End-of-life occasions are inevitably distressing for those involved, although from the philosophical viewpoint dying is as natural a process as being born and living. What often adds to the distress that many people feel when watching someone passing the threshold from life to death is the increasing gadgetry employed in attempts to postpone it. Such devices are symbolic of a medical and legal arrogance that seems hell-bent on preventing individuals from ending their earthly existence with peace and dignity.
In the Journal of the American Medical Association for September 27, two doctors, from California and New York, discuss the tricky topic of "end-of-life conversations". They are prompted by reports that many patients are dying, sometimes in unrelieved pain, after intensive care or prolonged stay in hospital, and that discussions of life-sustaining treatment and referrals to hospice or home care come late or do not occur at all. It is agreed that patients and their relatives sometimes avoid urgent personal topics and that physicians often desist from relevant discussions. They do so because they are afraid of causing mental pain, they lack knowledge regarding delivery of bad news, they regard death as a challenge to be overcome instead of a natural inevitability, or they try at all costs to avoid any disagreement with patients and families. They may also fear legal complications.
Research has shown that both patients and families tend to value good communications regarding the patient's condition and prospects, control of symptoms, and avoidance of any prolongation of the dying process. This indicates that, given appropriate cultural considerations, end-of-life conversations between patients and carers should be routine. The individual's physical, psychological and spiritual outlook should be taken into account as part of the caring procedure.
Since all health care professionals are to some extent concerned in the evening of life, medical and nursing training in particular should include developing the skills required to ensure as far as possible the peaceful and dignified end to a life.