What is a “bad death” and how can it be avoided?

Thursday, 18 Oct 2012 08:13

About Dr. Monica Williams-Murphy (120 Posts)

Dr. Monica Williams-Murphy is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital. Through her writing and speaking, she is devoted to transforming the end of life into a time of peace, closure and healing. Media Page

Last week, I wrote about the concept of a “good death” and how it can be created. If there is meaning and utility in comparing and contrasting ideas, then this week I should identify what might constitute a “bad death” and suggest ways to avoid this   Please prepare yourself, the “yuck” factor is, at times, fairly high in this discussion.

I will begin by begging you to avoid a bad death at all costs.  I have seen too many and can assure you that this is not the path that you should allow yourself, or any one to take. You should plan to avoid a bad death with just as much motivation as you plan to create a good death for yourself and those whom you love and care for.

Again, the “good death” definitions are taken from from Karen Kehl’s work, while the “bad death” contrasts are my own interpretations. I understand the sensitivity of labeling something “bad” and I ask you to read this understanding my intentions, not to offend anyone, nor disrespect anyone’s experience, but to offer a better way, when possible-

– If a good death means being in control, then a bad death means there are fewer to no elements within the patient’s or family’s control.

I know of one case in which a daughter arrived at a nursing home to see her elderly mother for their daily visit. Upon entering her mother’s room, she found the staff performing chest compressions on her mother and they asked the daughter to “Please leave the room.” She refused and said, “No, I will not leave the room, but you will stop doing chest compressions on my mother!” The staff replied that they could not without a doctor’s order, so this futile resuscitation attempt went on for about 45 minutes before a doctor returned the call and “allowed” the CPR to cease.  Because no advance directives to allow a natural death were on her mother’s chart, this daughter stood by powerless and endured witnessing rib-crushing CPR being performed on her mother. (The absence of an advance directive signifying previously thought out wishes directly led to this “loss of control.”)

– If a good death means being comfortable then a bad death means dying in agony or distress.

I have too often cared for stage 4 cancer patients who arrived to the ER in severe and uncontrolled pain, appearing to be very near to dying, but having never heard of hospice or palliative care before. To not discuss and offer palliative care and hospice services to terminally ill or elderly patients is an act of frank immorality- a grave sin of omission on the part of the doctors caring for these patients.

– Relationships are optimized in a good death, while in a bad death there are little to no opportunities for relationship healing and sharing to occur.

– If a good death provides for a sense of closure, then a bad death is having words left unsaid-with less opportunities for finding forgiveness or expressions of gratitude.

I have a haunting image engraved upon my heart regarding lost opportunities for closure: Early in my career, I cared for a young person who died tragically and unexpectedly. I was devastated that I could not save him, but I was equally devastated to witness his father lying on the hospital floor repeating over and over again: “There are things I never told him. I didn’t tell him that I loved him this morning. I never got to say good-bye.” I hear these words nearly every day of my life and try to make sure that I never leave things unsaid with my family and friends.  Although 90% of us will have a slower course leading to our own demise (giving us more time to talk), 10% of us will die unexpectedly. Say what you need to say today- for now never comes again.

– If a good death means affirming the value and wholeness of the individual who is dying, a bad death would include a loss of dignity or visualizing the dying one as fragmented, a stranger or just another “body.”

Some hospital-based deaths may create a loss of dignity for the one who is dying.  The dying person may be viewed as just “another code” by even the most compassionate staff members (do not blame them directly, desensitization occurs with repeated exposure to trauma and death, it is part of a coping mechanism for healthcare providers. Nevertheless, this mindset does not easily facilitate the creation of dignity and a sense of wholeness for the patient and family involved. However, hospice and palliative care specialists will be able to maximize dignity in any environment.)

– If a good death leaves the sense that everything has been appropriate, a bad death would feel like a violation of a code of dignity or standard of care.

– If a good death includes trust in healthcare providers, a bad death could mean distrust of the providers or the medical system. It could also mean that the healthcare providers seem to be strangers with whom you have no connections or rapport.

This is particularly challenging in the ER setting. The likelihood is that you and I have never met before, we are strangers, and ‘now’ we are trying to work out some of the most serious choices of your life and death, or those of a loved one. This is why the details of your end-of-life wishes need to be worked out long ahead of time with your primary care provider- so that you have a plan, created with someone you know and trust, which serves as a guide even in unplanned events such as an emergency visit to the hospital.

– If a good death includes recognizing impeding death, then a bad death might mean that the death was unexpected.

Sometimes this is unavoidable, but for the vast majority of us there is a pattern that should alert the doctor that you may be approaching the end of your life. He or she should be able to share this information with you and be willing to alert you as well, so that you might prepare. (You should also proactively question your doctor about this topic as well, see: 5 questions to change your end of life path)

– In a good death, the burden on the family is minimized, in a bad death the burden is maximized.

– In a good death,  your cultural beliefs and values are honored, in a bad death you or family would be limited or blocked from the free expression of your personal beliefs and traditions.

Again, hospital-based deaths can sometimes create limitations. I have a friend whose religious tradition involves the burning of incense and sage in the presence the one approaching death- the rising smoke symbolizing the easy release of the spirit from the body. As her close friend lay dying, this ritual was prohibited in the ICU setting (of course), and thus, there was a sense of limitation which would not have existed in a home-based death.

– A good dying experience would allow one time and energy to create and leave a legacy, while a bad dying experience would hinder or prevent the person from creating or gifting anything of lasting value which could have made a difference in the lives of others.

– Finally, in a good death, the family is prepared for death and is cared for throughout the dying of their loved one, in a bad death no counseling occurs and the family is left without support.

To the extent that a “good” dying experience can be created, create it. To the extent that a “bad” dying experience can be avoided, avoid it. Your intentions carry great power in making this happen. For a checklist to aid you in creating a “good” and peaceful end-of-life experience, click here.

Monica Williams-Murphy, MD

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"It's OK to Die" is a ground-breaking book filled with graphic stories straight out of the Emergency Room illustrating how most Americans are completely unprepared for death and dying. In response, the authors have created a unique and comprehensive guide urging EVERYONE to prepare in advance, to assure their own peace and to prevent the suffering of their loved ones.
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