The gift of death
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o393 (Published 15 February 2022) Cite this as: BMJ 2022;376:o393
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Dear Editor
I see a wonderful article on a beautiful life. A life which was a joy to everyone around her.
I do not see any excess or futility ; admittedly with the benefit of hindsight that she did indeed benefit from all medical interventions.
Competing interests: No competing interests
Dear Editor,
Tessa Richards' mother was a force of nature. She showed by her indomitable spirit that life is worth living - to the end. She was a positive presence right along her final way and a great inspiration to Tessa and all who came in contact with her. I recently attended the funeral of a mother of 7 who was 100 years old and had spent her last year touring the country visiting her daughters' and sons' houses celebrating her centenary. It was a moving occasion to see the 17 grandchildren at the funeral and see the marvellous legacy this lady had left. It is really about living, not about dying. "O death where is thy sting? O death where is thy victory?" asks St Paul 1 Cor 15.55. He then goes further to explain.
This lady's body language and spirit through it all - the final illnesses - speaks tomes about what is best in the human spirit and best in subordinating death to its proper place - a non event for those who live well to the end. The Lancet Commission on Death (if you have any time for their biased pronouncements) has good ideas for starters about death and dying but descends into assisted death, euthanasia as standard "care" and death at one's own hand as possibly their preferred outcome. Very sad. Everyone wants balance at life's stages, including death. ITU deaths and over medicalised deaths need to be assessed to see if they are really necessary, affordable and ethical. The western trend of hospital deaths like hospital births needs scrutiny. This is not an excuse for death by design. To bring about one's own death implies a lack of capacity to live - palliative care and terminal support services such as a doula or hospice nurse can enable those so tempted to live well 'til the end.
Competing interests: No competing interests
Tessa, thank you for sharing this, rich on multiple dimensions. I can imagine that your own medical challenges of recent years added a sharply personal lens to your experiences. It's quite something, being an actively engaged patient/person approaching this bend in the road, isn't it? Every story like this helps us anticipate our own.
Somehow this particular essay makes me realise we're also all preparing our own loved ones for their journeys, too.
Susannah Fox wrote of her experience being the guide for a loved one in his final weeks: Lessons learned about hospice care" [1], including obscene details of what it's like in the commercial American system.
I'm inspired by the "death doula" concept, which is new to me. Googling the term gives me a confusing array of results so I'd love to learn more. I suppose it's sadly predictable that the concept is being met with attempts to medicalise it, but that just urges me to learn about it myself, outside of regulators' constructs.
Competing interests: No competing interests
Dear Editor
There is no easy answer for what is excessive. As the living, we struggle as we see our loved ones suffer and fade but also when excessive intervention brings unwanted effects. Assisted death is challenging too. Gentle virtual hugs, Helplessness is the most difficult emotion. We all want quality of life for our loved ones until the day they die. Yet In this case, she chose life even with uncertainty and risk so she could spend longer with family and friends. We tend to remember the harsh days of frailty and the loss of independence as if it was our own. In the end, those precious times spent near the end of life can change lives, repair harms and bring hope and wisdom that lasts for a lifetime.
Competing interests: No competing interests
Re: The gift of death: Death and dying in Rural India
Dear Editor,
The recently-out and much talked about report published in Lancet Commission report: bringing death back into life, talks about a global paradigm about how people die. While many people are dying an overly-medicalized death in an intensive care unit, many unfortunates do not even get basic health services, die of a preventable cause and keep on suffering till their last breath. India is witness to both the extremes.
As you state in your opinion piece, the rich and the privileged are getting high-tech medicalized care almost equivalent to that available in affluent countries. They are living longer, with better quality of life and access to state-of-the-art medical care. The other end of the spectrum has the poor, forgotten people of this beautiful land, who die of tuberculosis, pneumonia, undernutrition, and drowning. Having limited access to primary health care, and non-existent secondary and tertiary level care leads to unpardonable delay in diagnosis and management and lives are lost by the clock. The inequity in health is most unbearable and monstrous.
I work in the most ‘backward’ of areas in terms of access to quality healthcare. The residents of this state are mostly tribal people, who live on hilltops and rely on forest products for their living. Needless to say, palliative care is an alien concept here. In my practice I see this paradigm every day. Symptoms are noted late. Local healers are the first point of contact for care-seeking. Doctors are often not well trained and lack motivation. Diagnosis process is lengthy and expensive. And quality management is not available anywhere within a 350 km radius.
How do we place these deaths? How do we justify these immense sufferings and indignity? How do you improve quality of death without addressing quality of life? How do you provide palliative care when you see people are dying prematurely and unnecessarily? How do you integrate palliative care in a health system which is not supported by quality and accessible secondary and tertiary levels of care? How do you improve quality of life in a community where loss of productivity literally means a death sentence?
While we should look at rationalising care at the end-of-life, we should not forget how we have left millions without any rational and quality healthcare.
Competing interests: No competing interests