In search of a good death

Strategies to mitigate moral distress as reported by eldercare professionals

Eldercare workers experience higher levels of moral distress than other health and social care service workers. Moral distress is a psychological response to a morally challenging event. Very little is known about moral distress in the context of eldercare and about the mechanisms of preventing or mitigating moral distress. This qualitative study was conducted as part of the "Ensuring the availability of staff and the attractiveness of the sector in eldercareservices" project in Finland in 2021. The data were from 39 semi-structured interviews. This qualitative interview data were examined using two-stage content analysis. The key finding of this study, as reported by eldercare professionals, is that strategies to mitigate moral distress can be found at all organizational levels : organizational, workplace and individual. The tools that emerged from the interviews fell into four main categories:) organizational support and education 2) peer support 3) improving self-care and competence and 4) defending patients. The main identified categories confirmed the earlier findings but the qualitative, rich research interview data provided new insights into a little-studied topic: mitigating moral distress in eldercare. The main conclusion is that, in order to mitigate moral distress, ethical competence needs to be strengthened at all organizational levels.

Cicely Saunders, 'Total Pain' and emotional evidence at the end of life

In this article I explore how Cicely Saunders championed the hospice movement and initiated what became palliative care by representing her emotional connections with others. She became friends (and, once or twice, fell in love) with dying patients and encouraged others to follow her example in listening to patients' descriptions of pain. Her approach was radical at a time when she believed doctors routinely 'deserted' dying patients because it urged them to understand another's embodied pain as inextricably bound up with the emotional impact of a terminal diagnosis. Saunders' attention to how patients expressed their experience is summed up in her term 'total pain', which communicates how an individual's pain is a whole overwhelming experience, not only physical but also emotional, social and spiritual. Previous research frames 'total pain' in terms of narrative, emphasising Saunders' focus on listening to her patients and her use of narratives as evidence in advocating for cultural and institutional change, both of which I understand as engaging with a patient's emotional reality. However, as Saunders' ideals become mainstreamed as palliative care and amid calls for 'narrative palliative care', I use evidence from Saunders' extensive written output alongside archival material to suggest that, just as palliative care is by its nature not a single specific intervention, 'total pain' should not be understood as simply narrative. Building on existing work in this journal questioning the primacy of conventional understandings of narrative in the medical humanities, I demonstrate how Saunders' prominent use of fragments and soundbites alongside longer case narratives demonstrates the limits of narrative, particularly when someone is dying. Saunders thus offers a case study for considering the implications that questioning the primacy of narrative as emotional evidence might have for our understandings of how empathy or advocacy can function, or be cultivated, in medical settings.

"My life became more meaningful": confronting one's own end of life and its effects on well-being-a qualitative study

Background

The perception of being closer to death can be experienced due to old age or life-limiting diseases, and can pose profound existential challenges. Actively confronting death-related issues and existential questions may increase psychosocial comfort and stimulate personal growth, whereas dysfunctional coping may lead to existential distress.

To date, research on individual and (semi-)professional approaches to confronting the own end of life and the effects on one’s well-being remain scarce. Therefore, the aim of this study was to explore individual strategies and wishes in order to derive ideas for appropriate support concepts.

Methods

Twenty semi-structured interviews were conducted with people over the age of 80 (n = 11) and with a life-limiting disease (n = 10). The interviews were transcribed verbatim and independently coded by two researchers according to Braun and Clarke's thematic analysis approach.

Results

While the use of (semi-)professional approaches (e.g., therapeutic support) to confronting existential questions in the shape of one’s impending death was rare, individual coping strategies did have a positive impact on psychosocial comfort. There were hardly any significant differences between the participants aged 80 and over and those with a life-limiting disease in terms of individual coping strategies or how they approached the ends of their lives. Both groups reported that theoretical education, preparing for the ends of their lives (e.g., funerals), talking about death-related topics, reflecting on death-related topics, and contemplating death in a spiritual sense had positive effects on their assurance, self-determination and relief. The necessity of confrontation and a desire for low-threshold, accessible and flexible services to meet their existential and spiritual needs were highlighted.

Conclusions

There is both a desire and a need for the addressing of existential questions. Outside of private contexts, however, the participants possessed little awareness of support services that focused on confronting end-of-life issues, and rarely used such services. Efforts to raise awareness for psychosocial and spiritual needs should be implemented within the care system, together with low-threshold support concepts, in order to increase psychosocial well-being. More research evaluating individual approaches to confronting the own end of life are needed to better understand this determinant of well-being and its mechanisms of action.

Trial registration

www.germanctr.de, DRKS-ID: DRKS00020577.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00950-3.

The effects of confronting one's own end of life on older individuals and those with a life-threatening disease: A systematic literature review

BACKGROUND

Awareness of the impending end of one's life can pose profound existential challenges, thereby impairing well-being. Confronting one's own end of life may be an approach to meet the psychological needs and consequently enhance overall well-being. Different approaches of confrontation have been evaluated positively using measures of psychosocial comfort. To date, there exists no systematic overview on the different ways of confrontation (e.g. psychosocial or individual coping approaches).

AIM

To synthesize the existing knowledge on the effects of different approaches of confronting one's own end of life on older individuals and those with a life-threatening disease.

DESIGN

A systematic review of quantitative, qualitative, and mixed-methods full research reports was conducted. The retrieved studies were screened and appraised for methodological quality by two independent reviewers based on MMAT and CASP. The findings were synthesized narratively using the meta-summary technique by Sandelowski and Barroso.

DATA SOURCES

Medline, PsycINFO, and Web of Science were searched from inception to 12/2020.

RESULTS

N = 49 studies reported on different approaches of confronting one's own end of life, including psychosocial interventions, meaning-enhancing approaches, educational programs, and learning from lived experiences. The results suggest a clear trend toward beneficial effects on psychosocial comfort (e.g. anxiety, sense of meaning, well-being).

CONCLUSION

Low-threshold opportunities of confrontation have the potential to improve well-being and should be emphasized in practical implementation. The results can serve as a comprehensive basis for future research aiming to investigate the determinants of psychosocial comfort for people nearing the end of life.

Perceptions of good and bad death among Korean social workers in elderly long-term care facilities

This qualitative study explored the perception of good and bad death among 15 social workers serving in elderly care facilities in Korea. A good death involved dying peacefully without much suffering, dying with family members present, death following a good life, and believing in a better afterlife. A bad death involved burdening children in the dying process, dying after extensive illness, dying isolated from family, and death from suicide. To ensure a good death and avoid a bad death for elders, social workers are encouraged to closely engage with not only elders but also their families.

Can there be a good death?

While some deaths are worse than others, there is no such thing as a 'good death' since the plausible desiderata of a 'good death' form an inconsistent set. Because death is of the greatest existential consequence to us, a 'good' death must be a self-aware death in which we grasp the import of what is happening to us; however, such realization is incompatible with our achieving the tranquillity of mind which is another requirement for the 'good' death. Nevertheless, the welcome recognition in recent years by medical personnel, palliative care workers and hospice staff that dying is an existential predicament as well as a physiological condition has enabled more people to avoid a 'soulless death in intensive care', even if it pays insufficient regard to the personal virtues that we need if we are to mitigate the worst evils of dying.

Beyond good intentions and patient perceptions: competing definitions of effective communication in head and neck cancer care at the end of life

Effective communication between dying cancer patients and their health care providers about prognosis and treatment options ensures informed decision making at the end of life. This study analyzed data from interviews with end-stage head and neck cancer patients and their health care providers about communication competence and approaches to communicating about end-of-life issues. Patients rated their oncologists as competent and comfortable discussing end-of-life issues, although few reported discussing specific aspects of end-of-life care. Oncologists viewed giving prognostic information as a process rather than a singular event, and preferred answering patients' questions as opposed to guiding the discussion. These data reveal subtle disconnects in communication suggesting that patients' and health care providers' information needs are not being met.

The Going Home Initiative: Getting Critical Care Patients Home With Hospice

Although considerable effort is being directed at providing patients and their families with a “good death,” most patients in intensive care units, if given the choice, would prefer to die at home. With little guidance from the literature, the palliative care committee of an intensive care unit developed guidelines to get patients home from the intensive care unit to die. In the past few years, the unit has transferred many patients home with hospice care, much to the delight of their families. Although several obstacles to achieving this goal exist, the unit has achieved success in a small-scale implementation of its Going Home Initiative.

Spirituality and aging

Interest in spirituality and aging has increased recently, owing to overwhelming evidence of positive health outcomes linked to spirituality and religious participation. Increasing longevity in modern society puts spiritual needs of older adults at the forefront of societal priorities. Understanding individual spiritual perspectives becomes increasingly important, given the issues of loss, physical illness and mortality that are confronted in old age. There are multiple barriers to the proper assessment of spirituality in clinical practice and research (e.g., the lack of professional training for healthcare professionals, shortage of time and comfort for healthcare providers when discussing spiritual issues and needs). Integrating an individual’s spiritual practice into their healthcare can help shape personalized medical care for older adults and improve health outcomes. This article reviews literature and research on spirituality, as well as spiritual interventions and their putative neurobiological mechanisms in relation to aging, mental and physical health, and coping with death and dying.