Dying a “good death”

I cannot help but resist posting my own thoughts on the debate spurred by Dr. Richard Smith’s BMJ article “Dying of cancer is the best death”. As I read Dr. Smith’s post I found myself nodding, agreeing that death by cancer was preferable to sudden death, organ failure, or dementia. This, despite a lifetime history of always stating that I would prefer a sudden death in my sleep. This new “preference”, however, was subconsciously tied to the vision of myself or one of my patients as an elderly man having lived a long and fulfilling life.

Then I read an excellent rebuttal from Marie Ennis-O’Connor, “Is dying of cancer really the best way to die?”. I was brought back to the reality that although some cancer patients have excellent palliative care and a comfortable decline towards death, a large number of cancer patients are not able to be kept comfortable and suffer tremendously. Also, Marie points out younger patients (such as mothers of young children) would never choose cancer as a means of death. I agree, but I don’t think it relates to age; any person who is nowhere near ready to die and still has long term goals in life has no good option when it comes to their means of dying.

Finally, @cancergeek posted his thoughts about “The choice in dying”. Yet again I was brought back to the cold reality that none of us get to choose the cause of our death; we only get to choose how we react to it. I was struck by the eloquence of his statement “[the] physical body withers away…in the struggle between taking their last breath in life and their first breath in death”. I have to disagree though with his statement that “Physicians romanticize their ability to heal, to help, to shelter their patients from the reality that we all die”. I believe physicians are more realistic about the chances of treatment than our patients, but that the public perception is that medicine has advanced to the point where doctors can fix anything, and this has led to an increasing demand for likely futile therapies in patients with advanced disease.

No one gets to choose what takes their life. But they can choose the
1. “How”: how to live their life with a terminal illness
2. “Where”: where to live their final days and where they die
3. “Who”: who to spend their remaining time with
4. “When”: in places where physician-assisted dying is available, patients gain the autonomy (should they choose) to decide when they die

These choices are best made when patients are well informed and realistic regarding their prognosis and the likely progression of their disease. And that is why doctors need to get better at talking about end of life decisions, at an earlier stage of patients’ illness. The stigma around discussing death needs to be lifted to improve end-of-life care for all.