What is a Good Death?
So live your life that the fear of death can never enter your heart. ...
Chief Tecumseh – Shawnee nation
How long is a piece of string? How many atoms are there in the Universe? What is a good death? These questions are seemingly unanswerable, or at the very least there are as many answers to the questions are there are those asking the questions. The question of what is ‘good’ also needs to be defined. The oxford dictionary describes good as something to be desired or approved of, pleasing or welcome. So to whom is the good death referring too? The one taking the journey or those witnessing it? Individuals and institutions can and do try to condense the myriad of ideas, thoughts and practices into lists, and guidelines to help and assist in defining what a good death can be , but are these lists too little too late and somewhat a one size fits all approach perhaps a good death is only as good as the life that is lived.
There seems to be a growing disconnect between living and dying. The medicalisation of death has contributed to this as it attempts time and time again to defeat death, with treatments and interventions. We no longer see death as a normal part of living but as the failure of the medical system to keep us alive. When Dr Atul Gawande was asked by Leigh Sales on the 7.30 report (21.05.2015) Is there such a thing as a good death? His response was that he was bothered by the goal being a good death, and should it not be having lived a good as life as possible for as long as possible. As Epicurus stated the art of living well and dying well are one
In Dr Ira Byock book The Four Things That Matter Most (2004) he explores and discusses the idea that at the end of life 4 things are most important to the death journeyer and those walking along side them.
I love you
I forgive you
Please forgive me
Thank you
While these 4 things may appear simplistic or even obvious, they can actually be very powerful tools in self reckoning the value of our lives.
Can we say we have truly loved another (and been loved) ? what is love anyway? And how have we given and received it selflessly and unconditionally.
Can we forgive another? We are not being asked to entirely forget past deeds but to let go of a past to enable a better future together. Do we have the courage to recognise and accept our frail humanity where we all make mistakes and are less than perfect and can acknowledge this by seeking and offering forgiveness? Perhaps holding onto a painful past prohibits us from moving gracefully into an unknown future.
And finally Thank you; to find a positive in every situation no matter how small or mundane it may appear fosters the amazing act of gratitude. Gratitude it can be said, and certainly in my opinion one of the most powerful and beneficial of human emotions.
For the death journeyer and those walking alongside to have these shared experiences if not throughout a life time together then certainly as the end of life draws closer, can bring a peace and acceptance of death that enables the process to be a more fulfilling and acceptable to everyone concerned. As Rilke says,” The great secret of death is that in taking a loved one from us it not only wounds us but it also lifts us towards a more perfect understanding of this being and of ourselves.”
The list below has been identified as the 12 principles of a ‘good death’. First Introduced in a report on the future of health care of older people as early as 1999 The principles were quoted by BMJ editor Richard Smith in a piece written in 2000. This same list was used again by the Grattan institute in 2014 in a report on dying well (Hal Swerissen and Stephen Ducket), over 14 years after it was first published
To know when death is coming and to understand what can be expected
To be able to retain control of what happens
To be afforded dignity and privacy
To have control over pain relief and other symptom control
To have a choice and control over where death occurs (at home or elsewhere)
To have access to information and expertise of whatever kind is necessary
To have access to any spiritual or emotional support required
To have access to hospice care in any location including home, not only in hospital
To have control over who is present and who shares the end
To be able to issue advanced directives that ensure wishes are respected
To have time to say goodbye, and control over other aspects of timing
To be able to leave when its time to go, and not to have life prolonged pointlessly
This list was said to be devised from three themes of control, autonomy and independence (A Good death BMJ Richard Smith 2000). However on reading them nearly all 12 are related in some way to having control over the physical end of life. Sadly this ideal is probably a little more Hollywood than reality. As Atul Gawande says theres some extent to which death and dying is never pretty and not in your control (7.30 report 21.05.2015). Acceptance is key; it’s the ability to accept whatever the moment brings. Resistance only results in further suffering.
So what if we were to combine both of these ideas and principals and take a more holistic approach to death. Instead of themes of control autonomy and independence being applied to end of life and a good death… perhaps a theme of, Body, soul, and spirit, (hands, heart and head) could be applied. Those words: hands, heart and head are often used to in relation to the delivery of care
Are our physical needs being taken care of (body)
Are we at peace with the 4 things that matter most (soul)
Have we sorted through all our baggage both external and internal to enable us to leave this life (spirit)
As humans we are a lot more than just our physical self. We are made up of minerals like earth and rocks, we have form and shape like the plants, instincts and voluntary movement like animals, but as human beings we also have a self-consciousness, and this is what makes us truly unique and individual. Therefore our journey to death and beyond is a truly unique experience. There are certainly general things which can be done and decisions which can be made to assist us in having a ‘good death’ such as looking after physical comfort and being surrounded by love, warmth, but the journey to the goodest death possible is ours and ours alone and will always be a reflection of the life that we have lived to the very end, and there is always the possibility of change and redemption up to the very last breath we breathe into our physical bodies.
…When your time comes to die, be not like those whose hearts are filled with fear of death, so that when their time comes they weep and pray for a little more time to live their lives over again in a different way. Sing your death song, and die like a hero going home.
Chief Tecumseh – Shawnee nation