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Renewing The Concept Of A “Good Death”

By Chris Iliades, MD

There was a time in America when we thought of death as a natural and important milestone. People wanted to leave this world at peace with their maker and supported by their loved ones. During the Civil War, soldiers mortally wounded on the battlefield would often surround themselves with family photographs to simulate a good death.

In the 20th century, antibiotics removed the imminent threat of death from infectious diseases, and new medical technologies allowed us to start keeping death at arm’s length, out of sight and out of mind. Americans started to live much longer. Some have described ours as a "death-defying" culture. Unfortunately, one of the results of our technology and our attitude is that many of us end up dying in a hospital room, hooked up to life support, isolated and alone.

"Patients whose physicians discuss end-of-life options sooner might be more knowledgeable concerning strategies to improve the quality of the end-of-life experience." —Cancer

A recent survey of doctors who treat patients with terminal cancer was published in the journal Cancer. The survey found that most of these doctors do not discuss end-of-life issues with patients who have less than six months to live if they are still feeling well. Studies consistently show that the majority of patients near the end of life want a peaceful and comfortable death outside the hospital, but very few communicate their wishes to their doctors.

The Role Of The Palliative Care Specialist

Elizabeth Collins, MD, is a specialist in end-of-life care at the Lahey Clinic in Burlington, Massachusetts. "Palliative care begins when a disease is still treatable but no longer curable. Patient options are best discussed early in the course of this process because there are so many issues that should be addressed. The goal of palliative, end-of-life care is to honor the patient’s wishes," says Dr. Collins.

"Ten years ago only about 10 percent of hospitals offered palliative care services. Today patients can take advantage of palliative care in about 30 to 40 percent of hospitals," notes Dr. Collins.  Services offered through palliative care include:

     
  • Symptom control
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  • Emotional and spiritual support
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  • Assistance with heath care goal setting
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  • Issues related to advance care planning
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  • Preservation of quality of life and dignity

Components Of A Good Death

"A good death is a death in which the patient’s wishes have been made known, and the patient remains in control of end-of-life decisions for as long as possible.  When the patient can no longer make decisions, doctors and loved ones know how the patient wants end-of-life care to proceed. In most cases patients can die in peace and dignity with family members knowing they did all that they could," explains Dr. Collins.

"Doctors have the responsibility to never abandon the patient. We need to let the patient know that we will be there until the end," says Dr. Collins. Components of a good death should include:

     
  • Control of pain and suffering
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  • Involvement of loved ones
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  • Acceptance and understanding of the medical condition
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  • Respect for spiritual beliefs
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  • A sense of closure and meaning

Start Making A Plan

Americans plan for almost everything. We plan for births, weddings, anniversaries and retirement. According to a recent Harris Poll, over 70 percent of American’s believe that death is not an end but only a transition. Why should we fear planning for the one event we are all sure to face? Here’s what you should consider:

     
  • Think about how you want to be treated at the end of life.
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  • Think about who you trust to make end-of-life decisions for you if you can’t.
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  • Make sure that person understands your wishes and feels comfortable carrying them out.
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  • Ask your doctor to help you with preparing advance directives. An advance directive can be a living will or a durable power of attorney for healthcare.
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  • If you are already sick, ask your doctor what to expect in the future and if a palliative care consultation is advisable.

A good death is possible but not without proper planning and communication. Research shows that if you wait for your doctor to initiate this conversation it may not happen. Take steps to make sure your wishes are known so that they can be honored.