Chapter-7
A GOOD DEATH
Francis Bacon in 17th century used the term euthanasia (Greek Eu-good, thantos death) or good death referring to an easy, painless, happy death. There is no single definition of what constitutes a good death. The definition of a good death will vary for each person.
What is a “good death”?
Poets, philosophers, religious scholars and plain folks all have spoken and written about what makes a “good death”. Some people would say there is no such thing as a “good death” – all deaths, are unnecessarily unwanted and unwelcome. That may well be true when you are young, health, physically and mentally intact or, if not all the above, at least still able to enjoy the good things and people in your life.
But what if you are very old and sick and no longer able to care for yourself? What if you have a incurable and painful illness? What if you have become demented and no longer able to recognize your family and friends? At such points, death might be a welcome exit to some. Each person is unique and so is his or her death. As Dr. Nuland points out in his book “How We Die” : “deaths are nearly as unique as the lives that come before them –shaped by attitudes, physical conditions, medical treatment and mixed of people involved.”
Still, many have pointed to a few common factors that can help a death seem good – and even inspiring – as opposed to frightening, tortuous, and sad. By most standards, a good death is one in which a person dies on his own terms, relatively free from pain, in a supported and dignified setting, surrounded by family and friends.
In 1997, The Institute of Medicine (IOM) of America defined a good death as: “free from avoidable distress and suffering for patients, families, and care givers; in general accord with patient’s family’s wishes; and reasonably consistent with clinical, cultural and ethical standards.” According Institute of Medicine, factors important for a good death include:
- Control of symptoms
- Preparing for death
- Opportunity for closure or “sense of completion” of life
- Good relationship with caregivers.
A central concept to a “good death” is one that allows a person to die on his / her own terms relatively pain free with dignity. An appropriate death is often considered to be one that occurs naturally and in old age, one that follows the natural order of things e.g. older members die before younger ones. Perhaps the best definition of an appropriate death is a death that someone might choose for himself or herself if he/she had the choice. Annals of Internal Medicine’s study (May 16, 2000) identified six components of a good death:
- Pain and symptom management
Patients are afraid of pain and do not want a painful death. A patient with AIDS described how he relieved his anxiety about painful death: “I don’t want to be in pain, and I’ve discussed it with my doctor. He said, “Oh, don’t worry about pain. We’ll put you on a morphine drip.” That sort of eased my mind.”
There are plenty of medicines to ease pain. Doctors are being trainees to treat pain aggressively. With the help of his/her caregivers, a terminal patient can expect a reasonably pain-free death. However, too much pain medicines will make the dying person drowsy or even unconscious, so that is a choice the patient and his family have to make in advance.
- Clear decision making
Patients want to have a say in his/her treatment decisions. The patient wants to have a say on whether he wants to continue painful chemo or radiation or other medical or surgical treatments for few more months of living. He wants to have inputs on all his medical care and caregivers should honor his wishes.
- Preparation for death
Too often, physicians and family members avoid talking about the end of life with people who are dying because they are afraid it will destroy their hope. Yet most patients who are dying want to know the truth and not the sugar coated truth.
- Completion
When patients recognize that the end is near, the time has come for many of them to tie all loose end. Resolving conflicts, spending time with family and friends, and saying good-bye become important. Spirituality also becomes important to some at the end of their life.
- Contribution to others
This can take the form of material or spiritual gifts or transmission of wisdom. For some, it means to give their organs to others whose lives depend on a transplant. Some donate their bodies to science. Many people want to share their wisdom with others-especially with the younger generation. Many of them try to mend their relationship with others prior to their death.
- Affirmation of the whole person
No patient, and especially someone who is dying, wants to be treated as “ a disease” or “the patient in room 101”. The dying person wants to be treated like a unique and whole person and being understood in the context of his life, value and preferences.
The Annal’s research team reported that descriptions of bad deaths “frequently included scenarios in which treatment preferences were unclear. Patients felt disregarded, family members felt perplexed and concerned about suffering. Decisions that had not previously been discussed usually had to be made during a crisis, when emotional reserves were very low.”
The researchers’ bottom line, “There is no single formula for a good death. Rather, they concluded, most of the time people choose to die the way they lived, “in character.” They may be angry, critical or mellow, dignified, at war, or at peace. (Brady).
Dr. Nuland in the Epilogue of his book “How we die” put it this way: “Life is dappled with periods of pain, and for some of us is suffused with it. In the course of ordinary living, the pain is mitigated by periods of peace and times of joy. In dying, however, there is only affliction. Its brief respites and ebbs are known always to be fleeting and soon succeed by a recurrence of the travail. The peace and sometimes the joy, that many come occurs with the release. In this sense, there is often a serenity – sometimes even a dignity-in the act of death, but rarely in the process of dying. The dignity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars Vivendi. “The art of dying is the art of living”. One cannot express it any better!