What is a “good death” and how can we create it?

Tuesday, 02 Oct 2012 18:50

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

I have decided that if I am going to continually encourage my very elderly and terminally ill patients to decline artificial life support measures at the end of the road, and instead, choose a “good death,” then I need to be able to explain and provide this “better” alternative more effectively.

So, I thought it time to revisit an article published in 2006, analyzing factors that define the concept of a “good death.” The author, Karen Kehl, MS, RN, ACHPN, gathered forty-two articles from diverse sources including medical, nursing, patient perspectives and sociological literature, and extracted concepts most frequently mentioned as contributing to the creation of a good death.

According to the article published in the American Journal of Hospice and Palliative Medicine, although death is a highly individualized experience, there are certain core characteristics which may contribute to the sense that a death is “good.” Without a doubt, I know that we can and should have more control over these characteristics so that we may know in our hearts that we have given our loved ones, friends and patients, the best dying experience possible.

Further, I believe that is the role of the healthcare provider to initiate the discussion of this process, although it takes the efforts of many others including nurses, chaplains, social workers, therapists, volunteers, family and friends, to assure success.  We can all support and help contribute to the following elements to create a “good death” for ourselves and all of those for whom we care…deep down these are the things that the dying desire:

• Being in control.

Which includes “(1) choices/ wishes being honored including communication of wishes, (2) clear decision making, (3) option for suicide/euthanasia [which I do not support], and (4) control over the death event including control of location, timing, and presence or absence of others.” [Words in brackets are my own]

• Being comfortable.

“(1) lack of distress (2) symptom management including physical symptoms such as pain management and dyspnea management, emotional/psychosocial symptoms such as fear or anxiety, cognitive symptoms such as remaining mentally alert, and symptoms of spiritual distress (3) comforting, including physical measures such as hugging and (4) hope.”

• Sense of closure.

“Sense of closure included the ideas of saying good-bye, completion of unfinished business, and preparation for death.” [Click here for an article containing tips for closure]

• Affirmation/value of dying person recognized.

“Recognizing the value of the dying person encompassed (1) dignity (2) wholeness or being a whole person, including having physical, emotional, social, and spiritual aspects; (3) quality of life, which includes living fully and (4) individuality.” [Sacred Dying Foundation has helpful advice on creating rituals to affirm the whole person during the dying process]

• Trust in care providers.

Included “good communication both between health care providers and with the patient and family,” as well as “that care providers should be strong patient advocates and should be non-judgmental concerning patient and family decisions.” [If you are a healthcare provider and struggle with this type of communication, the Esse Institute can help you.]

• Recognition of impending death.

“Included both awareness of the impending death and acceptance of the death.” [So, we healthcare providers have to actually tell our patients and their families that they are dying to give them the opportunity to gain acceptance and to more easily choose a “good death” pathway.]

• Beliefs and values honored.

“The importance of honoring beliefs, values, and practices of a personal, cultural, and spiritual nature,” were also cited.

• Burden minimized.

“Patients discussed being physically and financially independent as important to a good death,” with special emphasis on minimizing the burden on family members who would be caring for the one dying.

• Relationships optimized.

This included the ideas of having quality time and communications with family and friends, overall social support, and opportunities for reconciliation and forgiveness.

• Appropriateness of death.

“The issues of the age of the dying person, appropriate use or nonuse of technology such as ventilators and dialysis, and aspects of the illness such as its being of a terminal nature, were all part of the aspect of appropriateness of the death.”

• Leaving a legacy.

“The attribute of leaving a legacy included being remembered and contributing to others,” as well as “leaving behind an emotional, physical, financial, or social legacy.”

• Family care

“The attribute of family care consists of family involvement in the death and in the care of the dying person as they choose, the family as well as the patient being the recipient of care, and family preparation for the death.”

The clear identification of these domains creates an opportunity for all of us to reflect on our choices and actions regarding the end-of-life path. With knowledge comes responsibility- if you have read this article, then you now know what constitutes a “good death” and are now responsible for its creation.

Monica Williams-Murphy, MD

All quotes excerpted from the article reviewed: Kehl K (2006). Moving Toward Peace: An analysis of the concept of a Good Death. American Journal of Hospice and Palliative Care. 23, 277-286.

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