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To the Editors: We welcome Dr. Said's interesting report, “Sudden Death at Impasse” and commend the author's courage in writing it and the Forum's courage in printing it. Having devoted more than 15 years to an attempt to understand better the settings in which illness (and death) occur, we can fully support Saul's suggestion that what he calls “situations of impasse” represent circumstances in which illness and even death may occur. (3)
From the study of many hundreds of patients with all varieties of illness, including fatal illness, we have been led to delineate a psychological complex, which we are calling “giving up-given up,” as a non-specific onset condition in which illness develops. (2) It has the following characteristics: (a) It has an unpleasant affective quality, expressed in such terms as “it's too much,” “it's no use,” “I can't take it anymore,” “I give up,” and so on, sometimes ascribed to failures on the part of the environment and sometimes to failures of oneself. (b) The patient perceives himself as less intact, less competent, less in control, less gratified, and less capable of functioning in a relatively autonomous fashion. (c) Relationships with objects are felt to be less secure and gratifying, and the patient may feel himself given up by objects or he may give himself up. (d) The external environment may be perceived as differing significantly from expectations based on past experience, which no longer seems as useful a guide for current or future behavior. (e) There is felt to be a loss of continuity between past and future and an inability to project oneself into the future with hope or confidence. Hence, the future may appear relatively bleak or unrewarding. (f) There is a tendency to revive feelings, memories, and behavior connected with occasions in the past which had a similar quality. Though the data reported by Saul are sparse, his account of the settings in which these three fatal episodes occurred would seem to fit well with the “gi