Bioethics Discussion Blog: What is a "Good Death"?

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Wednesday, October 28, 2009

What is a "Good Death"?

What is a “good death”?


That is a question that every living person must eventually contemplate. Is a quick death, a sudden demise by a heart attack, some accident or by violence or intent, such as a self-inflicted gun shot to the head really a good death? Or is death which is delayed long enough to allow one to have the life issues settled and to see and relate to family for the last time good? Or is a death which comes on painless and without the burden of discomfort and anxiety also a good death? Each person may have a different view. Certainly, physicians should have the goal to understand and attempt to provide a good death for their patients when it comes. It is their professional obligation to the patient. But is a “good death” something that the doctor can define or must it come from the patient’s own lips? Often, physicians are unaware of how their patient might set the definition.


Tony Back, MD writing in the Ethics of Medicine End-of-Life Issues of the University of Washington School of Medicine sets some guidance for medical students and physicians. Amongst other advice he suggests:


In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. I find it doesn't take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, "Knowing that all of us have to think about dying at some point, what would be a good death for you?" What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can't always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What is your view of what would constitute a good death for you?

I would like to end this introduction with another way of looking at a “good death” but looking at death after one dies. It comes in the form of the lyrics of a song written by Lee Hays of the Weavers, famously sung by Pete Singer and immortalized by a film by that name. ..Maurice.


Dead Earnest

If I should die before I wake
All my bone and sinew take
Put them in the compost pile
To decompose a little while

Sun, rain and worms will have their way
Reducing me to common clay
All that I am will feed the trees
And little fishes in the seas

When corn and radishes you munch
You may be having me for lunch
Then excrete me with a grin
Chortling, There goes Lee again

'Twill be my happiest destiny
To die and live eternally

Lee Hays, 1981

8 Comments:

At Wednesday, November 04, 2009 10:28:00 PM, Blogger Christian Sinclair, MD said...

This post was featured in the November 2009 edition of Palliative Care Grand Rounds!

Congratulations and thanks for contributing to the palliative care blogosphere.

Maurice, I am sad to see no comments here on such an important question. This is so individualized but there are common themes of respect, dignity and comfort that we can improve upon in the medical field. I think Tony Back's advice is pretty accurate.

 
At Friday, November 06, 2009 5:05:00 PM, Anonymous Jan Henderson said...

Thank you, Maurice, for asking this question. Some random thoughts.

There have been moments in my life when something wonderful happened and I was very happy and the thought would cross my mind: If I were to die now, I would feel my life was complete.

As I get older (I’m ONLY 66), I find myself thinking: I’m glad that I’ve been able to live this long. Many of my contemporaries have already died. I’m healthy and look forward to reaching 100. But if I were to die now, I would feel satisfied with my life.

I hesitate to mention this – because I object to the frequency with which we’re assaulted with images of violence -- but another thought that occasionally crosses my mind is that I don’t want to die a violent death. I know this thought is the result of my exposure to media. I can avoid violent movies and TV news, but it’s hard to read about world events without encountering the idea of torture and headlines of “human interest stories” whose only appeal is their gruesomeness.

I’ve been meaning to write about the meaning of life at the moment of death since September, when I read a Lancet article on Tolstoy’s The Death of Ivan Ilyich (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2961616-0/fulltext - requires free registration). There’s a discussion of the article on GeriPal (http://www.geripal.org/2009/09/overuse-of-pain-medications-in-hospice.html ) (Two of the authors of the Lancet article are GeriPal bloggers.)

The article asks: Was it Ivan Ilyich’s physical and existential suffering that allowed him finally to gain an understanding of his life?

Chinese philosophy has an explanation for why people understand their lives at different ages. Feeling that your life makes sense – that all the aspects of your character are lined up correctly and you’re at the center of all crossroads – is a quality called Fate. Some people experience Fate in their childhood. Life has always made so much sense to them that they never need to question it. Others don’t experience Fate until the end of life. They go through life acting as if they understand what’s going on, but they don’t have a clue as to why they’re doing what they do.

I was told, by a scholar of Chinese philosophy, that I experienced Fate in my Education years and that this often makes one a life-long learner. This seems true for me. I go through life with a sense that there is so much new to discover. What this scholar told me about my death is that leaving life would simply feel like stepping out of my numerous interests. I would’t feel a need to engage in closing things down. The older I get, the more accurate I find this description. And I find it very comforting.

 
At Sunday, November 08, 2009 9:44:00 AM, Blogger Sally said...

As a hospice nurse (and blogaholic) I am very grateful to have come across a place where such issues are discussed...
Appreciate very much the advice that we should Listen more than we talk- and allow our patients and families to be our guides as they determine what is a "good death" for them..
thank you.. Looking forward to reading more..

 
At Monday, November 16, 2009 10:02:00 AM, Blogger MER said...

I don't think a hospital or medical staff can "provide" a good death to patients. They can provide the opportunity, perhaps, for the patient him/herself to reach that goal. Granted, there is much the system can do to create a situation and atmosphere for the patient. But the reality is, I think, that coming to grips with one's death is very personal activity. Only the patient can define what a good death means. My thought is that it involves a voluntary and positive shedding (both intellectually and emotionally) of all kinds of material attachments and an acceptance that death is just a part of life. A good death to me would also coming to some kind of integration of one's life, accepting both the good and the bad and, not only asking for forgiveness but also forgiving oneself. I suppose there are many things that a good hospice or hospital can do to help people deal with that. But, in essence, death is a one-person drama.

 
At Monday, November 16, 2009 12:43:00 PM, Blogger Snaps said...

I'm only 23 so my thoughts of my own death are usually only that I may die due to trauma.
In that case I always hope that some of my organs are salvageable.
Having no underlying medical condition it's hard to think of death and myself.

 
At Tuesday, November 24, 2009 10:42:00 AM, Blogger MER said...

I thought of this thread after rereading an extremely profound and relevant essay by George Orwell. Now, if you think of "Nineteen Eighty-Four" when you think of Orwell, get that out of your mind. His best works are non fiction, observations, essays, reporting. This essays, published about 1927, is called "How the Poor Die." About that time, Orwell was, as he titled one of his books, "Down and Out in Paris and London." This essay describes how patients are treated in the poor section of a Paris hospital. The horrible conditions are described vividly, as is the cold, clinical, almost inhuman attitude of the staff. Orwell talks about being treated like animals. ATt the same time, as I reread the essay, I was struck by how accepting the patients were of this treatment. They were poor, powerless, helpless and knew it. If not grateful, they were at least accepting of any help they could get. Many were dying anyway, so they had other things on their mind. Orwell focuses on one particular patient who dies alone and in pain at the end. His lat words: "Je pisse!" -- I have pissed. So much for dignity.

I thought of this thread when I read a sentence he wrote in that essay: "People talk about the horrors of war, but what weapon has man invented that even approaches in cruelty some of the commoner diseases? 'Natural' death, almost by definition, means something slow, smelly, and painful. Even at that, it makes a difference if you can achieve it in your own home and not in a public institution."

With all the problems we have in health care today, we must be grateful of the progress we've made in treating disease and caring for dying patients. Still, what we regard as a "good death" in Western culture, is quite different throughout most of the world where the vast majority of people don't have access to any kind of modern health care and often die terrible, painful, lonely deaths.

 
At Tuesday, November 24, 2009 3:13:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, many thanks for presenting us with the words of Orwell. They are very pertinent to the subject.

I would think that dying at home with family present and with nursing to provide medication to remove pain and suffering would be an ideal "good death" if death is not to be instantaneous and without warning.

..Maurice.

 
At Monday, December 07, 2009 11:18:00 AM, Blogger FredR said...

"I would think that dying at home with family present and with nursing to provide medication to remove pain and suffering would be an ideal "good death" if death is not to be instantaneous and without warning."
Exactly how my Father passed this August at 82yo and we all agreed we'd like to go that way if possible. We had a wake and celabrated his life. It would be nice if everyone could afford to leave life like this.

 

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