Wednesday, December 3, 2014

What's a Good Death?

When someone asked a philosopher how he would like to die he replied, "When I least expect it."  Woody Allen in a similar vein stated, "I'm not afraid of dying, I just don't want to be there when it happens."

Although we all may have similar wishes, we are vastly more likely to age slowly, acquire a few chronic conditions, have periodic illnesses with declining health, and then have some kind of "terminal event."  So most of us have time to think about a "good death", but what does that really mean?

There was a recent piece in the New York Times written by a knowledgeable woman, whose father didn't die the way he wanted to - no heroic interventions at the end.  He had a sudden cardiac arrest with subsequent cardiac resuscitation and invasive ICU care.  Once the CPR was initiated it was unclear at to whether her father would survive.  To me it demonstrates that all situations can't be anticipated and that often families need to sit down with the medical team participating in shared decision making.

So what is a good death?  I was asked this question by our local NPR radio station.  After talking to many patients over the years, the following seems most important to have our own wishes adhered to:
  • Pain and symptom management - palliative care consultation and hospice are often needed
  • Preparation for death – spiritual & natural - advance directives - POLST if indicated.
  • Completion of goals - each individual has his/her own wishes
  • Contributing to others – a legacy
  • At peace surrounded by loved ones - most people wish for a home or home-like death.  The ICU isn't a peaceful place necessarily, but at times I've felt a spiritual connection when tubes are removed, monitors turned off, and the family holding and talking quietly to their loved one at the end.

2 comments:

  1. Not sure you can answer these questions, but I've bookmarked this page to come back and check: regarding withdrawal of life support measures, which measures are required for comfort in death and which are not? If liquids and air are withheld, is there evidence that patients who opt for this suffer because they are dying thirsty or suffocating? If a patient opts for CPR, IV hydration and assisted ventilation, but no feeding tube, do they suffer because they are being starved to death? Would their suffering under these circumstances be prolonged, because they would live longer? Thank you.

    ReplyDelete
  2. Thanks for your questions. In general, with good palliative care technique, suffering can be well controlled. 70% of deaths in the ICU are related to withdrawal of life support (the ventilator) when all attempts to cure have failed. Usually morphine and sedation are titrated to provide comfort and the patient does not experience air hunger. This is simply allowing a natural death to happen.
    In terms of tube feeding, this can at times be withdrawn from a patient with severe brain damage - like the Teri Shaivo case. Again with appropriate use of narcotics and/or sedation the patient need not suffer. When tube feeding is stopped, it wouldn't make sense to continue a ventilator to support breathing. At times patients at the end of their lives will simply stop eating and drinking. This may happen more often than we know.

    ReplyDelete