What do you see when you picture an ideal death?
Are you surrounded by friends and family members, or is the setting more intimate? Are you at a hospital or at home? Are you pain-free? Were you able to feed yourself up until your death? Is there a spiritual element to your experience?
"We talk about personal medicine, but there should be personalized death too," said Dr. Dilip Jeste, director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego School of Medicine. "Finding out what kind of death a person would like to have should not be a taboo topic."
To help open up the conversation in our death-phobic culture, Jeste and his colleagues are working on a broad definition of a "good death" that will help healthcare workers and family members ensure that a dying person's final moments are as comfortable and meaningful as possible.
"You can make it a positive experience for everybody," Jeste said. "Yes, it is a sad experience, but knowing it is inevitable, let us see what we can do that will help."
The group's first step was to look at previously published studies that examined what constitutes a good death according to people who are dying, their family members and healthcare workers.
The results were published this week in the American Journal of Geriatric Psychiatry.
The researchers searched through two large research databases -- PubMed and PsycINFO -- but they were able to find only 36 articles in the last 20 years that were relevant to their work.
Jeste said the lack of studies on a good death was not surprising.
"We don't want to deal with unpleasant things, and there is nothing good that we associate with death, so why do research on it?" he said.
The articles the team did find included studies done in the United States, Japan, the Netherlands, Iran, Israel and Turkey.
From these, they identified 11 different themes that contribute to successful dying including dignity, pain-free status, quality of life, family, emotional well being, and religiosity and spirituality. Also on the list were life completion, treatment preferences, preference for dying process, relationship with healthcare provider, and "other."
The authors report that the most important elements of a good death differ depending on whom you ask, but there was agreement on some of them.
One hundred percent of patients and family members as well as 94% of healthcare workers said preference for the dying process -- defined as getting to choose who is with you when you die, as well as where and when -- is an important element of a successful death.
There was also widespread agreement that being pain-free at the time of death is an important component of successful dying. Ninety percent of family members, 85% of patients and 83% of healthcare workers mentioned it across the various studies.
Religiosity and spirituality -- meeting with clergy, having faith, and receiving religious or spiritual comfort -- appeared to be significantly more important to the definition of a good death by those who were dying than to family members or healthcare workers. The authors report that this theme was brought up by 65% of patients, but just 59% of healthcare workers and 50% of family members.
Family members were more concerned with the idea of dignity --defined here as being respected as an individual and having independence -- at the end of life than either healthcare workers or patients were. The idea that dignity was an important element of a good death was brought up by 80% of family members, but just 61% of healthcare workers and 55% of patients.
Similarly, having a good quality of life --meaning living as usual, and believing life is worth living even at the end-- was listed as an important part of a good death by 70% of family members, but just 35% of patients and 22% of healthcare workers.
"For a dying person, the concerns seem to be more existential and psychological and less physical," Jeste said.
And here the authors see a call to action.
"Although it is important that we attend to the patient's physical symptoms... it is crucial that the healthcare system... more closely address psychological, social and spirituality themes in the end-of-life care for both patients and families," they write.
They also say this work is just the start of a much longer conversation.
Jeste hopes that one day terminally ill patients might receive a checklist that will help them think about and express what they consider a good death so that family members and healthcare workers can help them achieve it.
"We are not just interested in research," Jeste said. "We are interested in improving well being."
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