A "Good Death": How Do Doctors Want To Die?

How do you wish to die? It’s an important question that, no matter how scary, should be considered by every person at different stages in their life. But do doctors, those people who tend to see death and dying more frequently than other people, have different views on how they want to spend their final days?

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To find out, researchers with the End-of-life Care Research Group in Belgium interviewed 45 doctors, 15 each from Italy, Belgium, and the US. The results showed a strong contrast to how many non-physicians regard a good death.

The idea of a “good death” is an old one and is often defined by one’s societal culture. For instance, if you were born in medieval or early modern Europe, the idea of a good death was wrapped up with spiritual affairs and making sure you were prepared to face the end without sin – because your deathbed would be a fighting ground where the forces of Heaven or Hell vied for your soul. Of course, death was a much more familiar feature of people’s lives during this era, when disease, warfare, and other forms of life-shortening events were more common and often more lethal.

Although death is still inevitable today, its realities are often banished from our homes or immediate circumstances. The gradual medicalization of death, whereby dying people see their final days in a hospital bed, has made it a more remote feature of our existence. But this is not the case for medical professionals, especially physicians who play a central role in end-of-life care and the decision-making for patients nearing death. So, how does this experience influence their wishes for their end-of-life care?

Past research reveals a stark difference between the care physicians provide patients and the care they choose for themselves. This discrepancy is partially driven by their individual approaches to practice.

But this does highlight a significant point, underscoring differences in practitioner attitudes, as well as potential professional or personal dilemmas posed by the challenges of patient end-of-life care. The existing research has, however, had a limited geographic scope and has focused on a narrow range of end-of-life decisions. This is where the new study comes in.

“International comparative research can provide valuable insights into how cultural, social, and system-level differences influence physicians’ personal end-of-life preferences,” the researchers explain in their paper.

“By exploring diverse perspectives, we can uncover commonalities and unique challenges, which lead to more informed, globally relevant evidence to help align clinical care with patient values.”

To gather their data, the researchers recruited three types of physicians: general practitioners, palliative care physicians, and other medical specialists with a high likelihood of seeing patients with end-of-life issues. The participants were identified through the networks of the project’s research partners in each country, as well as through medical associations and professional societies. The researchers then conducted semi-structured in-depth interviews with each participant.

The results showed a wide range of personal preferences related to various end-of-life decisions.

“We found that most physicians have considered their personal end-of-life preferences, and for many, their ideas have clarified over time. Many physicians shared that they think regularly or often about their own mortality and have given some consideration to end-of-life issues,” the team wrote.

“Palliative care physicians reported having reflected a lot on their own end-of-life preferences, which was not the case for general practitioners or other medical specialists.”

Many physicians stated that they have formed strong ideas about what constitutes a “good death” for them based on personal experiences with family members or patients they considered peaceful and positive or, in contrast, situations they would like to avoid.

“Physicians often cited the elements of a good death as being at home or in hospice, anticipating death, loved ones nearby, enough time for goodbyes, not suffering, pain and symptoms controlled, spiritual and practical affairs in order, a clear mind, and autonomy and dignity preserved.”

Despite physicians largely wanting to die at home, some admitted they had become accustomed to medical environments, so would not mind dying in a hospital. Many physicians also wanted to know that death was coming so they could put their affairs in order.

Many physicians reported seeing patients receive aggressive or “futile” treatments that they would want to avoid themselves. They also want to avoid mental suffering or being a burden to others.

“This aligns with research indicating that the emotional challenges of caring for dying patients can influence physicians’ thought processes and decision making,” the team explains. “Although some physicians highlighted experiences of observing peaceful and meaningful deaths, the most powerful influence seems to be the end-of-life experiences they found most challenging and hope to avoid.”

The results contrast with what many non-physicians want. For instance, existing research has shown that patients and the public often opt for treatments that will prolong their lives, despite expressing a desire for comfort-focused care. It seems physicians are more aware of the costs of this treatment and are more likely to avoid it. Patients may prefer life-extending treatments due to fear, uncertainty, or a lack of medical knowledge.

The team also found that physicians' views on some end-of-life preferences were influenced by cultural factors, the legislative environment, and their own specialty. For instance, physicians’ attitudes towards assisted dying seem to vary based on cultural and legal environments and their personal beliefs.

“Physicians in jurisdictions where assisted dying is legal or where laws have been considered (Belgium and Wisconsin) more often view it as a positive and important end-of-life option, while others express discomfort, especially if their cultural or religious beliefs, or the legal framework of their country, opposes it (Italy),” the team explains.

The study offers insights into the various factors that shape physicians’ end-of-life preferences and indicates how these preferences can form. The team suggests future research could explore, such as how these preferences influence their clinical practice or recommendations to patients, and whether physicians are separating their personal preferences from those of their patients.

The study is published in Palliative Care and Social Practice.