On the boundary: working with existential crisis in an acute hospital setting.
Abstract: The acute hospital setting can be psychologically demanding for medical professionals generally. Working within the medical model, with its focus primarily on the physical, and faced with the patient's fear and suffering, the clinician's self-defence can be to hold back from an empathic response, to concentrate upon attending to the patient's body rather than the mind. To empathise with the patient's suffering is often felt on some level by the clinician to be potentially self-destructive. The psychotherapist however, is, by definition, up close to the mind: that is the main focus. So how does one offer existential psychotherapy in an acute hospital setting with patients who are up against their own mortality, and their imminent death, and, moreover who may be in pain and suffering, without it having a destructive impact on the therapist? How does one face up to the physical process of dying--both others' deaths and one's own? This paper attempts to open up this question with reference to my own experience working within Palliative Care in the acute setting and with reference to the writings of Georges Bataille and the latter work of Heidegger.

Keywords

Existential psychotherapy, mortality, dying, death, Heidegger, Bataille, acute hospital, palliative care
Article Type: Report
Subject: Psychotherapy (Research)
Hospitals (Psychological aspects)
Hospitals (United Kingdom)
Existential psychology (Research)
Philosophy of mind (Research)
Author: Steel, Marion
Pub Date: 07/01/2010
Publication: Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616
Issue: Date: July, 2010 Source Volume: 21 Source Issue: 2
Topic: Event Code: 310 Science & research
Product: Product Code: 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 288874195
Full Text: Introduction

In his recent book, Into the Silent Land (2003), the neuropsychologist, Paul Broks describes the apprehension which the health professional commonly feels (but maybe does not often express) about getting too close to the patient's fears within the acute hospital setting: 'Anyone who has worked with patients on acute hospital wards,' he writes, 'will tell you that you cannot resonate with every tremor of feeling, and that sometimes there are visions of horror and raw fear that can only be observed obliquely. Perfect constant empathy in such circumstances would be suicidal,' he adds. (2003: 59)

Broks frames the dilemma for the clinician in the acute setting as real and deeply troubling--nothing less than a matter of self-preservation. Is full and constant empathy in such a setting perhaps more than any clinician can or should be expected to bear?

Clearly, this dilemma raises a particular challenge for the existential psychotherapist. The existential approach requires the therapist to seek to tune into the client's experience, and to resonate deeply with it, with the aim of helping the client to open out their understanding, and, often, to re-orientate themselves in a world that has in some way become distressing or confusing. To tune into and resonate with our patients' experience, all their pain and their fear, in the acute hospital setting, Brok indicates, risks going beyond the boundary of what is safe for the therapist.

I raise this question, not in order to proffer any systematic argument with a view to arriving at a conclusion but rather to provoke thought. With this aim in mind, I will offer you an account of some of my own experiences and subsequent reflections that have arisen out of my work, as a psychotherapist working existentially, within the setting of an acute hospital and then within that, palliative care, where patients are facing a short life expectancy, and if an inpatient, may be close to dying. How does anyone--be they the patient, relative or clinician--face death, and, moreover, the most painful deaths? In this context, I have found myself, as a therapist, both witnessing and experiencing myself a crisis of being. However, before I get to this--the heart of the matter--I am going to turn things around and offer you, first, some of the thinking that has, for me, arisen out of the experience and given me a frame to enable me to move up close towards death and with less apprehension. Over time, I feel that it has enabled me to attend more closely to both clients but also fellow-professionals, in this demanding context.

Death within Life: The Concealed within the Unconcealedness of Being

Existential philosophy draws our attention to how 'death in the widest sense, is a phenomenon of life' (Heidegger, 1962: 290). 'Death is not something that is simply added on at the end of our life,' Heidegger tells us in Being and Time, 'but alone of all the animals we live in the knowledge that we will die and in anticipation of it' (1962: 354).

Our mortality is a part of our being and yet, Heidegger points out, an evasive concealment in the face of death predominates in our current everyday life, where death is for the most part encountered as something that happens to others; it is not owned as part of our selves, as a possibility that is always present-at-hand, there before us. In this manner, Heidegger points out, there is a constant tranquilization about death (1962: 296).

If the reality of death is generally avoided, what about when death is not or cannot be evaded? What about when death does come to be 'present-at-hand', as for example, in the case of terminal illness and the physical process of dying itself, how do we then encounter that? How do we experience our mortality as we go through the physical process of dying at the end of our life?

The physicality of dying and of death is not very present in the existential literature, and yet in my experience, when death comes to be 'present at hand' and a threat, it is often around the physical process of dying that fear is most expressed : the dying as much or if not more than death itself as non-being. 'I'm not scared of death, I shan't exist so why should I be afraid,' one man said to me. 'But I don't want to die in pain.' 'I don't want to lose control,' a young woman with a terminal diagnosis said to me. 'I just don't know how I will be.' And 'I'm afraid of the dying bit, I don't want it to be slow and painful,' said another woman who had just told she had only months, maybe even weeks to live.

From my experience of working with patients close to death, and also their families, I want to shine a light upon how a fear of the physical process of dying may play a crucial part in the evasive concealment of death. I shall look at the crisis of being that can arise when faced with the unbounded body in the lead up to death. For this, I draw on the writings of Georges Bataille who, in my view, is unsurpassed in his articulation of how our horror at the physical process of dying and of death itself arises out of the realisation that, faced with the corporeality of our being in this way, we have no recourse to our intellect. The unbounded body, what Bataille terms 'the filth of physicality', perhaps exerts a particularly poignant crisis of being, for the human being defined as an 'animal rationale'.

Lastly, when we are faced with a crisis of our being in this way, where do we turn? Might a crisis of being possibly offer a way towards some realisation of Being?

If we follow Heidegger's turn in his later thought, it is only by giving oneself over to Being that one can touch upon what one's own being is. (In his Contributions to Philosophy (1999) Heidegger calls it Ereignis, which is accordingly translated in that work as 'enowning').

Through turning back to early Greek thinking and, most particularly, the thinking of Heraclitus and Parmenides, Heidegger came to understand the truth of Being, through ' aletheia'--the Greek word for truth--truth as 'unconcealedness', literally 'not concealing'. Translated in this way, the word thus carries the idea of actively taking something out of hiddenness. In considering the etymology of 'alethia', Heidegger extracts the 'concealedness' from within 'unconcealedness': For 'the proper essence of the word is that it lets being appear in their Being and preserves what appears, i.e the unconcealed, as such' (1992: 76).

'Beyond the modes of dissemblance and distortion, there prevails a concealment appearing in the essence of death,' Heidegger tells us, in his lectures on Parmenides, 'such concealment pervades beings as a whole, from first to last. Yet it bears on itself a mode of possible disclosure and unconcealedness of beings as such, one that in advance penetrates everything' (1992: 76).

In the acute hospital setting, and more specifically within it, in Palliative Care, death--both as future possibility and in actuality--is present. What is concealed and what is revealed there for us? And how can we, as existential psychotherapists, help our clients and ourselves withstand the crisis of being that such close proximity to death can evoke?

The Acute Hospital Setting and Palliative Care

A few years ago, I took up the post of Psychotherapist within the Dept of Palliative Medicine at Guy's and St Thomas's Hospitals.

Working within the NHS was not new to me, I had spent many years working within Primary Care, but I was to discover that I knew nothing of what it would be like to work within an acute hospital setting. My attraction to the job had been to the Palliative. Since a child, I had always been afraid of death (due to experiences that I explore, in relation to my work, in my forthcoming book, Do You Realize?). For now, I can only say that, naively, rather in the manner of someone who goes in for aversion therapy to shift a phobia, I think that my thinking then (although fantasy might be a better word) was that if I was to confront my worst fear in such a way, it might offer me the opportunity to, in some way, work it through, and to come to some kind of--if not conclusion--than a further understanding, or even an acceptance of death. Dimly, I was aware that, given my personal history, I was placing myself in a precarious position. And to further contextualise this, I should say that, at the time I took up the post I was going through much upheaval in my personal life, and considerable personal disorientation.

This is perhaps the point to say something about palliative care. That amongst all the fields of medicine, palliative medicine stands out in its interrelationship of body and mind. The physician has been trained to focus upon curing the ills of the body. Faced with a person who is close to death, the physician is confronted with their own limitations and those of science. Before them is a patient who cannot be cured. Before them is a person who is facing their own death as it approaches, who may be anxious and afraid, and confused, for as the body breaks down the mind can break down also.

When a person is dying and disintegrating before you, traditional medicine, with its emphasis on healing, with its emphasis on cure, is powerless and something else is called for.

Palliative care does not seek to cure. Usually, palliative care is administered when the disease is recognised to be incurable, it attempts to 'palliate: to allieviate the pain both in the body and the mind. The word 'palliative' comes from the Latin, 'pald which means cloak. The cloak can have an association of concealment, as in 'cloak and dagger'. You mask the pain. But I like to think of a cloak as also offering some kind of protection. You might place a cloak around someone's shoulders to protect them from the elements, as Shakespeare's Gloucester does to Lear in the eye of the storm.

You might place a cloak around someone's shoulders in order to offer protection from a world which has become inhospitable to them--a world where they no longer have a place.

They have no place in it because the world, that is to say our world, our Western society, largely turns its back on death. Death has been relegated to the fringes of our lives. Death and life have been separated out from each other. Death used to be located within the world of the everyday, most commonly, it took place in the home. In the last hundred years, death has become barricaded, and feared, just as madness was in the nineteenth century, when the 'mad' were shut away in asylums on the outskirts of towns, supposedly for the good of themselves and of others. Today, it is not madness, but death that our society attempts to shut away inside the walls of our hospitals, nursing homes, or hospices.

Particularly painful deaths.

And the acute hospital is the site for the most painful and difficult deaths.

Beyond the Boundary: The Unbounded Body

One day this living body will pullulate in my dead mouth

Georges Bataille (1993: 81)

Death is the boundary of life. Yet death itself respects no boundaries.

Working within palliative medicine in an acute hospital, you are faced with this.

The body is a boundary that we take largely for granted. As long as our bodies function as we expect them to, we are not always aware of them. We are often unaware of how we erect different boundaries though different clothes, different bodily practices. We do not even think about the level of privacy that we seek out for our bodily functions. At the most basic level, so long as we are healthy and able-bodied, we control any display of our body emissions. We urinate, defecate, bleed and vomit in private. Such things are largely hidden from others. (1)

The body of the seriously ill person, who is close to death, is often breaking out as it breaks down. The body bleeds and leaks; it can swell up, even burst.

The unboundaried body shocks us. Horrifies us. It has ceased to be private and is out of our control.

We are shipwrecked.

Writing about the decaying of the dead body, the writer and philosopher, Georges Bataille asserts that death does not just come down to the bitter annihilation of being. He refers to 'a shipwreck of the nauseous' (1993: 81)

Bataille writes of how for primitives, the dread of death is linked to the phase of decay. Whitened bones, which are often worshipped, have 'the look of death's solemn grandeur'. By contrast, the putrefaction of the body repulses. The aversion we feel towards the body's decay is akin to the other fetid and lukewarm substances where the eggs, germs and maggots gather, which turn our stomachs. Bataille suggests that the fermentation of life is the repulsive sign of our corporeality. We are reduced to the same level as the rest of nature.

It is a horror that repels us.

Bataille suggests that what horrifies us, in addition to the thought of annihilation, is the visible disintegration of what holds the highest value in our eyes (1993: 104)

We confront the visible disintegration of what holds the highest value for us when we witness somebody dying and their body is bleeding, and leaking, as both body and mind breaks down; we confront it too when we imagine ourselves dissolving into the living earth around us. For what holds the highest value for us, since it separates us from the animals, is our consciousness. And death appals by its very physicality.

'When you walked into her room, the smell was, just, so horrible,' a young woman told me. She had come to see me with panic attacks. She could not put out of her mind the images and the sensations that had accompanied the pain and fear she had witnessed her sister-in-law go through as she visited her in the last weeks of her life, as she died in hospital. Her sister in law had bowel cancer and had to have her bowel and her vagina removed. She had an open wound that went from front to back that would not heal and became repeatedly infected as her cancer advanced. The smell, as she lay dying, got stronger and stronger, a rotting stench that hit Tina every time she entered her sister in law's side room like an assault on her senses. 'It was in my nose, and my face and all over my body, my hair even ... and when I got home, I just had to get straight in the shower. It was, just, so horrible ... terrible,' she said, looking at me, the last word almost whispered, hanging in the air between us. And I understood, how for her, she was speaking what was almost unspeakable.

Death appals, Bataille suggests, because it is incomprehensible to us. In death and in dying we have no recourse to the intellect. The intellect fails us because it abstracts, it separates us, from what Bataille names as 'the concrete totality of the real' that is an end in itself, that is meaningful in itself and that doesn't have to answer to the demands of utility.

Following Nietzsche, Bataille challenges our reduction of ourselves to mere utility, to mere resource. Bataille draws our attention to how in a world dominated by utility every thing has to answer our question: 'What use is that?' (1993: 112). Yet, when we confront death itself, or life itself, there is no answer. In the face of death, or life, such a question cannot be posed.

For death is of no use.

So long as we see ourselves, our world, primarily in terms of utility, then we cannot face death, and our own death: that is our mortality as a part of our being. And so we lose touch with who we are. When we engage with the world almost solely in terms of its use for us, we lose touch with Being--that is what both us--our being--and what goes beyond us. Heidegger called this 'the oblivion of Being'.

How then might we find our way back towards Being? In What is Called Thinking? (1968) Heidegger tells us that 'we have to rip away the fog that conceals beings as such, 'whilst being concerned not to cover up the rift. 'Hegel once expressed the point as follows,' Heidegger recalls, 'Better a mended sock than a torn one--not so with self-consciousness." Sound common sense, bent on utility, sides with the "mended" sock. On the other hand, reflection on the sphere in which particular beings are revealed which is for modern philosophy the sphere of subjectivity--is on the side of the torn condition--the torn consciousness. Through the rift, torn consciousness is open to admit the Absolute' (1968: 89-90). Perhaps then, through the torn consciousness of a crisis of being, we become more open to Being.

One afternoon, not long after I joined the hospital, I went to see a man in a side room off one of the wards. Pausing at the threshold of the door, which was open, and looking in, I saw a man sitting on a bed. As I did so, the man looked up at me, then at my badge, and gestured to me to come in; as I introduced myself, it was clear that he was expecting me. As I sat down in a chair next to the bed, he told me that he was a man of few words, not used to talking much. He was wearing trousers, but bare-chested. I could see that one side of his chest was concave. The man had lung cancer and I knew that he had had one lung removed. Despite this, his chest appeared well toned, and it was tanned. There was a vigour about him, and whilst not young, he was not yet old. However, I noticed that he was sitting rather awkwardly on his bed. Awkwardly, because of the considerable pain, which he told me, he had been feeling for the last few weeks, most particularly on one side; this caused him to writhe a little, and to contort himself into what looked like uncomfortable positions, so I must excuse his shifting around, he requested from me, as he found it difficult to keep still.

I knew that he had been in the hospital longer than had been expected. This had been because of the high level of his pain. It had been difficult for the nurses to get on top of it. Sometimes it can happen this way. The palliative care nurses carry a huge body of knowledge, they are experts in pain relief, but not even they can conquer all pain. Occasionally, they don't get close. It is difficult for them to witness those few patients for whom they cannot provide the pain relief that they have been trained to administer, not to see the change that occurs when the right medication at last locates the pain and extinguishes it, to see the patient re-find their equilibrium, some peace of mind, even to be able to sleep.

The man, who I shall call Tom, began to tell me about his life before he got cancer. He described himself as an active man, he had never been seriously ill in his life. In his early adulthood, he had been in the Army. However, he had spent most of his life working for a large corporation. He had done well for himself, financially. He told me that he would leave his children, and his grandchildren, well provided for. He told me that his diagnosis had come as a shock. Particularly, coming on the heels of his wife's death a few years before, also of cancer. It had been hard, he said, watching her die. Watching her in pain. Wishing that he could take the pain away.

Tom told me that he didn't usually talk of such things. His philosophy was just to get on with life, and what it threw at you, although in the case of himself and his wife, it had seemed unfair. They had been unlucky, he said. Their lives had been caught short. The plans and dreams they had had, particularly for retirement, had not come to fruition.

He told me that he wanted to go home, he hoped for just a few more months to spend the summer in his garden. He wanted to go home and see his daffodils. There were always so many of them at this time of year.

I saw Tom a few times after that. Once, he sent me away, with a gesture, the pain was too severe to talk, but he asked me 'to pass by' another time.

The last time I saw him many weeks had passed since our first meeting. I had just returned from being away, and was told that he was dying, and that he had never made it home.

Everyone in the hospital, and his family too, were surprised that he had not died already in the last few days.

A nurse told me that the previous days he had suffered hallucinations and confusion, although it seemed to have passed and had possibly been opiod-induced, they had reduced the morphine, and the hallucinations seemed to have receded, although possibly the cancer had spread to his brain.

I went down on the ward, and knocked on his door which was closed. No one answered, so I opened the door a little, and I saw that Tom was lying on the bed which was now in the middle of the room and a woman was beside him--she was leaning over him. I took her to be his lady friend who he had mentioned. They had known each other for years, she lived nearby, her husband had died some years before his wife, of a heart attack. After his wife died, they had become close although he had felt that was difficult for his children and he had felt a need to be discrete about the relationship. Since he had got ill however, and been admitted to the hospital she had been much on the scene. I saw that the woman was washing his body with the greatest care. The woman did not see me. Congregated around the sides of the room were all his children. I withdrew and waited outside.

A few minutes later, they all came out and gestured for me to go in. Standing next to his bed, I was shocked by the dramatic change in his appearance from when I had seen him last. His whole body was now hugely swollen with lymphodoema. In the last days, he had suffered a stroke, and the left side of his face had collapsed. It was almost hard to recognise him at first. But then he looked me straight in the eye, and told me it was nice to see me, and I could see it was very much him. He told me that the pain was terrible, for six weeks now he had suffered so. He paused. 'I never could have believed it--such pain' he said. It was very difficult for him to talk. The effort of concentration to speak clearly and slowly each word clearly hurt him, his speech was distorted, and hard to decipher, his breathing was laboured. I stood up close and leaned down towards him, to catch his words, which were faint. He told me that it was his brother's birthday. He did not want to die on this day, he said. He did not want his brother to have to remember his death on that day for the rest of his life. He fixed his eyes upon me. 'I am just holding on' he said. 'If I can ... just. not die today.' he said. I acknowledged with him how death felt really close now, and the effort required bearing the pain, and the tremendous effort of this holding on. We talked a little about his brother, they were not close, he said in response to my asking, but they got along well enough 'and, well, he was always a good brother, he was just ... always there ...' he said. And he reiterated that he did not want to die yet. 'After, ' he paused, 'after this day, I ... will. go. I am nearly there ... now ... Just a few more hours.' Then his voice changed and became more distressed. 'Oh,' he said. 'I'm weeing.' His voice was almost plaintive, childlike. I did not know how to respond. 'Do you want me to get a nurse,' I said. 'No it will be alright, the bag ...' his voice tailed off, and he moved his hand back to his side away from the area where the bag was, under the sheet. I stood next to him suddenly feeling awkward--to my shame. He now had both urinary and faecal incontinence. His body now leaked continuously and had expanded too to accommodate the excess fluid to such a degree, I was feeling the change in him acutely, couldn't stop myself from recalling his fit and muscled body, only a matter of weeks before, yet almost as soon as the image came, it went, as I saw him wince from the pain, and my expression must have registered something, for then I felt that he was looking at me, looking at him, in pain: 'It never goes,' he said.' He did not say much after this. I stayed with him a couple more minutes, but I could see he was tired, that he had said to me what he had wanted. As I left, he gestured to me if I would get his family who were waiting outside the ward. As I nodded, and took my leave of him, he looked at me, and thanked me, he had to twist his head slightly to do so, then he asked me to pass by again some time.

But I did not see him again.

He died in the early hours of the next morning.

That evening when I went home, I went out into my garden. The day was still hot and I remember that the scent of the jasmine was strong, an intense heady scent. I breathed it in. I thought of him there in the hospital bed. And I thought of how he would never go home to his garden.

I found it hard to leave and go inside. I breathed in the heavy scent of the jasmine for a long time.

Beyond the Boundary: The Colours of Life

In the hospital grounds there is an eighteenth century chapel.

After I saw Tom for the last time, I left the ward, and went there.

As chance would have it, it was empty and silent. As soon as I entered, both the hospital and the outside world slipped away.

I sat in one of the pews halfway down the aisle.

I felt a sense of disintegration, like my self was slipping away. That and a terrible sensation like a feeling of falling. This sense of falling was familiar to me. From when I was a child. And a few months before, when I had experienced a crisis. A crisis in which I had experienced a falling away of myself and which had led to my visiting a psychiatrist and then being off work for a while. It was happening again now. And in my mind, the words appeared:

'No one can make it any better.'

The words surprised me. And I recognised them. These were the words that I had thought once before. I was seven years old, I had just been told that someone close to me had died and I had been inconsolable. I had never thought these words again until now and yet now they filled my mind and would not go away. At the same time I experienced the feeling, just as then, of a terrible emptiness, like a vast chasm just opening up, and up, emptiness and blackness, and the terrible sensation, like a kind of falling ... and I had the strongest impulse to lie down on the floor between the pews in the chapel. But I did not. I sat on one of the benches, for a long time, with my head in my hands, and wept. However, eventually, I looked up and straight before me.

It was the colours that caught my attention. The day had progressed and the angle of the sun had changed, it was now shining its light directly upon and through the stained glass windows.

First I saw red. It was an intense red.

Blood is red. The heart is red. The heart pulsates, then it stops.

My eyes moved from the red to the green. The green drew me in. I gazed into the green for a long time. The green of the coloured glass was deep. I sank into it.

The green was just green. It was just purely itself. It felt like I had never experienced the colour green before. It felt like I lost all sense of anything other than the greenness.

It was as if I gathered up all the bits of me, into the greenness.

The light shone through the green and illuminated it.

To me, it was a rapturous green.

A long time passed.

Eventually, I left. I did not return to the hospital, it was the end of the day in any case. I went to the station to take my train home.

Some time later, I read from Marsilio Ficino's Book of Life:

'I summon all of you to nourishing Venus--and while strolling through all this greenery, we might ask why the colour green is a sight that helps us more than any other colour, and why it delights us.'

Green is the colour of the grass, of the trees, of the leaves.

Standing as a child beneath the leaves of a giant tree in the midst of a storm as it crashed around us, I remember how the broad green leaves seemed to offer us some kind of protection...

Like a roof over our heads.

Green is the colour of the living world.

The colour of life.

An artist came to see me in the hospital who was struggling with his wife's new diagnosis: her cancer had spread, they had just been told her prognosis was likely to be less than a year. Our early sessions were full of death, his experiences of the war as a child, deaths he had experienced throughout his life: often both sudden and violent. He brought me some images of his paintings, all were in black and white.

Then one day many months after we first met, he came to our session, announcing that during the week, he had gone out and bought some red paint. It is scarlet, he tells me. To go alongside it, he had bought a vivid green. He had already begun the painting. White is still there: he told me. It is a pure white, almost transparent. And black, 'and all that means', he says, 'it is still there, but only around the fringes'.

He spoke then of how when he and his wife were first told of her diagnosis, and how far the disease had advanced, a terrible grief had swept over him. From that moment it had felt like his life was ending, along with hers. All he had seen was death and suffering.

But gradually, he says, he has begun to focus more on life: gradually, he has become aware that she is still living, she is not yet dying. With the passing of time, they are both more tranquil. Death is there, he says, but they are not in it, not yet. For now, it has receded more to the fringes, and he tells me how amazing it is to wake up to these mornings when the sunlight coming though the windows is so strong, so bright.

It is so amazing just to feel alive, he says.

Strange and paradoxical, how on the boundary of the abyss of death, suddenly it can be all the colours of life that leap out at you.

'Colour is alive, it alone can convey living things,' the painter, Cezanne once said. (2)

In 'The Origin of the Work of Art' Heidegger considers art as 'the becoming and happening of truth' (1971:69). Cezanne was a painter who Heidegger held in the highest regard. 'These days in Cezanne's homeland,' Heidegger is recorded to have said on one of his visits to Provence in the 1960s, 'are worth more than a whole library of philosophy books. If only one could think as directly as Cezanne painted.' (Young, 2002: 19)

A year after I joined the hospital, I went to an exhibition of Cezanne's paintings. Gazing at his major works, I saw a breathtaking unity of colour and light and form; however, it was the late watercolours that caught and held my attention. Cezanne painted them in the last years of his life.

Cezanne was above all, a painter of landscape. Yet, in these late paintings, the landscape appears to be retreating: it is barely there. The thinnest and faintest of black lines depict the sculptural forms of the trees as they sway and bend. There is still a dynamic movement at the heart of things: however, the thin dark lines now wave amidst a transparent white blankness which swirls around them, both circling and embracing. Looking closely, you can see that this blankness is the bare canvas. The trees in the watercolours are unfinished forms. These faint grey broken lines seem to merge into a light airy landscape that in turn merges in the sky ...

It is all lightness and air caressing a landscape.

Paradoxically, in these late watercolours, while the forms are incomplete and could be considered fragmented, the manifold hues fold together in their transparency and coalesce to give a sense of wholeness. And yet, through the gaze of light shimmering through the blankness, a feeling of absence: The Nothing within Being.

'We may think the essence of truth only if we tread upon the most extreme edges of being as a whole,' Heidegger states in his lectures on Parmenides (1992: 162). To me, looking at Cezanne's watercolours, it was as if Cezanne had caught the extreme edges of being on the canvas. And yet, gazing at what seemed to me, the edges of being, both something and nothing, I saw the strangest beauty.

On the Boundary: Opening up to Being

On the extreme edges of being, there is death. Death is both known and unknown. We know we will die. 'Only man dies,' Heidegger writes in his essay 'The Thing', 'the animal perishes. It has death neither ahead of itself nor behind it' (1971: 176). Death is always before us, in the fading glory of autumn, we know that winter will soon be upon us. Dead leaves, dead things all around us, they appear in the midst of life, among us. And yet, death, our death is beyond the boundary of our life and we cannot know what it is. Both our dying and our death is always unknown to us.

On the boundary of life and death, on the edges of Being, we can confront a crisis of our being, a crisis of our being as we know it to be, that is to say, our sense of our minds and our bodies in our everyday world. Yet, it is on this boundary, when we can touch upon owning death for ourselves, that, paradoxically, we perhaps have the possibility of becoming most fully ourselves, as we realise our own non-being within Being.

References

Bataille, G. (1993). The Accursed Share: An Essay on General Economy. Vol II The History of Eroticism & Vol III Sovereignty. Trans. Hurley, R. New York: Zone Books.

Broks, P. (2003). Into the Silent Land. London: Atlantic Books.

Heidegger, M. (1962). Being and Time. Trans. Macquarrie, J. & Robinson, E. Oxford: Basil Blackwell.

Heidegger, M. (1968). What is Called Thinking? Trans. Gray, J.G. London: Harper & Row.

Heidegger, M. (1971). Poetry, Language, Thought. Trans. Hofstadter, A. New York: Harper & Row.

Heidegger, M. (1975). Early Greek Thinking. Trans. Krell, D.F. and Capuzzi, F.A. San Francisco: Harper & Row.

Heidegger, M (1992). Parmenides. Trans. Schuwer, A. and Rojcewicz, R. Bloomington & Indianapolis: Indiana University Press.

Heidegger, M. (1999). Contributions to Philosophy (From Enowning). Trans. Emad, P. and Maly, K. Bloomington & Indianapolis: Indiana University Press.

Young, J. (2002). Heidegger's Later Philosophy. Cambridge: Cambridge University Press.

Notes

(1) In my analysis and use of the term 'the unbounded body' I am endebted to Julia Lawton, who in her book, The Dying Process: Patients' Experiences of Palliative Care (2000, London: Routledge), draws on the experiences of hospice patients and the bodily realities of dying in order to question the ideology central to the hospice movement, of the 'good death'. She argues that whilst the hospice movement has, through methods of pain control pioneered by Cicely Saunders, made a significant contribution to the alleviation of patients' suffering and distress, it has overlooked that the suffering the dying patient may endure is broader than the experience of pain, involving the loss of control through the breakdown of the body's boundaries and the humiliation of physical dependence, resulting in a consequent rupture of one's 'normal' (in the sense of the 'everyday') sense of self, and of one's relationships. This can lead to 'a state of psychic death', a 'psychic closing off' often referred to in end of life settings as 'turning one's face to the wall'. Lawton argues that an awareness of this kind of end of life suffering has to enter the debate about euthanasia.

(2) From Cezanne by Joachim Gasquet in Cezanne by Himself (1988), ed. Kendall, R. London: Macdonald Orbis.

Marion Steel runs a private practice and works within the Dept of Palliative Medicine at Guy's and St Thomas's Hospitals, seeing both patients and their families. She is also affiliated with the Early Phase Clinical Trials team there, working with patients who are not curative, and generally have a short prognosis. In addition, she provides consultation, teaching and supervision to other health professionals within the wider hospital setting. Her book, Do You Realize? A Story of Love and Grief and the Colours of Existence is published by O Books in September 2010.

Address: Palliative Care Department, Ground Floor, Borough Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT.

Email: marionsteel. ed@googlemail. com
Dying: Falling From the Skin to the Soul

   We die as if a ship were going down inside us,
   Like a drowning in the heart,
   Like falling endlessly from the skin to the soul.

Pablo Neruda
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