(Dr. Tammy Yu is an Internal Medicine and General Physician in University City, Philadelphia. She practices at Penn Medicine Surgery in University Penn Health System Oto and Pigmented Lesion Clinic. She completed her fellowship in Nephrology from University Of Pennsylvania in 2025, residency in Internal Medicine from Brown University in 2023 and MD degree in 2028 from Brown University in 2020. This article, used with permission, was published online at https://bhm.scholasticahq.com/article/66289-a-good-death.)
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“I know she’s dying. I just want her to be respected.”
A patient’s daughter had brought her back to the hospital only a few days after she had been discharged to home hospice, requesting that her mother be admitted for further treatment. Multiple providers, from the emergency medicine resident all the way up to the medicine triage attending, had attempted to parse this sudden change. The patient herself, a frail, cachectic woman in her 90s with severe dementia (as just the start of the list of ailments) lay unresponsive in bed, having received protocol treatments on her way up to the hospital floor. To our eyes, she was clearly dying. Did her family not want her to pass away at home? (Editor’s note: cachectic means emaciated, with severe muscle and fat loss.)
I stood across from the daughter, listening to her explain. Her mother had experienced a steep cognitive and functional decline over the past three months, accelerated by a series of admissions for various medical issues. She still lived at home but increasingly relied on family to manage her daily needs. She was also no longer able to consistently take her medications.
Given this pattern of decline, the palliative care service had been involved during the patient’s most recent hospital admission. After discussion with the medical and palliative teams, her family had agreed that home hospice, along with a “Do Not Hospitalize” advanced directive, made the most sense.
Her chronic medications had been discontinued in an attempt to decrease the medicating regimen. As-needed sublingual morphine had been provided for pain and air hunger. Home caretaker services had been offered to help offload some of the burden from her family, but the daughter had declined, since she had always been able to care for her mother.
Within days of discharge, Mom’s condition changed. Her family did not feel comfortable using the morphine: They felt it was only masking the underlying problem at best, and at worst, hastening her death. Her daughter had also grown increasingly concerned that she could no longer provide care at home, as the mother had completely lost the ability to feed or reposition herself. These factors had driven the patient’s daughter and son-in-law to bring her to the hospital.
The family knew she was dying, and they did not want interventions that would cause suffering in an attempt to prolong her life. However, it was clear that her current level of care was not meeting end-of-life needs.
We admitted Mom and continued supplemental oxygen and nebulizer treatments for symptomatic relief. After a careful discussion about the rationale behind morphine therapy, her family was open to its use. She died peacefully the next morning with her loved ones beside her.
Was this the most direct route to respect for the patient? Make sure acceptance and patience are in every caretaker’s toolkit – and compassionate listening in the practitioner’s repertoire.
Good and Bad Deaths
What is a “good” death?
We all have stories of “bad” deaths from the view of those left behind. They are some of the most emotionally charged events we experience in medicine: the COVID-era deaths when we, masked and face-shielded, carried iPads into patients’ rooms so families could say goodbye over video call; the husband who walked away, stunned, after his wife coded unexpectedly in the ICU; the 20-year-old who died alone in the hospital and estranged from his family.
Studies on bad deaths, as perceived by families and providers, have identified several universal themes: dying alone, unrelieved physical and emotional suffering, miscommunication among patients and the care team, and the use of futile life-supporting interventions. Unexpected deaths were traumatic for both families and staff.
On the other hand, families also emphasized the stress of a slow decline marked by the dreaded cycle of hospital readmissions, loss of function, prognostic uncertainty, and diminishing hope. When one of my patients died suddenly from an unexpected GI bleed, after a prolonged period of cognitive and physical decline, his son told me, “I don’t want to say it, but this is almost a relief. You never met my real father. We lost him a long time ago.”
It is harder to define a good death, studied only through the lens of those left behind. The concept is both deeply personal and rooted in the broader cultural narrative on when, how, and where death should ideally occur.
No event has reshaped the cultural landscape more than the rise of modern medicine, which not only has turned many previously fatal disease processes into manageable conditions, but also has prolonged and medicalized the dying process. Until recently, most people could expect to pass away at home, with their family members providing the majority of end-of-life care and support. Now, our patients often spend the last few months of their lives moving in and out of acute care settings, receiving treatment-directed care up until the time of death.
“Dying,” as DelVecchio et al. note, “is difficult, particularly in the modern hospital where there are so many treatment options and where relationships are short, discontinuous, without a perspective on the patient as a person, and with little time to acquire it.”
The modern hospice movement arose in response to a growing realization that aggressive treatment can cause more harm than good, particularly at the end of life when the benefits of continuing treatment become increasingly marginal. It seeks to reframe the goal away from treating disease and toward caring for the whole patient.
Several principles have emerged from the hospice literature on what constitutes a good death: consistent communication from the care team, treatment of patients as individuals rather than diagnoses, attention to both physical symptoms and psychosocial stressors, preservation of patients’ dignity and decision-making agency whenever possible, respect for family members as caretakers and advocates, and closure for family after death.
Trends are changing. Over the last decade, deaths at home and in hospice settings have surpassed hospital deaths for the first time since the early 20th century. For many patients and families, the ideal end-of-life scenario remains a death at home surrounded by loved ones. Applying the same model to every patient, however, can erase the complexities of each person’s situation. With adequate planning, good end-of-life care can be achieved in acute care settings.
Dying in a hospital setting may even be preferable under specific circumstances, such as the need for more frequent care or specific therapies. A patient’s family, for instance, was overwhelmed by her relatively rapid functional decline once she was discharged. While the transition back to a hospital in the last hours of life was not ideal – and may perhaps have been avoided by further exploration of her family’s goals and expectations prior to her return home – it allowed her care needs to be met while freeing her family to focus on saying goodbye. Ultimately, “access to loving, competent caregivers [is] more important than the location of dying.”
Similarly, there is no absolute dichotomy between “natural” and “medicalized” death. Certain medical treatments, such as antibiotics and blood transfusions, can contribute to the dying person’s comfort and their ability to engage with the world around them. It is best to take an individualized approach to each therapy. A patient’s chronic medications can become more burdensome than beneficial, but inhalers can be an indispensable part of end-of-life symptom management.
Each person’s needs are different, and only by asking can we begin to understand.
This profession humbles us. For all the power of modern medicine, we can seldom reverse a progressive disease process, and sometimes we cannot even stop the acute decompensations. But we owe it to our patients to explain the medical situation plainly, to listen to their wishes, and to help them delineate a plan so they live and die as they would have wanted to under the circumstances.
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Final Exit Network (FEN) is a network of dedicated professionals and caring, trained volunteers who support mentally competent adults as they navigate their end-of-life journey. Established in 2004, FEN seeks to educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence and defend a person’s right to choose. For more information, go to www.finalexitnetwork.org.
Payments and donations are tax deductible to the full extent allowed by law. Final Exit Network is a 501(c)3 nonprofit organization.
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Yes. This makes so much sense. My Mom died in hospice care at a group home after about a week. She had expressed her wish to finish her journey after 2 strokes. We children were able to be with her round the clock there without disruptions that hospital care would entail. I hope she would agree with our care, but it was difficult to know. It left us feeling we did our best.
Families have to rely on medical advice. It was comforting to read here that a hospitalization does not have to result in a lengthening of suffering for a frail patient, and can also aid the family in knowing their did their best for her.