Fear in Palliative Care

Fear has many faces. We encounter patients whose eyes are wide with fear and who are tense to the point of cramping. Fear can go hand in hand with a depressive mood and lead to discouragement. Many patients feel a loss of their “center”, others experience stressful shortness of breath. Finally, fear can lead to inner as well as outwardly perceptible agitation. The spectrum of fear-based reactions in palliative care patients ranges from the numbness of shocked fear and anxious difficulty in breathing, to anxiety accompanied by inner agitation and the urge to move. We find that fear experienced in the soul can be seen in relation to the threefold structure of the organism: the soul awakens in the highly tense consciousness of shocked fear in the neurosensory system, it experiences shortness of breath and also a threat to its “center” in the rhythmic system, and it feels anxious agitation to the point of motor agitation due to the dynamics of the motor-metabolic system.

Fig.: “The spirit fighter” of Ernst Barlach. © Ernst Barlach Stiftung Güstrow, photograph: André Hamann

Physical, mental and spiritual causes of anxiety and fear

Anxiety and fear can have different somatic causes . An underlying disease can predispose a patient to fear: in many ways, the inner reality of cancer is fear. Patients fearfully feel the physical threat, the “violence” of the disease, with its progressive course and stressful symptoms. But mental factors also contribute to the onset of fear. Here it is often the fear of losing familiar people, of being “separated” from one’s familiar environment. Finally, there are spiritual causes of fear. Patients are afraid of the future, which they picture in their thoughts or intuit inwardly. Anything that they do not understand or that they find incomprehensible can lead to fear: skeletal pain invokes anxious thoughts of metastases, even though a subsequent diagnosis may show it to be harmless. The often misinterpreted unknown induces fear which can also develop its own self-reinforcing momentum, while correct assessments tend to relieve anxiety. In addition, many patients report spiritual experiences associated with fear. They tell of unusual experiences of consciousness, out-of-body experiences or spiritual experiences that can arouse fear if they cannot make sense of them. Having to leave familiar surroundings that provide support, encouragement and help is often accompanied by anxiousness. A primal fear connected with being human arises when we “leave” the spiritual world and awaken in everyday consciousness. Conversely, this makes it understandable why a near-death experience can eliminate our fear of death.

Fear that develops at thresholds of consciousness

Fear arises at thresholds where people have to leave what is familiar to them and enter an area that is foreign, while feeling that this is a threat to their existence. Many patients experience fear before falling asleep—a moment when their ordinary consciousness is abandoned and their transition into the not yet consciously experienced spiritual world happens. Fear of losing oneself can arise as a threatening feeling. The same applies to the fear of death as the big brother of sleep. Apprehension and fear accompany the threshold to the spiritual world in this respect. In the Gospel Christmas story, an angel calls out to the shepherds, “Fear not”. This already indicates the need for healing: the essential basis for any multimodal treatment of fear is human support and help that must not be “infected” by the fear that sometimes spreads endemically through hospital wards and hospices.

The activity of the subtle members of the human being in fear

Fear leads to different symptoms in the physical body : wide open eyes, anxiety-etched facial expressions, tachypnea, possibly with hypocapnia and tachycardia, wet hands and cool extremities are physical expressions of feelings beset by anxiety.

At the level of the life organization, fear goes hand in hand with degenerative processes. Tense consciousness “consumes” up-building life processes. In this respect, it is necessary to treat more than the psychological aspect in fear therapy. The weakened life organization must also receive therapeutic support.

The sentient organization (soul organization) is the carrier of the emotional experience of fear. If the sentient organization is oriented towards tense wakefulness based on the neurosensory system, then the patient will have an alert, fearful experience of anxiety. If the sentient organization develops its dynamic from the motor-metabolic system, this will lead to agitated anxiety, often with an urge to move. In cases of shocked fear, the patient needs envelopment and warmth in order to release the one-sided tension often accompanied by centralized warmth and cool extremities. In cases of agitated anxiety, the soul organization must be directed back into the motor-metabolic system. Patients who are able to walk often report improvement through physical activity. External applications in the area of the lower legs and feet are equally effective and can contribute to calming and relieving the experience of anxiety. The activation of the soul organization is accompanied by catabolic metabolic processes (sympathiotonia). The soul organization must be led from one-sided activity oriented towards waking consciousness to the upbuilding activity that is characteristic of sleep. Medications such as Bryophyllum or Lavender applied externally have a psychologically calming and sleep-inducing effect and also strengthen the upbuilding nightly working of the subtle members of the human being.

Finally, fear refers to the “I” of the person, who feels that his existence is threatened and who may feel fear of death. Shocked fear often leads to inner numbness, while agitated fear overwhelms the activity of the “I” with mental dynamics, and existential fear and the fear of death focus on the sense of an immediate threat to the individuality. The “I”-organization can be strengthened by providing therapeutic support of the warmth organization. This can happen via external applications, therapeutic nursing measures (e.g., a five-star rhythmical embrocation) or medications that have a relationship to warmth (e.g., aurum). In addition, eurythmy therapy, music therapy, talk therapy and also pastoral care are of decisive therapeutic importance. Besides professional therapy, a patient suffering from anxiety needs a human companion—a supporter who can release him from the constriction and loneliness associated with fear.

Determining an individual therapy

Patients want quick help that relieves their anxiety. However, therapy only becomes effective and provides decisive help to the patient if his preferences and values are taken into account when determining his individual therapy. For example, is symptom control the aim, which should bring rapid relief, or is it to strengthen individual capacities for dealing with anxiety? Patients often do not wish to eliminate the symptom, rather they want to transform and overcome their fear and strengthen their own forces in order to be able to cope with it better.

Anxiety can be held in check by anxiolytic therapy. Various drugs and therapeutic methods are available for this (see also palliative cancer care guidelines or the S3 guidelines for palliative care in Germany). Anxiety can also be transformed: therapeutic touch (rhythmical massage therapy), external nursing applications, and medications (e.g., Bryophyllum ) can reduce and transform anxiety. Inner experiences and spiritual perspectives also have a fear-reducing effect. The disappearance of the fear of death after a near-death experience, and also just by knowing about near-death experiences, is a phenomenon often described. Looking at principles that follow the patient’s deeper questions and open up a spiritual perspective have a fear-relieving effect. Fear therefore needs a multimodal approach to therapy that includes the physical, mental and spiritual levels.

Case history

A 50-year-old female patient suffers from metastatic colorectal carcinoma. She stands out because of her great inner strength and positive attitude and she feels no fear. What powers are available to her in dealing with the illness and any accompanying fears and how can she develop them? In painting therapy she creates an image with a central light shining from a surrounding darkness. When asked by the therapist she reports on a near-death experience in connection with her previous operation, which she has depicted in this picture during painting therapy. Since this experience she has had no fear of death, the painting therapy supports the power that she developed to overcome fear.