How modern medicine can help patients achieve a "good" death

The overall quality of death of cancer patients who die in an urban Canadian setting with ready access to palliative care was found to be good to excellent in the large majority of cases, helping to dispel the myth that marked suffering at the end of life as inevitable.

"Fear of dying is something almost every patient with advanced cancer or other life-threatening illness faces, and helping them, to achieve a ‘good death' is an important goal of palliative care," said Sarah Hales, MD, Coordinator of Psychiatry Services, Psychosocial Oncology & Palliative Care at Princess Margaret Cancer Centre in Toronto. "We know a lot about disease and the physical symptoms that it may produce, but only recently have we focused on approaches to relieve the fear of death in patients and families and to address the emotional, spiritual, and existential concerns that support the quality of the dying experience."

Understanding the multiple dimensions of the dying process has helped us better care for patients and families at this stage of life, said Gary Rodin, MD, FRCPC, also of Princess Margaret. "We have found that individuals evaluate differently the dimensions of the experience, which include symptom control, the sense of life closure, and facing the end of life without overwhelming fear. The perspectives of patients on these issues at the end of life may differ from those of their family and health care providers."

According to their study, published in the Journal of Pain and Symptom Management (2014; doi:10.1016/j.jpainsymman.2013.12.240), 39% of the patients sampled scored in the "good' to "almost perfect" range of a scale measuring the dying experience, with 61% of the patients scoring in the "neither good nor bad" range of the scale.

Better scores were linked to older patients, high social support (most patients were not living alone), older caregiver age, English as the primary language of the caregiver, greater length of relationship between the caregiver and patient, less caregiver bereavement distress (ie, grief, stress-response, and depressive symptoms), and home death.

The study examined 402 deaths of cancer patients between 2005 and 2010 in the three acute care hospitals in Toronto. Caregivers of the patients who spoke and read English were contacted and, those who agreed, were interviewed about the quality of death and dying using the Quality of Dying and Death (QODD) questionnaire.

Home deaths were linked to better overall scores on the death experience, along with better Symptom Control and Preparation scores than dying in an acute-care or hospice setting. Surprisingly, home death with briefer palliative care was linked to better preparation and overall quality of dying than home death with longer palliative care involvement (ie, greater than 7 days). Also, no significant difference was found between a death in a hospice or palliative care setting and an acute care hospital. Hales noted that complicated symptoms, lack of advanced planning, and overwhelmed caregivers might make a hospice or hospital death better for the patient and family.

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