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.

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4 thoughts on “Dying a “good death”

  1. Thanks for sharing your perspective as a doctor on this. On more reasoned reflection today I can see there is some truth in what Richard Smith writes, however I still take exception to his simplistic ideal of having quality time before dying because you have cancer. I know from personal experience this isn’t always the case. I am glad we can have more open discussions on this – we need to keep the conversations going.

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  2. Hi Dr Detsky,
    I was an ePatient Scholar at MedicineX 2013, selected because of my as-a-layperson immersion in (some say obsession with) communication and education about end of life medical options and decisions.

    As a result, I now sit on Palliative committees, advisory boards and speak at health conferences. I give this this background to give context to my reaction to a couple of things in your post:

    <>

    Even those who are comfortable and/or motivated to talk about dying and death regularly find themselves not knowing exactly what to talk about, or the realities of their decisions – often this applies to healthcare professionals as well as us ‘non’.

    An example: “Where to you want to die” According to every poll, we all want to die at home. Yet few of us ‘non’ have been trained to handle crises that may arise as life winds down:. Shortness of breath, pain, delirium, agitation, bleeding, infections, a fall, an injury.

    Studies also show that even Health care professionals can be profoundly impacted by end of life ‘discussions’. As a public member on the West Park Health Center Supportive and Palliative Steering Committee, I consistently hear from healthcare professionals across the board (nurses, respiratory therapists, physio and occupational therapists, speech language pathologists etc) of their confusion, anxiety, tension, differing treatment opinions – along with fear and guilt – about discussing end of life options and repercussions. .

    While talking, learning, discussing, planning sharing is never a bad idea, the assumption that these steps will lead to calmly determining the ‘right’ plan doesn’t pay proper due to fears, hopes, expectations and emotions that accompany the tricky topic of dying and death.

    When I video’d a group of culturally diverse friends answering the question, Why is it so hard to talk about dying the answer that struck us all: “You never know what emotions you’ve put in a closet and now they all come tumbling out “
    http://www.bestendings.com/index.php/blog/bestendings-video-chat-talking-about-dying

    To quote Dr Robert Arnold, in his post on Pallimed.org: Are goals of care conversations about emotions or facts?
    http://www.pallimed.org/2014/12/cases-are-goals-of-care-conversations.html

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