[W Forum] A Good Death

"A grandmother who was discharged yesterday afternoon passed away at 4 a.m. Can I issue a death certificate?" This was the call I received on Tuesday morning as I arrived at work. As an internist with many elderly patients, I often witness patients passing away under my care.

This 104-year-old grandmother was discharged to spend her final moments at home. Though weak, she was a kind person who smiled with bright eyes and reached out to gently stroke the cheeks of the medical staff. Six months ago, on a cold December day, she slipped at home and underwent surgery for a hip fracture. The surgery went well, but while recuperating at home, she was hospitalized again due to complications including pressure ulcers, pneumonia, sepsis, and bleeding from a gastric ulcer. As her condition worsened, we sent her home so she could spend her last moments with family in a cozy environment, aiming for a 'good death,' even if not perfect.

What is a good death? According to overseas studies, Americans prioritize 'freedom from pain,' followed by 'spiritual peace' and 'being with family.' The British emphasize 'maintaining dignity and respect in a familiar environment.' Interestingly, the Japanese value 'physical and mental comfort,' 'preferred place of death,' and 'good relationships with medical staff.' In Korea, the most important factors are 'not burdening remaining family' and 'being with family.'

According to Statistics Korea, 76.2% of deaths in Korea occur in hospitals, while only 14.4% occur at home. However, the preferred place of death is home for 57.2%, hospice for 19.5%, and hospital for 16.3%. Although people want a comfortable death surrounded by family, the rate of hospital deaths remains high and continues to increase annually.

The four conditions for a 'good death' proposed in the UK's 2008 End-of-Life Care Strategy are universally relatable: ▲in a familiar and friendly environment ▲as an individual with respect and dignity ▲with close family and friends ▲passing away without pain.

Personally, if I were to identify the opposite of a 'good death'?a 'difficult(?) death' or 'undignified death'?I would say it is when a patient with no chance of recovery is surrounded by numerous medical tubes including intubation in the ICU, hooked up to a ventilator and countless machines, unable to say goodbye to family and friends. Many families believe such treatment is the best possible care based on the latest medicine and ask not to give up until the end. This raises the question of whether this contradicts the four elements of a good death.

Since the implementation of the 'Life-Sustaining Treatment Decision Act' in 2017, medically futile life-sustaining treatments can be discontinued even if the patient is hospitalized. Our 104-year-old grandmother refused intubation and feeding tubes. Although her time at home was short, it was fortunate she could share warm touches and farewells with her family. Then, my attention returned to the phone in my hand. "Ah, yes, since she passed away 12 hours after discharge with a predicted death, you may issue the death certificate at our hospital."

Baek Hyun-wook, Director, Biomedical Research Center, Department of Clinical Nutrition, Bundang Jesaeng Hospital