Unconscious dying: the lightly tilled soil of palliative care and psychodynamics

It goes without saying that death, and foreknowledge its inevitability, has always been the ultimate human challenge, that drives, at conscious and unconscious levels, everything that is done, thought and believed. Given the dominant worldview of logical positivism, scientific mastery and personal control, coupled with modern epidemiological realities, decision-making and care for people who are approaching death is a major challenge for society and health systems. For over 50 years the lead has been taken by the hospice/ palliative care ‘social movement’, and recently more broadly in health, especially in aged and intensive care, and by policy-makers. The overwhelming discourse and methodological approach tends to be linear, empirical and logical, in line with the zeitgeist, the ‘regimes of truth’ and ‘evidence base’ that are dominant in the system. This paper explores the possible unconscious personal and organisational forces at play when health services and society engage with the threat of death. It posits the view that a wider reticence to acknowledge the possibility of deep instinctual forces limits the capacity of the health system, its professional teams, individuals and wider society to work towards ‘healthier’ relationships with death, the dying, the dead and ourselves as ‘mortally threatened’ at all times. Concepts such as identification, projection, transference and ‘organisation in the mind’ will be explored in the death, grief and palliative care context, as well as a notion of ‘ingestion’ or ‘transmission’ of pain and loss of others as a driver of organisational discord and burn out.