We like to talk about “a good death.” But how often does this really happen?

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  1. Frank Gavin

    Thank you, Andreas. This is such an important topic.

    After reading this I thought of the distinction Daniel Kahneman makes (in Thinking Fast and Slow) between the experiencing self and the remembering self. For those who are close to the person who has died–and maybe this also applies to the care-providing doctors, nurses, etc.–what is remembered and/or focused upon in relation to the death and the whole experience of dying will change over time, inevitably. This isn’t a matter of falsifying the experience but of seeing it from a different perspective. That’s why the goodness of a particular kindness will grow in significance–and why a particular cruelty or display of indifference will wound more deeply.

  2. Pat Kelly

    Thoughtful and candid writing about a fearsome issue.

    Being with people at the end of life, we can never know if indeed, it was “a good death”.

    You can ensure in the end of life setting that caregivers have theoretical knowledge, practical skills and hopefully, the personal attitude of compassion and empathy to suffering.

    Your article demonstates the critical importance of developing the moral attitude or values, including respect, thruthfulness and dignity in medical eduction.

    Care for the dying helps physcians learn to tolerate a degree of intimacy and personal engagement that other aspects of medical training discourage.

    Especially in the field of palliative care, the core attitude of authenticity, manifest in relationships, requires a high degree of perceptiveness to contriute to the expereince of a good death.

  3. Caroline Park RN, PhD

    Dr Laupacis,
    Thanks for this interesting opinion/debate starter. It has given me much to think about. I am a seasoned health care provider and a cancer patient. In the last year I have had many thoughts about my own potential death, which is not imminent. I have ideas about how I want my dying to be, which would lead to a “good” death by my definition. How else would you describe death? Do you have other descriptors that don’t bug you? I have not read anything specifically on this topic but I guess the dying person is the only real judge.
    I’ve been wondering if people make dying plans like we made birth plans at another stage of our lives. I was always bugged because the maternity health care team always said, “Don’t count on things going like your birth plan”. Does that mean if I have a death plan I can’t count on it either?

  4. Mike Fraumeni

    Excellent thoughts and ideas, well thought out and personalized. Completely agree with you that the term “good death” is odd in many respects. I know for myself I do wish to die feeling connected to the universe in a personal and meaningful way. And I believe that will happen since I do feel as such now, while living. I don’t know how I’ll die, if I’ll be in pain or if will feel angry, sad etc. But I know I do want to feel connected as I say. Death just “is”, just like being just “is”. I do like this from Paul Tillich – “the courage to die is the test of the courage to be.” To me this means if you have had the courage to keep on living with whatever struggles and hardships come your way, then you will pas the test of having the courage to die with flying colours.

  5. Sharon Moore

    This is a very interesting article. I am a health professional (registered nurse and registered psychologist). Perhaps “meaningful death” is another way to look at it or do we really even need to classify it? I remember taking part in a research study as a participant, about 5 years ago after my father died and completing a survey. There were questions about a “good death” and I kept saying to myself “these questions do not really capture the depth and significance of the experience” and somehow by answering questions with a predetermined response seemed to trivialize the deep and profound experience I and my family lived through.

  6. Gerald Evans

    Nice piece Andreas; I have often thought about this particular subject off & on over the years. Don’t have much to offer other than thanks for putting pen-to-paper on this question.

  7. Nancy Jenkin

    Beautifully felt and said–no judgement,no suggestions.Awareness and appreciation is there to the best of our ability,always,I hope.

  8. Katie Lundon

    I very much appreciated this perspective and agree that a “good death” is not an achievable event. Having the benefit of a year between reading this and my brother’s most untimely death (age 56) it was like a dose of sense ascribed to what was and continues to be a non-sensical event. After committing to 4 trips overseas to be next to him as his closest blood relative and to represent our elderly parents I can attest to watching nothing but suffering through his decline. His wish for an opportunity to expedite his passage following his acknowledgement of the one direction his life was taking was not possible as he lived in Italy. The opportunity with much advocacy was to secure a place in a Palliative care facility in Turin where the mission was to neither expedite nor delay inevitable death. Philosophy aside, I found nothing but the most lovely of human beings providing for his every healthcare need however this did not improve the end point. It did not make a good death. Being there for the demise, knowing that there were no other choices, did however make for the best of the worst journey. Our goal as humans and healthcare providers should be to allow for a safe, kind passage and encourage our loved ones to be part of the process as directed by the individual. I have no regrets about being with my brother through an ugly time and take solace in that he knew I too was there for the journey which was never and will never be viewed as a good death. Buen Camino.

  9. Chris Yen

    Hello doctor Andreas. This is Chris Yen. I used to be on your Citizens’ Council. I want to say thank you for your work. I am visiting a neighbor of mine these days who is currently at St. Michael’s palliative care. I did not see this neighbor for some months and did not find out that he is at the hospital dying until I saw another neighbor last week. Now I try everyday to visit him on my way to work and to let him know that someone does care. I know from past conversations that he did not get along with his grown kids and they had pretty much disowned each other. Sad thing to die without patching things up! I agree that there is probably no good death but at least a peaceful death? My own father who was never sick died in his sleep. That was a peaceful death for my dad, the family was shocked, painfully sadden and we were lost. You have a good heart. I want to tell you that I appreciate what you do very much. Take care and may God bless and look after you. Thanks again doctor Andreas

  10. Frank Gavin

    I’m sorry if I’m breaking a rule by leaving two comments.

    Since reading this I’ve been thinking of the very long history of the idea of “a good death.” It has certainly been often depicted in paintings and described in print for many centuries. It would be good to see how the idea–the ideal?–has changed over time and what the changes reflect, especially about our contemporary views about pain–how much we expect to experience, how close we see the relation between physical pain and mental anguish, how much our particular cultural environments and traditions affect or even determine how we experience and understand pain and how much of it we are willing to tolerate, etc.

    When I taught in a community college one of the essays we used was one by Elisabeth Kubler-Ross in which she contrasted a very good death experienced by a man in Switzerland who had fallen off a tree and was able to say all he wanted to say to family and friends from his bed at home before permanently nodding off with a death of a supposedly typical hospital patient who is the hapless victim of an entirely impersonal and mechanized process. I always thought the contrast was far too neat, even dishonest, and likely to implant or reinforce an expectation that if only we have the right values and a bit of luck pretty much all of us could experience and indeed enjoy the Swiss farmer’s kind of death. Many movies and TV shows have conveyed a similar message, which can lead to terrible disappointment (at best) when death does not come as so depicted to a loved one–or to ourselves This piece, like Atul Gawande’s “Being Mortal,” injects some reality and, perhaps, some realistic hope into the mix.

  11. Kate Wood

    Thank you for these hauntingly honest insights. At best death is the lesser of suffering evils. It’s rare today to see the reasons for acknowledging “death is not good” set out so clearly. It’s valueable. Thanks

  12. Susan Greenfield

    Thank you Andreas. It’s late at night and I am sitting with my beautiful Dad right now at Rockyview Hospital in Calgary. Your words were very comforting to me and my brothers. So true what you reflect on. The connections between Dad and Mom and all of us during this time have been tender and precious and yet it is also comforting to validate the surreal sad weirdness of the exquisite, profound emotions, both sadness and some hilarity. And the underlying fear that Dad might be scared. Anyway we are all here loving him and each other and muddling through. Thanks for your lovely words.

  13. Andreas Laupacis

    I am moved and stimulated by many of the comments made to date. Thank you.

    I briefly thought of responding to each of them directly, but decided that would make the comments section cluttered. So I am penning this overall response.

    If I don’t like “good death” it is a fair question to ask what adjective I’d prefer.

    On twitter, @celinafcarter pointed out that the definition of “good” doesn’t always mean pleasant or enjoyable – “suitable”, “honourable”, “conforming to a standard”, and “adequate” are all listed. However, I am not sure any of those work for me when describing what I want from my death.

    Right now I think I like “meaningful”. I am moved when I see a dying person surrounded by family and friends, sometimes sharing things with each other that they’ve never shared before. As David Giuliano says, “having sacred conversations”. Conversations that benefit both the person who is dying and those who aren’t. Even if there is some pain and shortness of breath in the end, that would seem like a meaningful death to me.

    I think the main reason I wrote the article is that I worry that when we talk about a “good death” in our society these days, we often make death seem unrealistically good, like Frank mentions in his second comment (Frank, you are allowed three).

    Pat – I think lots of health care practitioners have the kinds of moral attitudes and values one wants. Unfortunately, the time pressures of much of medicine make these hard to express. I think I express them better now that I am working as a palliative care physician than when I worked as a general internist and felt like I was on a treadmill admitting and discharging patients as fast as I could.

    Thanks again for all the comments. I’ll end by quoting Katie, talking about her brother’s death.

    “Philosophy aside, I found nothing but the most lovely of human beings providing for his every healthcare need however this did not improve the end point. It did not make a good death. Being there for the demise, knowing that there were no other choices, did however make for the best of the worst journey.”

  14. Susan Bugow

    Thank you for bringing more light to this sensitive matter.

  15. kathy kastner (@KathyKastner)

    I so value your thoughtful and sensitive approach to this topic and concept. To quote psychologist Tony Walter in his book What Death Means Now: Thinking Critically About Dying and Grieving: “There was no golden age when every member of society faced death and loss with equanimity; nor will there be.” Having said that, when someone says to me their mother/father/whomever ‘had a good death’ I always want to learn more, toward sharing via my blog. It means something different for each of us. In most cases, it seems it’s what’s happened right up to death that’s made it a better ending- and felt as such by those left behind. New York Times columnist Paula Span wrote of her father’s most def not a good death: “90 good years. 4 bad days” While the current trend/encouragement to have conversations, and construct an Advance Directive, I wonder if there’s anything that can take away from, or soften the fact of a great gaping loss. Thank you again for sharing your thoughts

    • sam

      I would like to converse with you, what is the name of your blog, or email

  16. Dana

    Lovely article. I too don’t think the term “good” death is appropriate. For me, having attended several home deaths of natural causes, I prefer the term respectful death. However that may be for that person’s values and beleifs.

  17. Lisa Feldstein

    I use the phrase “a good death” from time to time as well. This article certainly puts the phrase in perspective and I am persuaded it may be appropriate to consider other terms. Thanks for a thought-provoking piece.

  18. sam

    Really like this article. I love the fact that you ‘think’. 🙂 It is odd that we now have one more item on our ‘advancing into the future’ list. One more thing to think about, or worry about. It speaks of possibly having a choice, but is it really a choice. Even the ‘best’ death, whatever that looks like, has pain. It gets easier the older people are, since we have it in our heads that between 85 and 100, it is time. I think I’d like to simply vanish, with no one remembering I was here, so that I leave no pain behind, yet this is not a possibility. I think most people really don’t want to leave someone behind that is hurting or grieving too much. And that is where good care comes in, long before the death, care, affirmations and kind treatment by the medical community in case of illness and disease. There can be no good death if all patients have felt is coldness, disconnect or the emotional distancing from their body and mind of the patient. I truly believe we could say we had a good death if good care did not just come right at the end. And for a lot of people, they never experience it at all, not even at the end, save for one sensitive nurse. The bad death then leaves family or loved ones feeling that there was no closure. Palliative teams should not be the only ones concerned with the patient’s time on earth, it should be a medical effort. The narrative of the individual is at stake, if heeded and heard, the family is left to remember the death in a much better way.

  19. William Henderson

    A good death is an ancient Greek idea, and it referred primarily to a death that comes in the midst of what one was in life. It would be a quick or sudden death, often in the midst of one’s work, dying in the traces. The tremendous powers of our medical technologies and their bureaucratic management and administration have generally extended the process of dying. Before the present century, people did not linger as they do now. Death was often sudden. Not always, of course, people with tuberculosis in the nineteeth-centruy often died by degrees, and their death-in-life was miserable, but in less materially advanced cultures, the sick seldom endured. People did not live as long as they do now, and they did not take so long to die. We have extended both life and dying, and it is a reasonable question whether we have improved either. A shorter life of greater physical challenge that ends abruptly when vitality declines may be prefereable to a life with few (or any) physical demands that can be prolonged by medical management and intervention. Our powers have consequences. The appearance of progress may be a mirage. The plowman who died at his work in his 50s, after a lifetime of labor, may have lived a life no more to be regretted than that of a cruise ship idler eating four meals a day who ends up in intensive care on life-support. We all die, and death can be a beneficient deliverance as well as loss. Better, perhaps, to die earlier and faster when our life begins to fail than live on only with the massive intervention and support of machines and technicians in hospital rooms and nursing homes.

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