The Art of Dying (well)
Many years ago, I read "Being Mortal" by Atul Gawande. It’s a powerful book that explores the "art" of dying. Gawande argues that we often remember loved ones by the circumstances of their death. This resonates with me regarding my grandparents.
My grandfather's life ended with tubes and wires after numerous unfruitful surgeries, leaving me with initial memories of his suffering before recalling our shared moments watching the Buckeyes or fishing. In contrast, my grandmother passed away peacefully in her favorite chair, surrounded by loved ones, thanks to hospice care. My first memories of her are of her kindness, giving me an extra slice of pizza in the lunch line (she was the school lunch lady), playing solitaire, and her warm demeanor. It’s only when pressed do I think about the circumstances around her actual death.
These experiences raise an important question: What do we want our loved ones to think about first when they remember us after we leave this Earth?
How we die matters.
Death is a universal experience, yet it remains one of the most challenging topics to discuss. However, confronting mortality and planning for it can lead to a more dignified and peaceful end-of-life experience. The following discussion will explore the concept of dying well, the role of hospice and palliative care, and the importance of making end-of-life decisions:
Hospice Care: Enhancing Quality and Longevity
Hospice care, designed for patients with a life expectancy of six months or less, focuses on comfort rather than curative treatment. Interestingly, studies have shown that hospice care can sometimes extend life. A 2007 study published in the Journal of Pain and Symptom Management found that patients with terminal illnesses who received hospice care lived an average of 29 days longer than those who did not receive hospice care. This may be attributed to the comprehensive care provided, which addresses physical, emotional, and spiritual needs, reducing stress and improving quality of life. Many times people associate hospice with “giving up,” when in fact, the opposite might be true where hospice extends life.
Palliative Care vs. Hospice Care
People are often confused with this distinction. While hospice and palliative care both aim to provide comfort, they differ in timing and scope. Palliative care is appropriate at any stage of a serious illness and can be provided alongside curative treatments. It focuses on symptom management and improving quality of life, regardless of the prognosis. Hospice care, on the other hand, is reserved for those nearing the end of life and who have decided to forego aggressive treatments. I’m a huge proponent of palliative care but one of the biggest obstacles that I face is educating patients that this does not equate to “giving up.”
Insights from Atul Gawande's "Being Mortal"
In "Being Mortal," Atul Gawande emphasizes the importance of quality of life in end-of-life care. Gawande argues that modern medicine often prioritizes extending life at the expense of its quality. He highlights the significance of having honest conversations about goals and fears, which can lead to care that aligns with the patient's values. This approach not only enhances the patient's remaining time but also provides a sense of control and dignity. A crazy but true statistic…nearly 1/4 of ALL Medicare spending is spent during a patient’s last 12 months of life. We need to learn in America that more is not always better.
Survival Statistics for Resuscitation Efforts
Resuscitation efforts, including CPR and mechanical ventilation, have varying success rates, often depending on the patient's overall health and the context of the intervention. According to the American Heart Association, the survival rate for out-of-hospital cardiac arrests is about 10%. For in-hospital cardiac arrests, the survival rate is higher but still only around 24%. In other words, the odds are very high favoring death over survival. Moreover, survivors often face significant physical and neurological impairments leading to months with a low-quality life in a nursing home. Unfortunately, the public perception of survival from a resuscitation effort is much different than reality probably due to Hollywood’s portrayal of these events. In TV shows, we watch dramatic resuscitation efforts with heroic outcomes leading to the patient leaving the hospital unscathed and resuming a fantasy life. This is NOT reality. CPR and other resuscitation efforts are brutal and traumatic. In fact, I was taught that if you aren’t breaking ribs during CPR, then you’re not doing it right.
Understanding Code Status: Full Code, DNR-CCA, and DNR-CC
Choosing a code status is a critical aspect of end-of-life planning:
- **Full Code**: Indicates that a person wants all possible life-saving measures, including CPR and mechanical ventilation, in the event of a cardiac or respiratory arrest.
- **DNR-CCA (Do Not Resuscitate – Comfort Care Arrest)**: Specifies that a person wants all appropriate medical treatment until they experience a cardiac or respiratory arrest, at which point only comfort care measures will be provided. In this situation, life-saving medications like antibiotics or heart medications are still on the table.
- **DNR-CC (Do Not Resuscitate – Comfort Care)**: Indicates that a person wants to receive only comfort care measures and not any life-saving interventions, even before a cardiac or respiratory arrest.
The Importance of Advance Care Planning
Discussing and documenting end-of-life wishes is crucial to avoid family conflicts and ensure that one's preferences are respected. Having these tough conversations with loved ones can prevent uncertainty and disputes during emotionally charged times. Legal documents such as a living will and a medical power of attorney can provide clear instructions and designate a trusted individual to make decisions on one's behalf if they become unable to do so.
Conclusion
Dying well involves more than just medical interventions; it encompasses ensuring comfort, dignity, and alignment with personal values. The lasting memories that our families hold of us after our deaths are often around how we die, especially if traumatic. Hospice and palliative care play pivotal roles in this process by focusing on quality of life. Understanding the implications of resuscitation efforts and making informed choices about code status are essential steps. Ultimately, open communication and thorough planning can lead to a more peaceful and meaningful end-of-life experience for both patients and their families.
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**References:**
1. Connor, S. R., Pyenson, B., Fitch, K., Spence, C., & Iwasaki, K. (2007). Comparing hospice and nonhospice patient survival among patients who die within a three-year window. *Journal of Pain and Symptom Management*, 33(3), 238-246.
2. American Heart Association. (n.d.). Cardiopulmonary Resuscitation (CPR) Facts and Stats.
3. Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y., Krumholz, H. M., & Chan, P. S. (2012). Trends in survival after in-hospital cardiac arrest. *New England Journal of Medicine*, 367(20), 1912-1920.
