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The Elusive “Good Death”

Peter L. Slavin and David F. Torchiana enlist a trio of physician-essayists to examine their own feelings and ideas about death.

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Medicine’s goals are to prevent illness, to heal, to cure and to maintain as high a quality of life as possible. Despite our best efforts, however, there will be one day in every person’s life when those things are no longer possible. Death comes to everyone, and though physicians have little trouble initiating conversations with patients and families about treating even the most serious diseases, they tend to be less comfortable when it comes to talking about dying. Discussions about death are often handled poorly, or not done at all.

That’s unfortunate, because just as we want our patients to live well, we should also want them to die well. The Institute of Medicine defines a good death as “one that is free from avoidable suffering for patients, families and caregivers in general accordance with the patients’ and families’ wishes.” Yet too often, the end of life for seriously ill or elderly patients involves invasive tubes, machines, painful tests and uncomfortable treatments. And unless decided otherwise in advance, when a patient’s heart stops, a code team is called in to attempt resuscitation—with rib-cracking chest compressions, powerful electric shocks and intubation. The process can be brutal, even violent, and it’s usually futile. Departing life in the wake of such trauma is not the kind of death anyone would choose.

In this issue of Proto, physician-essayists Ken Murray, Danielle Ofri and Charles Bardes examine their own feelings and ideas about death. Drawing from personal experience and well aware of the grim reality of end-of-life treatments, physicians often choose to forgo them, instead seeking to die in a calmer, gentler way. This is medicine’s insider trading, with caregivers possessing special information and then acting on it.

Yet even though they may understand what lies ahead for their patients approaching the end of life, physicians often feel pressure to offer something—a glimmer of hope in the form of a new treatment, a different drug, one last option. The fact is that sometimes heroic attempts to save lives do succeed, and very few of us would choose to die when there appears to be a solution that offers a chance of survival.

As a society, we have to get smarter about medicine’s burden-benefit equation. Physicians need to embrace the idea that just because we can do something doesn’t mean we should, while patients must recognize that simply because something is available doesn’t mean it has to be pursued. A more realistic, informed approach to care at the end of life will enable more of us not only to choose how we die but also to experience that much-coveted and all-too-rare good death.

Peter L. Slavin, M.D.
President
Massachusetts General Hospital
David F. Torchiana, M.D.
CEO and Chairman
Massachusetts General Physicians
Organization
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