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In some way I dismissed Reverend Smith's dignity when I failed to consider in my message his position in the world and his own mission. Somehow I disowned him once I announced to him his death, without considering the repercussion that his death would have had on the wealth of activities that represented the current source of his own dignity.

Both cases show the difficulty in conducting clinical research on the issues of death and dying. The patients' own statements concerning their desire may be unreliable, and some patients would refuse to participate, to sign the informed consent to the study simply because they are not ready to accept that they are dying. Not surprisingly, most of the studies on death and dying are based on personal experience as well as qualitative research [ 8 , 9 ], as the externally validated research instruments are relatively few [ 7 , 10 , 11 ].

The analysis of our two cases revealed three constructs that are paramount to honor the patients' wishes. The enunciation of a person's existential values has two essential and distinct roles in palliative care. That defines the conditions in which each patient wishes that any form of intrusive life-supporting treatment be instituted, continued or withdrawn.


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Ideally this discussion should occur before the death is imminent and with a practitioner that has a long familiarity with the patient [ 14 , 15 ]. This approach would avoid the emotional overtones and conflicts likely to emerge when the end of life is imminent. The second role is to provide all possible emotional and spiritual support to a patient close to death. Once I took care of the chief of a disbanded tribe of American Indians with metastatic prostate cancer who confided in me that the main goal of his life was to finish writing the history of his tribe that would have been completely lost with his death [ 16 ].

Together we decided to forgo chemotherapy that might have prolonged his life of a few months but would have prevented him to complete his book by causing fatigue, nausea and other distracting symptoms. Likewise, the exploration of one's personal value may help restore a sense of positive narcissism [ 17 ], i. Once I ministered to a young man, a talented violinist desperate because he was dying at 18 from metastatic sarcoma [ 16 ].

The exploration of his past life with the hospital chaplain made him realize he had been endowed with unique talents that had left a perennial imprint on this earth and had gained him love from a dedicated girlfriend who accompanied him throughout to his death. Another important resource is represented by a patient's religious and spiritual beliefs [ 17 , 18 ]. The discussion of these beliefs may lead to the acceptance of death and even suffering as a unique living experience that should be treasured as any other living experience [ 18 , 19 ], Many patients come to realize that the way they die is the way they will survive in their loved ones.

Last, but not least, a value history is also important for the support of overstrained home caregivers [ 20 , 21 ]. A review of the literature revealed that spiritual and religious resources were beneficial to the self-esteem of the caregiver, and reduced the burden of caring for terminally ill family members. In the Christian tradition caring for a dying person is interpreted as caring for the dying Christ himself.

In the Moslem and Jewish tradition caregiving is a specific commandment to honor one's elders.


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The idea of a good death is not new. However, this association and other similar initiatives emphasized the Christian construct of death which is not applicable to a secular and multicultural society. At least three of the domains — time with the family, whole person concern, and treatment preferences — emphasize that autonomy, personal relationships, and personal concerns are critical to a good death.

This statement could be also phrased by saying that spiritual elements are critical to a good death.

How Can Hospice Care Help Cancer Patients?

At this point it is important to emphasize the difference between pain and suffering, and the spiritual nature of suffering [ 19 ]. Suffering is a personal experience that includes but is not limited to the awareness of one's pain [ 19 ]. Suffering may be caused by symptoms different from pain, such as dyspnoea, nausea or fatigue. Most important, suffering may be independent from physical symptoms and may be caused by the inability to appreciate the reason of one's pain, as well as the meaning of one's living experience.

In the USA, hospital chaplains receive a very special training called Clinical Pastoral Training [ 24 ] that enables them to minister to patients of any religions as well as to those without religious beliefs. Any health care personnel should be able to identify spiritual and existential suffering and refer the patient to the proper specialist, i. It may sound self-evident that a good death is a death with dignity, as all models of a good death emphasized patient's autonomy as central to a good death.

Sessions were recorded, transcribed and edited and the final version was returned to the patients who could bequeath them to friends and family member. Illness-related concerns Symptom Distress Physical. Dignity-conserving repertoire Dignity-conserving perspectives Self continuity.

Communication About Death and Dying—Three Little Words | Humanities | JAMA Oncology | JAMA Network

In my view, dignity therapy allows the patient to see their death as a unique living experience to be treasured and bequeathed. If the patient autonomy is central to end-of-life care, should a practitioner honor a request for euthanasia or assisted suicide? The arguments in favor of these practices vary in their scope [ 26 ].

Some physicians believe that to deny this option to a dying patient is tantamount to desertion in times of need. Others prefer to skirt the ethical issue and take a more practical approach: since some forms of euthanasia and assisted suicide are practiced daily, in the shadow, it would be safer for both patients and practitioners to establish clear rules related to when and how these interventions should be implemented, I believe that the first argument is flawed as it fails to take into consideration the autonomy of the practitioner.

Nobody will ever deny that the patient is entitled to refuse whatever intervention is proposed, but it is much less clear whether the patient is entitled to ask for interventions with which the practitioner disagrees. This is true for every profession. Why should it not be so for medicine? The second argument has merits as it is inspired to the principle of lesser evil.

A lady, who is also a well-known physician, reported how her father shot himself after discovering that he had terminal prostate cancer.

I’m a doctor with end-stage cancer. I support medical aid in dying

The family members who loved him had to carry two burdens for the rest of their lives: the gory scene of the suicide and the pain of having been excluded from this terminal determination. If physician-assisted suicide had been available the patient might have been able to communicate with his family without concern of being restrained and his death might have occurred in a much less dramatic context.

He might have peacefully died in his own bed, surrounded by his loved ones and maybe he could have even received religious or spiritual comfort. As I said, I respect this argument and I believe that in borderline situations, where the management of pain, discomfort or anxiety may hasten one person's death the practitioner should always err on the side of compassion and implement an intervention that may ultimately end a patient's life. The goal of the intervention is to restore a patient's comfort and this is legitimate. Death is an acceptable and accepted side effect as it would be for virtually any medical intervention.

Personally, however, I like to offer to the reader two reasons to oppose the legalization of euthanasia and physician-assisted suicide. The first reason is that as physicians we are duty-bound to preserve life.

Possible changes in consciousness

The American Medical Association code of ethics prevents a physician from participating in an execution, even when physician participation might relieve the suffering of the person condemned to death, because termination of one's person's life is seen as antithetic to a physician's duty. For the same reason, to hasten a patient's death appears incompatible with a physician's duty. The second reason is that euthanasia or suicide are tantamount to a declaration that a life is not worth living, i. I offer these arguments as the beginning of a dialogue on the issue, of course, not as conclusions.

Terminal sedation involves the use of medications to blunt a patient's consciousness and relieve terminal pain [ 27 ]. There are two forms of terminal sedation. One is not controversial and is applied to a conscious person after withdrawal of life support, to blunt the related symptoms that include air hunger or chest pain. Controversial is instead the use of terminal sedation in the presence of existential suffering, i. This review demonstrates that the practitioner of oncology should be involved in the treatment of the dying patients.

The physician should also be familiar with the issue of existential and spiritual suffering and involve the chaplain in the management of that type of suffering. Finally the physician should face controversial issues including euthanasia, assisted suicide and terminal sedation, and develop a personal position on these issues based on an appropriate study and congruent with one's ethical principles and personal values. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

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Volume Article Contents. Oxford Academic. Google Scholar. Cite Citation. Permissions Icon Permissions. Abstract A good death and a death with dignity may be achieved when death is congruent with the personal values of the patient. Open in new tab. Search ADS. Construction of a new objective prognostic score for terminally ill cancer patient.