Coping with a child’s eye

A baby’s smile reflects the purity in their heart.   An infant’s world is a marvelous place of possibility and love.   Children see themselves as special, capable, even omnipotent.   Time teaches failure, loss, and mortality.  How much we lose of that original perfection, that first excitement, that natural confidence, determines how we face the challenges and tragedies of life; whether we will be happy.  It may even determine how we cope with the infinite loss of dying.

As adults, we know life is limited, that we will die; still we pass each day in a state of denial.  As long as our bodies are without grave pain, as long as the maladies from which we suffer heal, as long as chronic problems can be controlled, we live without constant awareness of death.

However, eventually, that will change.  Something happens which cannot be fixed; a failure in our body to stain forever that denial.  Cancer patients know that the fear of relapse sits always in the back of the mind.  It seems to me how we cope with the harshest of realities reflects the person we became, back in childhood.

There is a great range in how patients adjust to illness.  Some are able to understand and confront their disease, to adjust to limited time, to plan and continue to live without devastating anxiety.  It is not that they welcome loss, but they find balance.  They rely on family, laughter, art, discovery and dreams to get by; they may still experience joy.

At the other extreme are patients who cannot handle even basic news about their disease.  They shut out discussions about diagnosis, treatment and, certainly, prognosis.  They live day-to-day through suppression of life-threatening reality.  They do not seek appropriate care, or at least not until it is too late.  Even then, they cannot comply with medical treatment or goals.

Most of us are in between.  One day, perhaps when we are visiting our grandchildren, we are hopeful, positive and can enjoy life with laughter.  Another, perhaps when we have received bad news from the oncologist, or maybe just have an upcoming appointment, we are emotionally overwhelmed and can not sleep, focus or function.  Real people reflect life … they change a little with each moment, each day.

Many factors determine how we will cope with the end-of-our-lives.  They include personal factors such as age, disease, education, and life experience. They include family support, the quality of relationships, the presence of guilt and the simple geography of where we live.  They include societal issues, such as finance, availability of quality care, spiritual foundation and community stability.

Nonetheless, it seems to me that one of the most critical factors is the base on which we are built, how we are raised.

If a child spends her first years in an environment where she is supported and which seems stable and loving, she will learn to feel that the world is stable and loving, even when it is not.  She will have a core belief that life makes sense, that it is good.  If a child who misbehaves is shamed and told she is bad, she will learn to be defensive and frightened.  If a child who misbehaves is told that she is a good person and good people usually do not act that way, she will learn confidence and a deep goodness.  If we suppress that first purity, discourage that excitement and undermine that natural confidence, the child will lack the inner strength to handle daily life in a holistic and positive manner, let alone cope with real tragedy and the transformations of terminal disease.

I do not recommend Freudian therapy for everyone diagnosed with metastatic cancer or Alzheimer’s.  It is too late for psychoanalysis. Rather, we must appreciate that we enter the final part of life with the strengths and weaknesses that have marked our entire passage through this world.   Coping with final battles is complex and different for each of us, because it is built on different foundations.  Thus, we must be patient, giving and supporting as each requires.

In the best of all possible worlds, we would all cope like an innocent child.  If that is true, the best way to help someone cope with the extremes of life may be to give them a smile, hug and kiss, when they are pure, frail and very young.


  • I think having a good partnership with the oncologist is critical to the cancer journey. Does he understand that your child like optimism is how you have chosen to deal with your fate, does he know that you don't want to seek treatment when disease management begins to take over your life, and will he answer your questions and be a partner in your journey? Or will he forcefully remind you that the disease will come back, or push treatment to save you no matter the side effects, and answer questions in a way that allows him to remain in charge? How we march toward the end is all that we can control.
  • Paula Kaplan-Reiss
    A beautiful piece. I would like to add another important aspect of how we deal with stress: our genetically endowed nervous system. Some people grow up in very loving nurturing families. Yet, these same families may pass on a predisposition to have an anxiety disorder where the world can feel very scary, despite a secure family unit. During these times, both therapy and pharmaceuticals can make a big difference in how stress is faced. I am a walking example!
  • meyati
    My HS math classroom was next to the ISS-In School Suspension- Everybody wandered into my room asking where ISS was. I slammed the door- shut-it had a sign with an arrow pointing to ISS. So, they pounded on the door and asked me where ISS was. 2 girls told me that I was the only nice teacher, and I smiled at them and called them "Darling" or "Sweetheart". It made them feel better, like somebody liked them, and they wanted to be like me. I pulled the sign off. and left the door open except during tests. I grew up with a horribly abusive mother. I learned from my teachers, and hookers that had sailors and marines draped over them. I watched them put on that glorious lipstick in a restroom. They'd notice me staring at them. They'd give a smile and say something like like "Darling, do you like this pretty lip stick? When you grow up you can wear pretty lipstick." My mother would come out from the stall and grab me by the hair and drag me off. When we left after the movies, sometimes these women would see me, and as they came by-they'd say to their date-- "See the girl in the red dress? She's such a darling." We are capable of seeing the best of people, and deciding if we want to do what is best. My father told me that. This was when a woman no matter how cruel, got the kids.
  • susan
    A nice article. It is important however to recognize that oncology must demand the new cancer immunotherapy be made available for ALL PEOPLE ASAP. Oncology must finally comport itself into the present day with the realization that at long last drugs are here and soon will be available which will significantly raise expectations in metastatic cancer. it is about time. Depriving patients of this immunotherapy such as the pd-1 inhibitors, or the pd-l1 inhibitors will be imminently viewed as reckless as akin to withholding antibiotics from treatment of meningitis, or sepsis. It is bad public policy and reckless endangerment, now that medical science has the wherewithal to deal with cancer, not to make this therapy available immediately to all. A civilized society demands it, same as releasing the new ebola drug for folks in other lands. Change is a coming to cancer land and the cancer machine may not be happy about it. Patient well being in bringing in these new drugs to replace surgery, radiation, chemo, hospital stays, etc, is going to be pitted against practitioners jobs and practices, facilities which count on patient usage, equipment, and chemo dispensaries all which will soon be much less than optimally utilized. In the first years additional costs will be layered on the system as drugs are adopted while the fixed costs remain high. Soon, cancer land will be a shadow of its former self, as a major disruption to the current system is at hand. Can;t say that I will miss a system which goes through the motions while seeking to crush patient expectations. That is certainly not a comment directed at the excellent doctor here, but at the vast majority of this self serving system which has claimed for years that there is no solution.
  • D Someya Reed
    Isn’t it paradoxical, perhaps hypocritical, that you condemn us, as healthy adults, for living our lives “in denial” of our deaths; yet, when we are at the end of our lives and our deaths are just as inevitable (but now imminent) you promote that we ignore that and focus solely on living? Why? Just as odd is that you would state in a post revolving somewhat around “denial” and in support of your position that “one of the most critical factors is…how we are raised” that you would then state “If a child spends her first years in an environment where she is supported and which seems stable and loving, she will learn to feel that the world is stable and loving, even when it is not.” Are you promoting naiveté or textbook denial here? And that does not even address your choice of words for describing the environment as “SEEMS stable and loving.” Is fake OK? There have been many studies, both good and bad, where "fake" has been used to solicit desired results. I don’t believe that any part of our lives no matter how joyous, dramatic or traumatic shapes the essence of who we are more than any other. We are all the sum of our collective experiences at any given point in time. I am not the man I was yesterday. Come tomorrow, I will not be the man I am today. This we cannot change even in isolation. There is something in nothing and our minds will continue to interpret both. Note to pam956…I echo your sentiments and yours was an excellent response.
    • Thank you for reading my response. Yes, I too think we are continually being shaped by people and events in our lives. It is how we choose to respond to our circumstances not the actual events that really matters. Regarding stable and loving families, there are a lot of "fake" happy families out there. I know because I have professionally photographed them and had a hard time making them all look happy.
      • D Someya Reed
        To apply critical importance to any event or portion of our lives removes conscious thought and effort of the individual to change their circumstance. It remains popular because it is often used to remove accountability of the individual from the equation by virtue of placing the blame elsewhere; in this case, parents. I shudder to think what I should have become had I adhered to this pop-psychology philosophy in consideration of my own childhood upbringing. Dr. Salwitz did, however, cover his bases with the all-inclusive "Coping with final battles is complex and different for each of us, because it is built on different foundations." He followed (that) with "Thus, we must be patient, giving and supporting as each requires." Unfortunately, this last remains largely unfulfilled for most of us and by even most medical professionals in my experience and from what I've read of studies in the same vein. Those who do provide support (and all it entails) have made a choice to do so regardless of their upbringing. Even the child of two vicious, serial killers can learn the difference between right and wrong and choose the course that is right.
  • Another thoughtful and thought-provoking essay, Dr. S. Thank you for this. When you write: "There is a great range in how patients adjust to illness", I suspect this also includes ALL forms of serious illness, whether end-of-life or not, cancer or not. As you correctly point out, the nature of one's childhood is just one of many important factors that influence how we will react to/cope with/manage/adjust to living with any diagnosis. The late Dr. Zbigniew Lipowski of the University of Toronto described these eight coping assessment tools that patients typically use to view serious illness: as a challenge, an enemy, a punishment, a weakness, a relief, a strategy, an irreparable loss, or an opportunity. More on this at: Speaking of punishment, my late mother (a devout Roman Catholic her whole life and a person relentlessly obsessed with guilt and sin), viewed virtually anything bad happening in life as punishment. "God punishes bad children!" she would often observe in a resigned matter-of-fact fashion to her own five children to help explain anything from accidentally stubbing our toes on the living room coffee table leg to not winning the school spelling bee. g Children who grow up surrounded by that kind of Godly image no doubt absorb some of that through sheer osmosis - a vengeful God always on the lookout to deliver swift punishment to all those bad children in the world. Sheeeeesh....
  • This is a very perceptive blog post. I've often wondered what makes such a difference between and among people at the end of life. Perhaps you've hit on it. Too bad it's too late at that stage to change a person's childhood. Psycho-therapy when you're middle-aged is a good alternative possibility, though. Get over childhood hurt and pain while you still have some resilience!
  • Kris
    You can't change the past. You can only deal with what you face right now. You become anxious, reluctant, fear and even surrender to the death when it stands right in front of you. Yes, that is human being's pure and basic feelings. We understand you are very fragile. We need to do our best to comfort you and help you enjoy every moment with smiles and positive aspects for the rest of life you've got. The past doesn't really matter at this point when you have the limited time to live. All you can count is not to waste the rest and take advantage of all the time you've got. Make the rest of life worthy, valuable and memorable. Right now counts.
    • D Someya Reed
      I agree that you can't change the past but disagree that your "past doesn't really matter" ("at this point when you have the limited time to live"). What if you could use your (negative) past and your last, dying days to create a positive future and an ending with a more dignified death for just one other person? Maybe a hundred...a thousand or millions? How meaningful would that be? Would you sacrifice the remainder of your life to ensure that those surrounding you during your last, dying days weren't displaying "plastic" smiles and producing "fake" positive aspects largely not even applicable to you? Would you do it for a stranger? I would! Remember Elisabeth Kübler-Ross said that people tend to die in the same manner in which they lived. Countless people in countless cultures over countless centuries have said the same. We've forgotten this. We now abhor it. Today, we are trying to mass-produce and homogenize the death experience so as not to upset those who will live on (for however long they have) and, perhaps, as a bonus side effect not fear (or fear a bit less) their own deaths. Plus, if we make a couple of bucks in the process, well, that's good for the economy, too. But we all know it just doesn't work that way, does it? Got denial?

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