A good death - An important aim for health services and for us all

BMJ Clinical Research (Impact Factor: 14.09). 02/2000; 320(7228):129-30. DOI: 10.1136/bmj.320.7228.129
Source: PubMed


The art of living well and dying well are one.

Death is one of the attributes you were created with; death is part of you. Your life's continual task is to build your death.
Are you ready to die? If not, then you might begin some preparation. Every BMJ reader will die this century, and death is constantly beside us. Montaigne urged, “One should be ever booted and spurred and ready to depart.” Yet that has not been the attitude of the past 50 years, and modern medicine may even have had the hubris to suggest implicitly, if not explicitly, that it could defeat death.1 If death is seen as a failure rather than as an important part of life then individuals are diverted from preparing for it and medicine does not give the attention it should to helping people die a good death. We need a new approach to death, and the debate of the age on older people has provided a clarion call: “We believe it is time to break the taboo and to take back control of an area [death] which has been medicalised, professionalised, and sanitised to such an extent that it is now alien to most people's daily …

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    • "The development in the field of hospice and palliative care has significantly improved the situation of people at the end of life [7-10]. A “good death” at home without pain after a long and fulfilled life, with the dying person being at peace with the environment and having at least some control over the events remains a desire for most people [4,11,12]. However, the final weeks or days in human life still remain the greatest challenge for all persons involved (family members, informal caregivers and professional staff) [13]. "
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    ABSTRACT: The terminally ill person's autonomy and control are important in preserving the quality of life in situations of unbearable suffering. Voluntary stopping of eating and drinking (VSED) at the end of life has been discussed over the past 20 years as one possibility of hastening death. This article presents a 'systematic search and review' of published literature concerned with VSED as an option of hastening death at the end of life by adults with decision-making capacity. Electronic databases PubMed, EBSCOhost CINAHL and Ovid PsycINFO were systematically searched. Additionally, Google Scholar was searched and reference lists of included articles were checked. Data of the included studies were extracted, evaluated and summarized in narrative form. Overall, out of 29 eligible articles 16 were included in this review. VSED can be defined as an action by a competent, capacitated person, who voluntarily and deliberately chooses to stop eating and drinking with the primary intention of hastening death because of the persistence of unacceptable suffering. An estimated number of deaths by VSED was only provided by one study from the Netherlands, which revealed a prevalence of 2.1% of deaths/year (on average 2800 deaths/year). Main reasons for patients hastening death by VSED are: readiness to die, life perceived as being pointless, poor quality of life, a desire to die at home, and the wish to control the circumstances of death. The physiological processes occurring during VSED and the supportive care interventions could not be identified through our search. The included articles provide marginal insight into VSED for hastening death. Research is needed in the field of theory-building and should be based on qualitative studies from different perspectives (patient, family members, and healthcare workers) about physiological processes during VSED, and about the prevalence and magnitude of VSED. Based on these findings supportive care interventions for patients and family members and recommendations for healthcare staff should be developed and tested.
    Full-text · Article · Jan 2014 · BMC Palliative Care
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    • "Choice and control over where death occurs (at home or elsewhere) is one of the 12 principles of a good death (Smith, 2000). Place of death also has a significant meaning in the allocation of medical resources. "
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    ABSTRACT: Aim: To investigate factors that affect the place of death (POD) of terminal cancer patients. Materials and methods: We recruited 702 consecutive patients (>18 years) from 12 centers during July 2005 to October 2006, and 481 completed the questionnaire. In April 2011, we linked the data for 96.0% (n=462) of the deceased patients to the POD using the 2005-2009 death certificate data of Korea's National Statistical Office. The primary outcome variable was POD, and the predictive value of variables pertaining to patients and caregivers was evaluated using univariate and multivariate analyses. Results: Most patients died in a hospital (91.5%, n=441) and age, education, preference for place of terminal care, wish to use hospice/palliative care services, terminal cancer awareness, time between diagnosis and death, and global quality-of-life subscale of the EORTC QLQ-C30 of patients, and education and preference for place of terminal care of caregivers were significant predictors in univariate analyses. On multivariate analysis, patients and caregivers who preferred hospital/palliative care as the terminal care option over home care [adjusted odds ratio (aOR), 2.68; 95% confidential interval (CI), 1.18- 7.04 and aOR: 2.65; 95%CI: 1.15-6.09 for patient and caregiver preferences, respectively] and caregivers who were highly educated (aOR, 3.19; 95%CI, 1.44-7.06) were predictors of POD. Conclusions: Most of the terminal cancer patients died in a hospital. Our findings indicate that major predictors of hospital deaths are preference of both the patient and caregiver for hospital/palliative care as the terminal care option and higher education of the caregiver.
    Full-text · Article · Dec 2013 · Asian Pacific journal of cancer prevention: APJCP
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    • "Richard Smith [32], remarked in a British Medical Journal editorial that health services need to change its view of death and dying so as improve the chances for achieving good deaths. He argues: “If death is seen as a failure rather than as an important part of life then individuals are diverted from preparing for it and medicine does not give the attention it should to helping people die a good death” [32]. If society as a whole was better informed about the dying process, conceivably, this would help facilitate more open discussion about end-of-life care and wishes [33]. "
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    ABSTRACT: Background: Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a "bad death" experience for the patient and family. We aim to describe Canadian family physicians' experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients. Methods: Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged. Results: Eleven family physicians with a range of 3 to 40 years in clinical practice participated.The family physicians expressed a desire to achieve a "good death" and described their role in positively influencing the experience of death.Finding Common Ground to Achieve a "Good Death" for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described. Conclusions: A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a "good death". These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.
    Full-text · Article · Jan 2013 · BMC Family Practice
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