‘Healthy’ dying: How do we improve care and decision-making at the end of life?

There is an ongoing global conversation about death and the process of dying. Despite half a century of clinical, academic and public policy activity by specialist palliative care workers, and by many others including health administrators, academics, artists and writers, it is still common to hear the same issues recycled with the oft-repeated comment that we “do not do this well”. Clinicians still struggle with treatment abatement decisions and issues related to causation and responsibility for death. The pathways to death are changing as described in Lynn’s model, with increasing numbers of people dying in old age, slowly over one to two years, with multiple co-morbidities, high incidences of dementia, and more significant medical decision points. The public often have expectations of curative capacity that exceed reality (fed by a technically optimistic health industry) on the one hand, and exhibit widespread concern about bad dying on the other. Kellehear has challenged the over-medicalisation of dying and proposed a health-promoting palliative care approach of community engagement. This paper draws on the author’s experiences in Tasmania of delivering clinical palliative services at the same time as attempting to bring about enduring changes in preparation for death both inside the health sector and in the wider community.

References
Lynn J, Adamson DM. Living well at the end of life; adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003.
 
Kellehear A.1999. Health promoting palliative care. Melbourne: Oxford University Press.

Ashby M. The Futility of Futility: Death Causation is the ‘Elephant in the Room’ in Discussions about Limitation of Medical Treatment. Journal of Bioethical Inquiry, 2011; 8: 151-154.