A Good Death

Death is inevitable, however our western society has a zeitgeist that ignores death and the dying. Shneidman (2010) proposes to build a criteria for a “good” death, though recognizes there is no single best death. A good death is one that is appropriate for that person. The criteria for a “good” death is listed below.

Natural A natural death, rather than accident, suicide or homicide
Mature After the age of 70, elderly yet lucid and experienced
Expected Neither sudden or unexpected; some warning
Honorable Emphasis on the honorifics and not failures
Prepared A living trust, prearranged funeral, some unfinished tasks
Accepted Willing the obligatory
Civilised Attended by loved ones
Generative To have passed the wisdom of the tribe to younger generations
Rueful To experience contemplative emotions of sadness and regret without collapse
Peaceable With amicability and love; freedom from physical pain

Although in the therapy setting there is little control over natural, maturity or expected death, a therapist may assist clients towards an honourable, accepted, civilised, generative, rueful and peaceable death. Of these qualities, experience from clinical practice would suggest that some of these qualities can be focused on in advance of palliative care such as accepted, generative and honourable. Music therapy can allow clients to come to terms with the inevitability of death, to share knowledge and focus on achievements of life. Similarly a music therapist can assist in creating an atmosphere where loved ones are eased through the dying experience and provide a rueful atmosphere. Song-writing provides the perfect opportunity for clients to share their wisdom and to give this as a gift to others.

Whilst Shneidman (2010) focused on the aspects of a good death, Wilk and Grimby (2010), explored the importance of physical, psychological, social and spiritual needs through the process of dying in a geriatric palliative ward. It was argued that there was evidence lacking for older adult patients views and needs in the terminal phase of life. To be able to provide a high level of quality care requires an understanding of the needs.

Wilks and Grimby (2010) conducted a pilot study with thirty older adult palliative patients whereby patients needs and rankings of their needs by degree of concern were evaluated. Participants were admitted to the Geriatric Department, Sahlgrenska University Hospital and were willing to participate in the study. Exclusion criteria included aphasia, dementia and lack of strength. Fifteen men and fifteen women participated with an average age of 79 years. The primary diagnosis was cancer, however life expectancy ranged from 1 month to several years. Information was gathered through interview with variations in length of time due to patient’s ability.

Interview/open conversation method was used whereby patients ranked important needs for the moment, things patients wanted help with at that moment and what patients wanted to speak about. It was argued that open conversations were necessary in identifying actual needs for a specific age group as opposed to fixed ideas about needs for that population. Needs were ranked and answers categorised

61% of participants shared a desire to spend their last days in their own home, in contrast to the 39% who preferred to stay in an institution where best care could be received. There was significant confusion over participant’s diagnosis and transition to palliative care (50% were not quite sure, 20% were completely unsure). This finding raised significant concerns in regards to patient understanding and therefore ability to make choices. The transition to palliative within aged care or hospital care does not mean death is expected soon, with even some participants having a 2-year life expectancy. In reference to Schneidman (2010), preparation for a good death includes acceptance that also requires understanding, yet when the nature of palliative care/diagnosis is misunderstood how does a therapist assist in this preparation?

In the first interview 14 participants ranked physical needs as primary, 10 participants ranked psychological as primary and 6 ranked social needs as primary. Differences in rankings throughout the study may have been reflected on length of time in hospital, existing social or psychological support and participant’s resilience. Although Wilks and Grimby (2010) reflected on the physical needs, this will not be evaluated.

Psychological needs identified were as follows: anxiety, uncertainty, security, peace, opportunity to see relatives, to be freer to express emotions and reactions, to reflect, to reconcile, find a meaning for life, contemplating, thinking over their life, summing things up and sharing experiences of life with others. Social needs identified were as follows: spending time with loved ones, finances and accounting in order, privacy. Finally one person identified spirituality as a primary need. For the purpose of the evaluation of literature, these needs were attributed to Schneidman (2010) “good” death construct in order to further develop a basis for assisting clients towards a “good” death.

Honorable To reflect

Contemplation

Thinking their life over

Summing things up

Prepared Anxiety

Uncertainty

Finances and accounting in order

Accepted To find the meaning of life
Civilised Spending time with loved ones

Privacy

To reconcile

Generative Sharing life experiences with others
Rueful To be freer to express emotions and reactions
Peaceable Peace

Spirituality

The study took place over a 4-month period, with most of the findings coming from the initial interview due to participants’ death. It is suggested that an extension of this study with a wider population to identify if needs to change over an extended palliative period. It was identified that issues that had been neglected over a life-time (psychological/social) appeared to be a priority.

From a therapy perspective Wilks and Grimby’s (2010) findings of the needs of geriatric patients in palliative care supported Schneidman’s (2010) “good” death construct. These concepts and information can then be applied to an aging, non-palliative population, who will meet death eventually. Perhaps the greatest benefit of music therapy is that it can simultaneously meet multiple needs. The power to relax, to engage with another socially through music, to express and to transcend allow multiple needs to be met within one therapy. Similarly music therapy can meet engage in all aspects of a “good death”.

With an aging population, the process of death and dying and dying with dignity will become a rising issue. As suggested earlier, perhaps the greatest contribution to healthcare for this population of music therapy is the total benefits received from music therapy making it cost effective.

References:

Shneidman, E. (2010). Criteria for a Good Death. In G, Dickinson, & M. Leming (Eds). Dying, Death and Bereavement. (pp14-15) New York: The McGraw-Hill Companies Inc.

Wijk, H. & Grimby, A. (2010). Needs of Elderly Patients in Palliative Care. In G, Dickinson, & M. Leming (Eds). Dying, Death and Bereavement. (pp29-33) New York: The McGraw-Hill Companies Inc.

 

 

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