Have you thought of your death?
Author/Affiliation: Marina Kotsani, Geriatrician (France)
“Have you thought of your death?”. “How do you visualize your last days?”. “How far do you wish doctors go in order to maintain you alive (but not necessarily to save what represents life for you)?”. Advance Directives concerns us all no less than death itself. But how many of us have expressed our wishes on paper or even to people close to us?
As a nursing home’s physician, I have been recently asked to collect the Advance Directives of the residents. Most of them are no longer able to express their will. So, I needed to address the awkward questions to their families. “What do you think your mother/father would wish in that case or the other?”. I have been dreading those discussions, but as it turned out, probably for the wrong reasons.
I expected that people would hesitate in front of dilemmas such as quitting from artificial means of life prolongation. But most of them were actually ready to let go of this claim. What was hard to manage for most of them was their fear of their beloved person dying in hospital. Fear of the way an average hospital is dealing with an older person with cognitive and behavioral problems, fear of ending one’s life in physical restraints, unmet simplest needs (such as sweeping up one’s face) and gaps in the humanistic accompaniment anyone would wish for and deserve in the end of life. Some of the families have also been traumatized by the lack of the opportunity to say goodbye to another beloved person du to visit restrictions during the COVID-19 pandemic. But we need to admit it: busy, noisy acute care wards with inadequate number of personnel, exhausted staff, frequently over-familiarized with death, are not the ideal scenery for a smooth life-to-death transition, the peaceful death that everybody is wishing for. Still, hospitals are nowadays the places where most people get born and die.
Death is never cheerful but it does not need to be devastating either. How can we, as medical society, create a warmer and “softer” end-of-life scenery in our hospitals? On the other hand, how can we assure appropriate palliative care at home and even in nursing homes with (at least in France) no medically qualified staff at the nightshift?
Discussing these concerns with families it turns out that for most of them it all wraps up to two sentences “I don’t want him/her to suffer”, “We need to avoid useless hospital admission at all cost”. I am not certain if I could guarantee the exact application of this will, but I guess I, too, would prefer dying at home …