For years, as part of my health-promotion courses, I have introduced the idea of “healthy death.” The initial reaction, not surprisingly, is that this makes no sense; it’s an oxymoron. So then I ask if people know what an unhealthy death is — and the light goes on.
I think we all know what an unhealthy death is: long, drawn-out, painful, in an alienating institutional environment, plugged into machines, alone and scared.
The converse of that is a healthy death: fairly swift, pain-free, in comfort, preferably at home, able to engage with family and friends. That is presumably how all of us who do not suffer sudden death would presumably like to go, the form of dying and death we would wish for ourselves, our families and friends.
The first part of ensuring a healthy death is to support people in preparing for death. We need to encourage and support people who are aging or have chronic or incurable diseases to have conversations with their family, friends and caregivers about end-of-life expectations.
These conversations are often not easy, but are essential; people close to us need to know our wishes. We also need to create advanced-care directives and “living wills,” so our wishes are documented and can be followed.
Second, we need a transformation of our health-care system to ensure that we fully support people who are dying, in the most humane way possible. Palliative care, including palliative care at home, is an essential service. Good palliative care can ensure a more healthy death, a comfort to the family as well as the dying person.
One of my favourite studies in this area was conducted 20 years ago at the University of Washington. This is the only study I am aware of where the mortality rate in the study went up and yet the project was deemed to be a success!
They worked with elderly people on enhancing their sense of autonomy. As part of that project, they were assisted in the development of living wills. It seems the study group did indeed complete advanced directives and those directives were heeded by their attending physicians, because the study group was twice as likely as the control group not to receive life-sustaining treatment.
Thus a classical health-promotion strategy addressing issues of autonomy and self-esteem resulted in people having more control over the manner of their dying, which is what the vast majority of people with terminal illness want.
In the world of health promotion in which I work, our aim is to enable everyone to achieve a life of health and well-being. There is no reason why that would stop just because someone is dying. Moreover, a fundamental tenet of health promotion is that we “enable people to increase control over and improve their health.” The process of empowerment — personal and collective — is central to our approach.
Which brings me to the third and final part of healthy dying and to the recent Supreme Court decision on physician-assisted suicide. I remember someone years ago remarking that the generation that demanded birth control would later demand death control, which always struck me as a wise observation. We can’t let autonomy and empowerment stop at the process of dying.
As a dog owner all my life, I have always thought it absurd that while I could protect my dogs from a painful and drawn-out death, I could not protect my loved ones or my patients from the same without becoming a criminal. So I welcome the decision just handed down that will allow physician-assisted suicide.
But this is not the first step in ensuring a healthy death — it is part of the continuum that starts with preparing for our death and includes effective palliative care. The choice of controlling the manner of our dying and death is right for some, and should be available to them, but there is more to dying than death.
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.