Dying With Panache*

Posted on March 28, 2013

Through my work as an advocate in various healthcare positions over my nursing career, I have witnessed the deaths of many of my beloved patients.  Some of those deaths can be labeled “good” deaths; others, “bad” deaths.  This week, I was asked to consult on a patient, John, who is dying with advanced lung cancer, but who is still being treated aggressively in a local hospital. As I witness John’s suffering and the anguish of those who love him, I am anticipating a bad death. The power of John’s experience caused me to reflect on what differentiates good deaths from bad deaths.

In general, we know that a good death includes; receiving care that is consistent with patients’ wishes, being treated with respect and dignity, good pain and symptom control, not being a burden to others and receiving the support of loved ones. On the other hand, a bad death involves; prolonged deaths with the use of invasive medical technology, unrelieved symptoms, poorly controlled pain, care that is not consistent with patients’ wishes and values, lack of family support and poor quality care. Arguably, the definition of good and bad death can be subjective. However, it is clear that aggressive treatment can create greater suffering, and respecting patients’ wishes, providing good pain/symptom relief and strong support are important aspects of a good death.

In many ways, the advances in science and medicine have made ‘‘living easier and dying harder.’’ (IOM,1997). With today’s high tech medical care, there is always another treatment to be considered; another medication to be used. When to stop aggressive treatments for patients with advanced disease and begin palliative, supportive care is one of the most difficult decisions that patients, their doctors and families must make.

Since serious illness is often approached using the metaphor of war, death becomes the enemy. “We will not give up”. “We will fight this illness”.  “We will beat this disease”. With the battle mentality, many patients and families expect that all the medical technology available should be used to fight death.  But, there is wisdom in knowing what battles cannot be won; understanding when the war is simply not worth the cost; knowing when the time comes to surrender; recognizing the strength in surrender. Each of us must make the difficult decision of whether to continue to fight or to surrender when our time comes.

Perhaps, what emerges, as the most essential element in a good death is that patients are receiving end of life care, which is consistent with their wishes and values. Trumping everything else, is the importance of dying on one’s own terms- “dying with panache”* (Walters, 2004).

So then, my goal is to help John, to die on his own terms with unconditional support and good symptom control. Making clear that he has choices, and that those choices will be respected. That is indeed a “good” death.

 

 

References

 

Callahan D. (1993). The Troubled Dream of Life, Living with Mortality. New York, NY: Simon & Schuster.

Granda-Cameron, C., & Houldin, A.D. (2012). Concept analysis of good death in terminally ill patients. American Journal of Hospice and Palliative Medicine. 29(8):632-9.

Institute of Medicine (IOM). (1997). Approaching Death. Washington, DC: National Academy Press.

McNamara B, Waddell C, Colvin M. (1994). The institutionalization of the good death. Social Science Medicine. 39(11):1501-1508.

Walters G. (2004). Is there such a thing as a good death? Palliative Medicine. 18(5):404-408.