Due to medical advances over the last half century, people expect to be cured of all their illnesses and live forever. However, death and dying are inevitable. For people facing death as well as for those around them, the process of dying can be stressful. We as physicians can ease the process for our patients, caregivers and ourselves. To be able to do this, we have to understand what dying entails, and then prepare for the event.
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Picture: “6” by Alex Dixon. Lizenz: CC BY-ND 2.0

Stages of Dying

Dr. Elizabeth Kubler-Ross described the following stages of dying: shock, denial, anger, bargaining, depression, acceptance, and decathexis.

When individuals and their relatives are first confronted with the news of a fatal disease, they are shocked.  They cannot accept that the illness could affect them (stage of denial). Then they become angry with the universe, environment and the physicians for their illness. In the next stage they “bargain” with the universe/God to cure them and to prolong their life. Once the disease progresses, they become depressed which is soon followed by acceptance of their fate. In the final stage, they emotionally withdraw (decathexis) and blank out all thoughts of death.

A person going through all these stages is able to set his/her affairs in order, make peace with friends, relatives, and enemies and say goodbye. Unfortunately, not everyone goes through all these stages. When deaths occur suddenly e.g. following a traffic accident, there is no time to say goodbye and there is no closure for the loved ones.

Process of Dying

A majority of patients will follow one of the following paths:

It is difficult for physicians to predict the timing of death but taking into consideration that the patient has a fatal illness which is likely to worsen and death could be imminent within the next 12 months, an estimated time period could be provided. In addition, the physician should:

  • Inform the patient (and their family, with the consent of the patient) regarding the course of the illness, and range of probable survival period.
  • Discuss end of life care – palliative/hospice/resuscitation with the patient and their caregivers. Patients should be provided an opportunity to participate and choose their preferences.
  • Arrange for care
  • Provide medications for symptoms: Opioids are the mainstay for management of pain but are associated with side-effects like constipation which will also require medication
  • Address patient’s ethical, financial and legal issues
  • Manage the patient’s and their caregiver’s stress: arrange religious support; prescribe anxiolytics

Fears/ Goals at the End of Life

Different people have different goals:

  • Some people want to be independent as long as possible
  • Some want spiritual solace and reconciliation or want to ensure that their loved ones are provided for
  • A few want to prolong life irrespective of the cost and stress caused to their families

However, almost all are afraid of dying alone, and in pain. A majority of the patients want to discuss end of life care when they are mentally and physically healthy and they also prefer to involve their family members. It is important for physicians to understand, address and involve the patients and their families in this process.

Financial Concerns

Health care costs have been steadily increasing and often families spend all their savings to prolong the life of a loved one. Families should be advised to investigate the cost of medical care, and insurance coverage necessary to care for a dying family member and determine whether they are able to afford it.

Fatal illnesses are associated with progressive functional disability and patients may not be able to care for themselves. Services such as home care, occupational and physical therapy add to the cost. The health care team should discuss all these issues when discussing options and choices for the patients.

Legal and Ethical Issues

It is important for physicians and health care teams to be aware of the laws concerning physician-assisted suicide, euthanasia, power of attorney, living will and advance directives as they can vary geographically. Only a few states in the United States have laws for physician-assisted suicide. In other states, opioids have to be titrated to provide pain relief and to avoid respiratory depression.

Palliative Care and Hospice

Palliative care encompasses measures to relieve physical, emotional and spiritual issues. It can be and ideally should be, provided concomitant with curative treatments. Palliative care teams are interdisciplinary and consist of physicians, nurses, social workers, chaplains etc. who together help to resolve the patient’s stress.

On the other hand, hospice care is restricted to those who have six months or less to live and aims to provide relief but not cure. Services included under hospice care include nursing, physical care, medications, spiritual counseling, and providing medical equipment like oxygen cylinders, masks etc.  Hospice care can be either hospital based or home based. Patients have the option of enrolling in hospice care or leaving it and re-enrolling in it later.

Planning for Death

Symptom relief is the most important aspect of death planning. A comfort kit consisting of opioids and oxygen is provided by the hospice team for home based care along with instructions about using it.

Family members and caregivers should receive information about delirium, confusion, dyspnea, bluish discoloration of the skin, death rattle etc.

Organ donation, autopsy as well as funeral arrangements should also, if possible, be discussed prior to death to diminish the stress.

Supporting Caregivers

The death of a loved one can be very stressful for families and caregivers. Once a physician has confirmed the demise, a death certificate is provided to enable the funeral directors to carry out their jobs.

Informing family members should be done with respect, composure, and sensitivity. Families and caregivers may need psychological support as well as anxiolytics as they grieve and come to terms with the inevitability. This is especially important in sudden deaths.

Successful Dying

The concept of a good death is not new and has been previously addressed in arts, social sciences, and health sciences. An accurate definition of successful dying is difficult to find, however, there is a clear “theme” of what can be considered as successful dying by the patient and his or her caregivers.

Several questions about successful dying exist. For instance, one might ask whether successful dying is the consequence of successful aging? Another might associate successful dying with the preservation of dignity. Others might consider a good death as one that comes after the completion of life goals and the exhaustion of treatment preferences. Accordingly, we will discuss the mane core themes of successful dying per the most recent published scientific literature.

Successful Dying and the Dying Process

Some might consider a successful death is determined by the dying process itself. For instance, the death scene (how, who, where and when) are known to play an important role in the definition of successful dying. Dying during sleep is usually considered as a good death by many patients and people. Preparation for death by funeral arrangements can be also seen in the definition of a good death by some patients.

Pain and Successful Dying

Many patients, especially those with chronic or malignant disease, prefer to die without suffering and pain-free. Therefore, to them, successful dying is one that is achieved while pain-free and under good symptomatic management.

Emotional Support and Successful Dying

The presence of emotional and psychological support to the patient is quite important. Therefore, a successful dying theme usually involves emotional well-being.

Family support, the acceptance of the idea of death by family members, and the preparation of the family for the event of death of a loved one are also associated with the perception of a good death or successful dying.

Dignity and Successful Dying

Patients might prefer to not to receive cardiorespiratory resuscitation if they develop a cardiac arrest because they want to be respected as an individual and want to lead a life of independence. Therefore, for them to die while still independent on others is considered as a good death.

The Concept of Life Completion

Patients who have said their goodbyes, lived a good life, and accepted death are also considered as having a successful dying.

Treatment Preferences

Prolongation of life without the preservation of dignity might not be preferred by some patients. To them, a good death is one that is not associated with prolonging life. Moreover, if the patient truly believes that he or she has tried all available treatments and death is inevitable, they can accept death and have successful dying.

Religion and Successful Dying

Patients who are at religious or spiritual comfort might accept the concept of dying. For instance, those who believe in an afterlife might find it easier to accept death and have a successful dying. This, however, is a double-edged sword. Patients might consider faith as an important factor in determining successful dying.

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