What Makes a "Good Death"?

Mallory McClester, MD, is a first-year geriatric fellow in the Division of Geriatrics at the University of North Carolina (UNC) School of Medicine, Chapel Hill, NC. She was previously co-chief resident, Department of Family Medicine, UNC. Dr. McClester's blog is about her experiences as a geriatric fellow.

Throughout my family medicine residency, I had a handful of my own personal patients die. One from liver disease, one from drug overdose, one from metastatic cancer. That was over the span of 3 years. In just 2 months of geriatric fellowship, I have already cared for four patients who have passed away.

In life, there are few things that are absolutely certain. One is that we are born. The other is that at some point we all die. So, over the years, many of my colleagues and friends have said to me, “Why would you want to enter the field of geriatrics? All your patients die.” We all know there is some truth to this. But, I am repeatedly struck by how much modern medicine can do to make this happen peacefully and with dignity.

As I mentioned, so far in fellowship I have been actively involved in the care of four patients who died and I was more passively involved in several other cases. The fact I am finishing my palliative care rotation certainly adds to the increased frequency of end-of-life care. And on top of that, one of my closest friends recently lost her mother to her battle with cancer. All of these deaths, a phenomenon that I infrequently encountered in residency, made me revisit what I think is important in the care of those facing death and dying.

My first encounter, a gentleman in the health center of my long-term care community, was surrounded by family. His dementia prevented me from knowing him well, but he was well known to staff and other residents. His passing happened quickly and it was a surprise to many. There were tears in his room at the time of death, but also happy memories to be shared. Most importantly for all of those involved, he died peacefully with excellent symptom management.

The next patient was a elderly woman with end-stage dementia left alone in a hospital bed, passing away in her sleep. This is a blessing that, in my experience, many people wish for. She also seemed to have excellent symptom control and to the best of our knowledge died comfortably. Her husband had said goodbye days earlier and had not returned to her bedside.

A third patient, a 65-year-old man with a multitude of medical issues, had been on our geriatric inpatient service throughout most of the month. He and his wife had been actively involved in decision making about his goals of care, stating clearly that he did not want to be rehospitalized even if his infection was to worsen. He died peacefully in the facility to which he had been discharged with his wife close by.

Another gentleman was weaned from his ventilator and his life ended with respiratory distress. Our palliative care service was able to aid in excellent symptom management. His wife was at his bedside while he peacefully slipped away.

The most difficult for me was the death of a young man again surrounded by his family. Again, he was a patient with significant illness, with what was felt to be excellent symptom management. The hardest part for me, to be completely honest, was his youth.

In each scenario, there are two key factors or themes that I have identified as being key to a “good death”. The first is comfort. Symptom management seems an absolute necessity for a “good” death. In order to have good symptom control, it seems that typically you need one of two things; you need to be in the right place (for these patients, this was in the hospital or a facility with hospice) or have the right caregiver/advocate to fight for your needs. Especially in those without a clear voice (dementia, intubated, or otherwise), best care goes to those who are monitored closely whether by nursing staff or by an advocate. Maybe “good death” translates to “peaceful death” in some ways.

The second key factor is family. The family members involved struggle, suffer, and grieve the loss from the first moment they know the end is near until much later. My toughest residency loss did not get the support that she needed before her husband’s untimely passing. Now months later she is finally moving on with her life. All of the patient’s families mentioned above had either additional support from clergy, counselors, case managers, or at least from the physicians. Grief is a hard road, and having some extra cushion certainly seems to help those along their way whether that is a shoulder to cry on, an additional body to bounce ideas off of, or a smile in Starbucks.