Thoughts about a good death and dignity in dying

Those of us who hope for a good death have accepted that all living things die in due course. What concerns us is how we die. Most of us have had some experience with the dying of others–family members, close friends, even pets–which often is what motivates us to explore this issue of having a good death.

Nothing is more personal than how we define a good death, yet our definition may not be obvious at first. Consideration of this question leads me to the idea that a good death is a dignified death; that is, the dying process is dignified. To maintain dignity in the dying process depends greatly on how our death comes. If it comes through violent means, dignity may not be found. And violence comes in many forms–from a weapon, by hanging, by jumping, by receiving unwanted CPR, ingesting caustic substances, and other ways.

A violent death usually means that we have lost control of our dying. Perhaps it always means that. This explains, in part, why the Final Exit Network (FEN) disclaims dying by violent means. FEN supports instead a right of every person to have a peaceful death. If we can also choose the timing, that is about as much as we can hope for.

I’ve written about what a “good death” means to those with whom I have discussed the subject, and now we have a study in the American Journal of Geriatric Psychiatry that may shed some light on what kinds of deaths many (or most) of us want. But in thinking about this research and considering what a good death means to many people, I realized that a good death is always described in terms of dignity, usually including a dignified dying process.

For some of us, the dying process may not be a process at all. I’m thinking of someone whose heart stops while they sleep, or who is killed instantly during an automobile accident. But most of us will have some time, whether brief or drawn out, when we know that we will die relatively soon, or soon begin to lose awareness and cognition essential to our perception of who we are. A good death depends, for most of us, on how we die. And how we die can determine whether we will have dignity in dying–a good death.

One way to view dignity in dying is to look at the characteristics of a good death. The Geriatric Psychiatry article suggests the following thematic characteristics as having the most agreement between patients, family, and health care providers:

• a preferred dying process
• freedom from pain
• emotional well-being

Most people I have encountered throughout my life have wanted to be in control, to the extent possible, of their dying process–how they die, where they die, who will be with them, whom they want to visit with before they die, whom they want to say something special or particular to, how their pain and other unwanted symptoms will be controlled, how long the process will take, and related matters. If the dying process is successful, their preferences will be achieved, unwanted symptoms will be ameliorated, and they will have emotional comfort. This will be a good death because the dying process is dignified.

Being in control of our dying means, for most people, that they have taken care of putting their lives in order before they die, and this may contribute to a feeling of satisfaction and of dignity. There is satisfaction, esteem, and dignity in being responsible about the details of our lives. For instance, many people want to be sure that their estate is in order. They want to make known to appropriate survivors what disposition arrangements are desired and assure that there are adequate funds to pay the cost of the arrangements. [For more information about this, look back at this post.]

Taking care of these matters often gives peace of mind to those contemplating death, contributing to their emotional well-being, and helping to assure a dignified dying process.

Psychologist Charles Garfield offers advice about a good death based on his work with cancer patients that began over forty years ago. He has served as a Clinical Professor of Psychology in the Department of Psychiatry at the University of California School of Medicine at San Francisco (UCSF), a Fellow of the American Psychological Association, and as a Visiting Scholar at the Graduate Theological Union in Berkeley. He writes, “What I’ve learned through my experience is that what people most need on their deathbed is to be heard—to have their wishes considered and, whenever possible, fulfilled.”

Garfield agrees that dying patients should “experience as little pain as possible.” He includes not only physical pain, but what he terms “psycho-social” and spiritual pain. The latter kind of pain may be eased by the presence of someone who can focus, one way or another, on whatever spiritual concerns the patient may have. The psycho-social pain may revolve around relationships. Recognizing and resolving interpersonal conflicts can often be accomplished, according to Garfield, by relying on four messages suggested by Ira Byock, a palliative care doctor:

• I love you
• Thank you.
• I forgive you
• Please forgive me

For Garfield, “a good death creates a space for people to say those words.” He believes it is important also that a dying patient “satisfy any remaining wishes that are consistent with their present condition.” But these must be the wishes of the patient, not of someone else. He emphasizes the importance of being present for the dying person, often without doing anything but being there.

As we have learned from many people FEN has served, and from those who have used the physician-assisted dying (PAD) laws in Oregon and elsewhere, dignity can be found in having that final choice, knowing that the dying person has control of a future, however limited, and the end-of-life decisions important to her.

Brittany Maynard, who was 29 years old when she died using Oregon’s PAD law, explained her decision in an essay for CNN. Her final Facebook post on the day of her death read: “Goodbye to all my dear friends and family that I love. Today is the day I have chosen to pass away with dignity in the face of my terminal illness, this terrible brain cancer that has taken so much from me … but would have taken so much more.”

These are the things I mean when I speak of dying with dignity and finding a good death. They apply whether facing a terminal illness or irreversible health conditions that destroy the ability to have a satisfying life on acceptable terms.