeutung verlieren und klassische Begräbnisse den immer beliebter werdenden Feuerbestattungen weichen, entstehen, wie der Hamburger Kulturwissenschaftler Norbert Fischer sie nennt, »gruppenspezifische Miniaturlandschaften«: Begräbnisanlagen jener sozialen Gemeinschaft, der sich der Tote zu Lebzeiten zugehörig fühlte. Das können Grabanlagen von HSV- oder Schalke-04-Anhängern sein, von Kirchengemeindemitgliedern und Kegelvereinen. Freundeskreise und Fans bestimmter Bands sind im Tode vereint wie vorher im Clubhaus oder in der Südkurve.
Familien sind zersplittert, Lebensformen diversifiziert, Angehörige sind oft weit voneinander entfernt, Singlehaushalte Normalität. Die Begräbniskultur ist daher auch nicht mehr das letzte Hochamt einer bürgerlichen Zivilisation mit verbindlichem Regelsatz. In ihr findet ein Leben in der Unverbindlichkeit von Projekten und im Patchwork widersprüchlicher Lebensstile seinen Ausdruck, wobei es durchaus dem Zufall geschuldet ist, in welchem sozialen Verbund jemand sich am Lebensende befindet. Mehr und mehr fungiert der Friedhof auch nur noch als funktionaler Bestattungsort. Trauer und Gedenken wandern entweder in den öffentlichen Raum, wo sich, wie im Falle des Todes von Lady Diana oder Robert Enke, Emotionen kollektiv entladen und spontan sozialromantische Gemeinschaften stiften. Oder sie werden konserviert in der immateriellen Ewigkeit des WWW-Gedächtnisses, wo man den Verstorbenen per »Digital-Memorial« auf virtuellen Friedhöfen kommerzieller Portale »Internet-Gedenkstätten« errichtet.
Marterl oder Memorials für Unfalltote an Straßen wachsen sich zu Erinnerungsorten aus. Die Kirche hat nicht mehr den Alleinvertretungsanspruch auf Tod und Trauer, Seelsorge ist nicht mehr das Kerngeschäft gestresster Priester. Die profane Gegenbewegung wider die Einsamkeit und die Atomisierung hat sozialromantische Züge und lautet: Zurück in die Natur, zur Zeremonie, zum Ritual. »Der Tod ist der letzte existenzielle Bereich, in dem es zu einer gesellschaftlichen Befreiung gekommen ist«, befindet der Kulturanthropologe Fischer in Analogie zur sexuellen Revolution post 1968. Er muss das wissen: Seit 25 Jahren forscht er über Begräbnis- und Trauerformen.
In mehreren Genres und Formensprachen ist Alter und Vergänglichkeit mittlerweile auch im Wahrnehmungsraum der Massenmedien angekommen – eine ganz neue Botschaft an die werberelevante Zielgruppe bis 49. Eine sich dem Imperativ des unbedingten Fortschritts ausliefernde Gesellschaft, die im Strudel des demografischen Defizits zugleich Gefahr läuft, ihre Reproduktion zu verpassen, beginnt allmählich, so scheint es, das Leben auch vom Tode her zu denken. In dieser Enttabuisierung steckt eine große Chance zur Veränderung. Denn wer mit dem Tod nicht umgehen kann, kann auch andere existenzielle Krisen nicht bewältigen.
Noch immer ist der Tod der blinde Fleck eines Lebens im Betriebssystem der allgemeinen Optimierung, noch immer bleibt er die größte narzisstische Kränkung des auf seine Autonomie pochenden Individuums. In keinem Rechtsgebiet ist eigenständig definiert, was genau der Tod ist. Die Wissenschaften sind sich uneinig, wann exakt der Mensch tot ist – nicht einmal Pathophysiologen vermögen festzuschreiben, was Sterben eigentlich ist. Nach Grundgesetz Artikel 2.2 hat jeder Mensch das Recht auf ein gutes Leben; das Recht auf einen guten Tod ist nirgendwo verbrieft. Jedes Nachdenken über einen solchen setzt deshalb bei einer zeitgemäßen Auslegung des Begriffs Menschenwürde und der intellektuellen Neubestimmung dessen an, was ein »würdevoller Tod« sei. Zwischen würdevollem Leben und würdevollem Sterben besteht freilich ein bedeutsamer Unterschied.
Wem früh im Leben der eigene Tod bewusst ist, geht mit Sterben bewusster um
Die Betonung der Würde im Diskurs über Sterben, Tod und Trauer deutet zweierlei an: dass der Wahn einer totalen Kontrolle über das Leben mittlerweile als Illusion überführt ist – und dass sich zunehmend mehr Menschen der Instrumentalisierung und Fremdbestimmung durch eine religiöse Weltanschauung, die moderne Medizin und staatliche Bürokratisierung entgegenstellen.
Im Rekurs auf den Kantschen Imperativ hat sich weitgehend eine Ethik ohne Gott durchgesetzt. Ihre Maxime: Begegne jedem Menschen so, wie man dir begegnen soll, wenn du in einer solchen Situation bist. Vor fünfzehn Jahren hätten viele dem Satz, Wachkomapatienten seien Lebende, nicht zugestimmt, bemerkt der Psychologische Psychotherapeut Michael Wunder, Leiter des Beratungszentrums der Evangelischen Stiftung Alsterdorf in Hamburg und Mitglied des Deutschen Ethikrats. Die Wahrnehmung habe sich stark verändert, es scheint sich Grundlegendes gewandelt zu haben: Der Respekt dem vergehenden und eingeschränkten Leben gegenüber sei gestiegen.
Die Palliativmediziner definieren Sterbenlassen als letzten Akt eines menschenwürdigen Lebens, Ethiker erklären Schmerzminderung zum Nukleus des Begriffs der Würde, Rechtsphilosophen denken über die Legitimation einer Beihilfe zum Suizid in Ausnahmesituationen nach. Die Grenzen zwischen passiver und indirekt aktiver Sterbehilfe verschieben sich in dem Maße, in dem das Wissen über Sedativa, Narkotika und Anxiolytika zunimmt, die Zahl stationärer Hospize in den Krankenhäusern wächst und ambulante Palliativmedizin es Todkranken ermöglicht, von der Familie umsorgt zu Hause zu sterben. Die Patientenautonomie, Ausweis des allgemeinen Persönlichkeitsrechts, wird als höchstes Gut der Selbstverfügung verstanden, das Ärzte zunehmend respektieren. »Man nimmt den Menschen in seinem Wunsch, zu sterben, heute sehr viel ernster, als man es noch vor ein paar Jahren getan hat«, bemerkt dazu der Münchner Strafrechtsprofessor Ulrich Schroth.
Nach wie vor degradiert die funktionale Zergliederung des Todes durch Professionalisierung den Menschen an und nach seinem Ende zu etwas Unbrauchbarem – der Tote als Ware, das Tote als Müll. Vor Kurzem noch, berichten Bestatter, Ärzte und Pfleger, seien Sterbende systematisch in Abstellkammern der Krankenhäuser geschoben worden, ohne Ruhe, ohne Beistand, ohne Reaktion auf Schmerzen und Ängste. Dem einsamen Tod in der Kälte folgte die Verfrachtung in den Keller, dann die kommerzielle Entsorgung im Bestattungswesen. Und wer den Tod des Angehörigen nicht finanzieren konnte oder wollte, setzte und setzt womöglich auf die »Tiefstpreisgarantie« des Discountbestatters »Sargdiscount«.
Seit zehn Jahren aber greifen alternative Formen von Tod, Abschied und Erinnerung Raum, und alle Trends zusammengenommen, lässt sich von einer neuen Ars Moriendi sprechen. Diese »Kunst des guten Sterbens« – im späten Mittelalter auf das Himmelreich gerichtet, heute aber völlig entchristlicht gedacht – wurde maßgeblich von der Aids-Selbsthilfe-, der Schwulen- und der Hospizbewegung seit Ende der neunziger Jahre beeinflusst und vorangetrieben. Aus diesem Geiste heraus ist 2007 auch das »Lotsenhaus« unter dem Dach der Landesarbeitsgemeinschaft Hospiz in Hamburg-Altona gegründet worden, ein Bestattungs- und Beratungshaus in einer ehemaligen Filiale der Dresdner Bank. Seine Räume stehen allen offen, vor allem will man nicht vorgeben, was würdevoll zu sein hat, sondern dem entsprechen, was der Einzelne als für sich würdevoll erkennt. Was kann daraus folgen? „Knockin’ on Heaven’s Door“ zur Totenfeier etwa, freie Trauerreden im Ruheforst, Trauerzüge zum Friedwald, Gesänge, Luftballons, Flusszeremonien, Seebestattung oder die Pressung der Asche zum Diamanten. Während im Raum Angehörige singen, lachen, weinen, Filme zeigen, Anekdoten erzählen und den Toten anfassen, fahren städtische Busse vorbei, verharren Passanten vor den Fenstern, beobachten vorbeikommende Kindergartenkinder den Toten und die Trauer unbefangen. Der Tod kehrt durch seine Sichtbarkeit ins Bewusstsein zurück. Die gezielte Transparenz neutralisiert Ängste und führt im besten Fall zur Normalität – wer einen Toten sieht, nimmt Anteil.
Das mag Vorhut, die Avantgarde einer Entwicklung sein, die sich nicht überall wird durchsetzen können. In jedem Fall aber ist der Begriff der Menschenwürde heute anders als noch vor zehn Jahren gefasst: In seinem Mittelpunkt stehen das konkrete Individuum und seine Emotionen. Der Zeitgenosse kreist nach wie vor um sich, aber in seiner Ichbezogenheit nimmt er auch sorgenden Einfluss auf
die Art und Weise seines Endes.
Ein solcher Wertewandel hin zu einer höheren Lebensqualität im Sterben ist vor allem das Resultat einer erhöhten Sensibilität gegenüber der Selbstbestimmung und der Autonomie des Einzelnen. Selbstbestimmung bezieht sich auf die Kompetenz einer Person, ihre Handlungen als eigener Akteur zu initiieren. Autonomie bezieht sich auf die grundsätzliche Zuschreibung des Menschen, als solcher selbstzweckhaft und niemals Mittel zum Zweck zu sein. »Würde heißt heute, im Sterben nicht instrumentalisiert zu werden«, meint der Bonner Philosophieprofessor Dieter Sturma, Direktor des Deutschen Referenzzentrums für Ethik in den Biowissenschaften. Er erklärt die Ideologisierung der letzten Fragen durch eine christliche Weltanschauung für weitgehend erledigt. Die Konstanten katholischer Vorschriften erodieren: Mit dem »ewigen Leben« lässt sich kaum noch jemand beruhigen, der Glaube an Wunder und Auferstehung weicht der Bejahung des alltäglichen Lebens, das Versprechen eines transzendenten Paradieses entfällt. Die Vorstellung des Menschen von der Ebenbildlichkeit Gottes hat sich definitiv verändert. »Was einem Patienten von kirchlicher Seite unter dem Stichwort Akzeptanz des Leidens zugemutet wurde«, resümiert Sturma seine Studien, »wollen wir heute zu Recht nicht mehr hören.«
Was folgt daraus? Womöglich die Erkenntnis, dass der Kampf gegen den Tod für jeden Menschen von vornherein verloren ist. Das klingt nach einer Banalität, ist es aber nicht. Sich früh im Leben den eigenen Tod bewusst zu machen könnte zu einem bewussten Umgang mit dem Sterben führen. Will heißen: Sich rechtzeitig in die eigene Endlichkeit einzuüben fördert die Einsicht, dass die Autonomie
am Ende doch begrenzt und die Abhängigkeit von anderen groß sein könnte.
Ist aus alldem zu schließen, dass dem Leben an sich heute ein anderer Wert beigemessen wird als vor zehn, fünfzehn Jahren? Eindeutig ja. So lässt sich das Ergebnis der gerade beendeten Arbeit des Heidelberger Marsilius-Kollegs zusammenfassen, eines interdisziplinären Forschungsprojektes innerhalb der Exzellenz-Initiative der dortigen Universität. Vertreter aus Palliativmedizin, Gerontologie, Germanistik, Geschichtswissenschaft und Recht befassten sich unter der Leitung des Medizinhistorikers und Mediziners Wolfgang Eckart und des Rechtsphilosophen und Medizinrechtlers Michael Anderheiden mit dem Thema »Menschenwürde am Lebensende«.
Die Medizin lässt sterben, wo sie Leben nur künstlich verlängert.
»Zum ersten Mal wird jetzt in Deutschland das Sterben als eine Phase des Lebens wahrgenommen«, sagt Anderheiden und verweist auf mögliche Ursachen für die bislang organisierte Verdrängung des Todes: Zum einen habe Deutschland während der NS-Zeit zu viele Tote erlebt, zum anderen sei die 68er-Bewegung eine der Lebensbejahung gewesen. Hedonismus und Frohsinn der achtziger sowie Schönheits- und Jugendkult der neunziger Jahre hätten den Tod aus kulturellen Gründen weiter tabuisiert. Der Paradigmenwechsel habe erst eingesetzt, als im Einzugsbereich der hoffähig werdenden Hospizbewegung die Selbstwahrnehmung einer immer älter werdenden Bevölkerung zum Wunsch nach größerer Selbstbestimmtheit führte.
Analog dazu wurde die Palliativmedizin stets wirkungsvoller. Sie ermöglicht heute ein nahezu schmerzfreies Sterben, parallel dazu brach die Zurückhaltung deutscher Ärzte peu à peu auf: Die Angst vor Verstößen gegen das restriktive deutsche Betäubungsmittelgesetz und damit die Furcht, jemanden versehentlich zum Sterben zu sedieren, scheint zu weichen. Vor allem im veränderten Selbstverständnis der Ärzte ist nach Auffassung der Kollegmitglieder ein kolossaler Wandel abzulesen. Die Mediziner, fasst Eckart zusammen, begriffen sich nicht mehr als Halbgötter in Weiß, die es als persönliche und berufliche Niederlage auffassen, wenn sie jemanden sterben lassen müssen. »Zu den ärztlichen Aufgaben gehört es genauso, Menschen beim Sterben zu begleiten und den Zeitpunkt zu erfassen, an dem
aus der kurativen eine palliative Therapie wird.« Es gehe nicht mehr darum, dass unbedingt geheilt, sondern dass mit einer Krankheit oder Behinderung gut gelebt werde. »Wir können heute besser sterben lassen, ohne zu töten.«
Die Medizin lässt los. Sie lässt sterben, wo sie Leben nur künstlich verlängert. Sie lindert Schmerzen tödlicher Erkrankungen, ohne das Leben aktiv zu verkürzen. Diese Hilfe zum Sterben als Grundgedanken einer zeitgemäßen Ars Moriendi zu begreifen hieße, menschenwürdiges Sterben als würdevolles Leben zu verstehen. Im Zentrum eines gewandelten Verständnisses der Menschenwürde am Lebensende stehen das Wohlergehen des Einzelnen und die normative Frage: Wie soll nicht gestorben werden? In die Tiefenschicht des Bewusstseins sickert beständig tiefer ein, dass zur Menschenwürde körperliche, psychische und auch soziale Aspekte gehören und dass beim Sterben eines Menschen Pfleger und Palliativmediziner mindestens so wichtig sind wie der verehrte Chefarzt.
Ein Recht auf einen guten Tod innerhalb der Kunst des guten Sterbens ist weder juristisch einklagbar noch moralisch verbindlich, aber es ist zu einem konventionellen Anspruch des Zeitgenossen an sich und seine Umgebung geworden. Womöglich ergibt sich so ein Bild vom Menschen, der nicht stark und effektiv zu sein hat. Der im Alter weder rüstig noch fidel sein muss, der weiß, wer ihm wodurch Atemnot und Todesangst lindern kann und darf, um die letzte Phase des Lebens als Leben wahrnehmen, wertschätzen und gestalten zu können. Heute lässt sich unbestreitbar sagen: Der Tod wird ins Leben zurückgeholt, nicht nur jetzt im November.
Vorwort/Suchen Zeichen/Abkürzungen Impressum