A Good Death and How to Achieve It
Is it possible to create a good death? Or is someone simply lucky if he or she dies well? These are the fascinating questions Dr. Ira Byock, a professor at Dartmouth Medical School, raises in his important 1997 book, Dying Well: Peace and Possibilities at the End of Life.
Both my parents have died (four years apart), and neither experienced what Byock would call a good death. None of us in the family—neither my parents, nor their three sons, nor their eleven grandchildren—experienced increased closeness, expressed much gratitude or affection, or offered much in the way of tender goodbyes. In retrospect, I fear that my parents felt lonely and frightened as they were dying.
This sad experience has led me to think about whether it’s possible to prevent the kind of suffering my parents experienced—in short, to die better. Can someone create meaning and purpose out of the dying process?
Byock says a good death includes expressing love (for example, saying I love you), accepting love, thanking loved ones, expressing appreciation, forgiving, apologizing, and saying goodbye.
The goal is to find peace and satisfaction by completing and resolving the issues that deeply matter. Of course, there is no need to wait until the last year of your life to do these things.
But let’s get real for a moment. Dying isn’t pretty. An implacable and ravaging illness can undermine your sense of who you are. Your very identity, what gives your life purpose and meaning, can wither and bring on feelings of profound despair.
When deteriorating, you are no longer all those things—father or mother, husband or wife, nurturer, initiator, organizer, caregiver, resource, breadwinner—that once defined you as a person. You are no longer living as you did at your peak. All the “work” that used to give your life meaning has disappeared.
In dying, you become a different person. The strong, independent, loving person you once were painfully fades away and the memories of you in peak health grow faint. You can no longer fulfill your responsibilities and in fact have become a burden to those you love. Sickness and senility leave you a far less appealing and attractive person.
In the face of losing your responsibilities, roles, and abilities, is it still possible for you to have mastery in some sense as you weaken inexorably and slip towards death? How do you avoid feelings of helplessness, humiliation, fear, and despair? These are the issues that Byock’s book grapples with. He argues persuasively that a dying person and his or her family can take many steps to achieve a good death.
One of them is not to let doctors do what they’ve been taught to do in medical school. Doctors are taught to give patients aggressive life-prolonging treatments and to keep them alive by whatever means possible. This makes no sense if the only thing accomplished is to delay death by a few days accompanied by intense pain, suffering, and even trauma (to say nothing of the incredible expense). What is the point of allowing a semi-conscious, terminally ill patient to linger? We don’t treat our dogs this inhumanely. Each of us has a right to choose a good death.
Good deaths can also be prevented by failing to control pain, especially when it is agonizing and explosive. I’d rather be sedated than be in unbearable pain or have my family see me in such pain. I know there is a fine line between sedation for the treatment of extreme terminal pain and euthanasia. Byock points out in his book that the line between ensuring comfort and hastening death—between refusing unwanted medical intervention and euthanasia—is a fine one.
For some, a good death means assisted suicide, but, says Byock, better efforts by doctors at relieving pain might make discussions of assisted suicide or euthanasia less necessary.
A good death is fundamentally about a person experiencing something that has meaning and value. Is it possible to transform the experience of dying into a process which includes peace and serenity? The question may seem absurd when most of us associate dying with emotional anguish and extreme misery, exacerbated by the morbid prospect of annihilation and leaving projects unfinished. Still, it’s a question worth asking and Ira Byock provides a great service by provoking his readers to reflect on how it might be possible.
This coming March, Dr. Byock will publish a new book called The Best Care Possible. I will be the first in line to buy it.