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I have just watched one of the most intelligent and thought provoking programs.
Esther Rantzen has over the last couple of years experienced the death of both her parents and her husband.
She was left traumatised lost and bewildered.
So she decided to look into the facts of dying.
And she asked a simple question WHAT IS A GOOD DEATH?
AS a Health Care Worker i meet feet which are attached to People who are ill some of whom are dying.
And as a casual observer i can say that i have been a witness to many of the scenarios presented in the program.
Certainly the main character in the program Stan is something that i see regularly from my side of the fence.
I watch a patient embark upon the final journey and over a period of a few months i am a part of the pts experience.
Asking the simple question "How are you today" and the reply is "Bloody Horrible I Just Want To Die" is not uncommon. I like to think that for the short period of time the pt spends in my clinic is of benefit not only from the provision of appropriate foot care to promote the pts mobility and thus independence but is also part of the relief from one additional source of pain and thus discomfort .The straw that breaks the camels back is evident here. Also talking to some body who is not a family member or somebody Directly involved in the management of their terminal disease. A sort of Good Samaritan, or confidant.
Indeed Stan in the program actually stated that he wished he could die there and then and not have to endure any longer.
It seems that the Philosophy of the Hospice movement is at long last getting credence within our Hospital System and certainly the Consultants involved in Palliative care teams were acutely aware of the impact upon the pt for whom Medicine could do no more.
So should Voluntary Euthanasia be legalised for the dying?
I believe that it is your life you should decide what is in your own and families best interest and NOBODY ELSE SHOULD INTERFERE or be in judgement.
I would like to thank Esther her team and all those brave enough to appear on and put together this excellent program.
A most inspiring program especially those poor patients for whom life was at an end and yet they were able to share with us the audience their opinions fears and indeed wishes.
I enjoyed Stans comments with his wife over what to do with his ashes.
I am not one for funerals, but the reading of the poem , which he had selected was evidence of the intelligence and foresight shown
by Stan and his desire to help his family and friends after his death.
Here is what I gave students in past as part of the Gerontology course:
Quote:
Death and Dying
Death is an inevitable, universal, final and a natural part of the lifecycle. The western culture perspective on death is that it is an unnatural event that is to be fought off.
“Physicians and other health professionals, at all levels of training should receive concrete, insightful, and culturally sensitive instruction in the optimal care of dying patients” (Position 6, Position Statement on the Care of the Dying Patient, American Geriatric Society , 1998).
Bereavement Experiences/Grief responses
Bereavement and grief are all significant events in individual’s lives and all health care professionals are likely to, at some stage, need to be involved with people experiencing these emotions – they are an integral and inevitable part of the human experience. Grief and bereavement care is an important component in the health care continuum. Many factors can determine the way an individual reacts to bereavement.
Grief – the acute psychological reaction to one’s perception of loss.
Mourning – the longer process of resolving the acute grief reaction.
Bereavement – the state of having experienced a significant loss; (Dening (1994) defined it as ‘being robbed of anything we value’) – it is a normal part of the healing process.
Four tasks of mourning :
1) Accepting the reality of the loss
2) Working through the pain of grief
3) Adjusting to an environment in which the deceased is missing
4) Emotionally relocating the deceased and moving on in life
Grief reaction may be complicated if they are chronic, delayed, exaggerated or masked. Reactions to death are variable and do not necessarily follow set patterns. Death and dying have different meanings for different individuals. Rituals, such as funerals, can help ease the mourning process.
Individuals will each have their own way of handling grief, yet Robnett (1999) offers the following generic advice as being helpful in talking to the bereaved person:
• as much time as allows, let the person talk about their loved one and their loss. Asking about the deceased person is generally acceptable and may even be desired. Shedding tears is a natural, healthy experience that can aid the healing process.
• assure the bereaved person that their feelings are legitimate. Euphemisms, cliches, and sympathising remarks are generally regarded as not helpful (eg “I understand”, “It’s all for the best”).
• It is okay not to have the right words or the answers – just being there and offering your care and support does help.
• allow the bereaved to make decisions (well meaning individuals often attempt to take over the decision making for grieving persons)
• recommend counselling for those who need additional help
A pathological grief reaction occurs when the bereaved person is not able to express or work through their grief --> unable to recover from the loss and adapt to life without the deceased person.
DSM-IV (1994) differentiates between normal bereavement and major depression – a major depressive episode should be considered if:
• marked grieving symptoms that have persisted for more than 2 months
• guilt about things other than actions taken or not taken by the survivor around the time of death
• thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person
• morbid preoccupation with worthlessness
• marked psychomotor retardation
• prolonged and marked functional impairment
• hallucinatory experiences other than hearing the voice or transiently seeing the image of the deceased person
Approaching Death
A persons approach to death will be shaped by social, cultural and religious backgrounds; physical and functional status; social isolation and loneliness; and the meaningfulness of everyday life. A range of carefully integrated approaches is needed to manage the patient that is terminally ill.
People who are dying:
• most want opportunity to make decisions regarding death
• many will want to complete ‘unfinished business’; ‘mend fences’ in personal relationships
• open communication with the dying is the preferable approach
• want preservation of dignity and to be valued
• all differ in what they consider important --> their preferences should be paramount
• care should be guided by the preferences of the dying person
Social death:
a psychosocial ‘death’ can begin well before physical ‘death’ (ie disengagement theory)
related to the social status of those who are dying ? implies that social value has declined so low that they are no longer considered part of the living world
eg talking about the person in their presence without acknowledging that they can hear; making decisions for people that they are capable of making
eg treating them in a dehumanising way, being given mechanical care without addressing social needs
if personal control is taken away ? go into ‘failure-to-thrive’ syndrome ? further decline
Theoretical psychological stages of facing a terminal illness :
1) Denial/isolation – “can’t happen to me”, “why me?” – considered a defence mechanism
2) Anger – after they recognise that denial can no longer be used --> anger, resentment, rage --> can be difficult to care for as anger can be projected onto health care providers
3) Bargaining – develops hope that death can be postponed or delayed – begin to bargain or negotiate (often with God)
4) Depression – begins to accept the certainty of their death --> depression, grief, crying, withdrawal
5) Acceptance – develop a sense of ‘peace’, an acceptance of fate and often a desire to be left alone
However - some may go through different stages in different sequences and some may repeat some. For some individuals denial and anger may be a healthier response than acceptance. There may be a variety of reactions rather than the above proposed orderly progression of stages.
Hospice programs:
These types of programs or philosophies provide a non-curative medical and support services for those with a terminal illness. The aim is to help persons dying to live as fully as possible on a daily basis by trying to provide a blend of institutional care and home care – the primary emphasis is on quality of life.
The World Health Organisation defines palliative care as: “An approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems physical, psychological and spiritual”.
Provides:
symptomatic relief/pain control
team approach
enhancement of quality of life
regards dying as a normal process; does not hasten or postpone it
addresses psychological needs
supports family and helps them cope
assistance with spiritual needs
bereavement counselling
Tips for talking with those that are dying :
• be at some eye level
• don’t be afraid to touch
• avoid excessive small talk
• don’t insist on acceptance, if they are in denial (and don’t insist on denial if they are in acceptance)
• allow expression of anger or guilt
• don’t be afraid to ask prognosis
• encourage reminiscence – especially if have memories in common
• share your feelings
• express your regard for them
• don’t be afraid to say goodbye
The patient’s perspective on a “good death :
• Control of pain and other symptoms
• Avoid inappropriate prolongation of dying
• Relieve burden on the family
• Achieve a sense of control
• Strengthen relationships with loved ones
Definition of Death:
Death has needed to be redefined due to the ability to keep the human body biologically alive for longer periods of time. Previously death was the cessation of biological functioning (respiration and circulation), but with these advances in technology it became increasing difficult to make the medical pronouncement of “death”. Brain death (the cessation of electrical activity in the brain, determined by ECG) meets the legal criteria for death in most jurisdictions.
Brain Death Criteria (UK):
Brain death is the death of the brain stem, recognised by:
deep coma with absent respirations (ie on a ventilator)
the absence of drug intoxication and hypothermia
the absence of hypoglycaemia, acidosis and electrolyte imbalances
In USA, an ECG is required to confirm absence of cerebral activity.
The United Nations Vital Statistics definition of death is ‘the permanent disappearance of every vital sign’.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Last edited by Admin : 30th March 2006 at 06:54 PM.
There is a lot of very interesting literature in Thanatology (death studies) about what constitutes a 'good death'. Too often it is defined by medical persons as one which causes them the least discomfort, regardless of the patient and family's needs or wishes. The Palliative Care movement is really moving along in Australia, with Professor Alan Kellehear of La Trobe University heading the charge.
Just out of interest, what was the name of the program you watched David, I would love to get my hands on it for the students.
Another way to help those left behind is to leave a biography or diary - as those who have read Bridges of Madison County will appreciate. Now you can do so online. An interesting and deeply moving collection of writing.
Also a collection of short video clips available on line:
Quote:
We've produced a range of films to tie-in with a one off documentary on BBC 2 about changing the way we care for the dying called How To Have A Good Death. We asked our contributors to send in films about their thoughts on death and the experiences they've had of losing someone close to them.
My dear mother died in December.I was at her bedside,so I got to see her one final time.According to the nurse,she died painlessly.That is a source of comfort to me.Ironically,though I was closer to her than my sister,she took it harder that I did.I cried,true,but my sister still cries a lot.I cried the other day at work.I miss her.I,however,threw myself into my work.That kept me a little sane.In addition to being a podiatrist,I also have a seasonal job not related to podiatry.And since 'tis the season for that,I have been busy indeed.
My mom was philosophical re her death.She had a feeling she would not be long for this earth.Her kidneys started to act up last year,and try as we might to save her,her fine doctors could not do so.I know she is resting in peace and in no pain.Of course,I would rather her be here,but near the end,she was in constant physical and mental distress.At least now,she is no longer in any distress.
One of the interesting things that has happened of late has been the move towards the 'good death' and appropriate palliative care. This is wonderful, as we all deserve to depart this world with grace and peace. However, modern society has abandoned the grieving people left behind. Today you get a couple of weeks - tops - and then you 'get back to work, work harder, distract yourself, don't wallow....'
In fact many cultures have long and quite structured mourning periods for a good reason - we spend a lifetime in a relationship with someone like our Mother, and you can't get over that in a hurry.
I also find myself grieving for the patients that I have come to love when they finally die. In a Nursing Home where I was working there were a number of residents that I came to 'adopt' into my family; and even my children would join me in visiting them outside of work hours. I think we as health professionals need to give ourselves the time and space to mourn our patients.
But most of all John, be kind to yourself. Allow yourself a little insanity, that comes with grief, and it's good for the soul.
Esther Rantzen - A Good Death
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