1.4.13 Defining a ‘good death’
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Read ‘The good death?’ by Mary Bradbury. She suggests three representations of ‘a good death’. Try to categorise the case study deaths above using her criteria of a ‘medicalised’ good death, a ‘sacred’ good death and a ‘natural’ good death.
Many of the testers found this exercise difficult because, as they noted, deaths are not so easily categorised. Some testers told us that they found themselves becoming particularly aware of their difficulty with the term ‘natural’. The case study deaths were complex, but that is often the reality. Some testers also highlighted the subjective nature of the exercise. These are all valid comments and you may agree with them. There are no right and wrong answers as to what constitutes a good death. They are a useful way of thinking about death and hopefully they will have challenged and stimulated your thinking in the same way that they did the testers’. The following comments are from both the testers and course authors.
Vic was given optimum medical treatment; care was taken to represent his religious needs, but no one knows whether these coincided with his own wishes. Despite the prematurity of his death, Vic was not treated so aggressively that he was kept alive artificially. If you agree with some of the comments from course testers that the treatment was poorly managed then you might have categorised the death as a bad one medically. One of the testers described Vic’s death as falling outside the sacred/medical ‘good death’ categories.
Li’s death was well managed medically, in that she was in a nursing home receiving good quality care but was not being treated with inappropriate invasive procedures. Also Li’s final wishes were related to her spiritual needs, which were both cultural and religious. Dying at the end of a long and relatively good life could be considered to be a natural death.
Andrew died despite all medical attempts to cure his cancer. We don’t know his religious beliefs but the accompanied stage of dying seems to have fulfilled a spiritual need for Andrew and his mother to be together at the end of his life – to be accompanied and in familiar surroundings. There was also evidence that Andrew was afraid the night before his death, which influenced some of the testers’ comments on the spiritual dimension of the death. Again, Andrew’s young age seems to contradict the timeliness of his death, but dying without life-sustaining interventions suggests one dimension of a natural death. Alternatively, the treatment of the symptoms resulted in the death being categorised as medical.
Meg’s death was not a good medical death because it was not anticipated and the direct cause was unknown, but medicine had kept her alive longer than she would have otherwise lived. The treatment did prolong Meg’s life but there was a cost. Meg had a strong faith but no one knows if she was ready in a religious sense. Because her death was premature and the result of a degenerative disorder and because of attempts to resuscitate her, the death was not natural. Meg’s body was subjected to a lot of medical intervention in an attempt to reverse death. However, the suddenness of the death could have spared her from much more intensive medical rescue and could also have spared her some of the fear which may precede death.
The lesson to be learned from Mary Bradbury’s article is that a death can only be judged ‘good’ in relation to specific criteria: it will depend upon which criteria you are using. This should not lead to a conclusion that a ‘good’ death is not achievable but that the quality of dying will be judged differently by different people, as we have seen from the comments. Even then the dimensions were not always clear and often highly subjective. What did seem to be clear from the testers’ comments was that we can never be certain of giving someone the type of death they want without ascertaining their wishes.
Hart et al. (1998) argue that the ‘good death’ is a form of social control and ask whose interests the ‘good death’ serves and to what extent the choices of dying people are increased or constrained by this ideology. They further suggest that ‘good’ and ‘bad’ deaths connect to stereotypes of ‘good’ and ‘bad’ patients who do and do not conform to expected norms of behaviour. While they argue that the ‘good death’ which has emerged from the hospice movement may serve the interests of dying people and their care-givers, they also point out that there are significant challenges from the pro-euthanasia movement and other struggles which support the needs of dying people. Euthanasia is an area of considerable debate and you might like to consider in what circumstances the ‘good death’ does not suit everyone.
As we draw to a close we remind ourselves of other factors that contribute to our assessment of a death as ‘good’ or ‘bad’. Issues of social inequality and deprivation affect the dying as well as the living, and these should be high on any agenda to improve the quality of dying.