To the Editor:
Re “People Say They Want to Die at Home. I Think About It Differently,” by Daniela J. Lamas (Opinion guest essay, nytimes.com, Sept. 28):
As a trained end-of-life doula, I am grateful for Dr. Lamas’s essay reframing what constitutes a “good death.” Location alone, home versus hospital, does not make a death good or bad.
The transformation comes when people make a plan for care before a medical crisis. Studies show that only about one in three American adults has a health care directive, and almost half of those who do wait until 65 to get one. Additionally, racially and socioeconomically marginalized groups face barriers to end-of-life planning support and hospice services.
We need policy changes to normalize these conversations and expand access.
First, health insurance should reimburse nonclinical providers, including social workers, end-of-life doulas and community health navigators, who have the training to guide end-of-life planning.
Second, public health funding should be directed to trusted local entities, such as faith-based groups, public libraries and civic organizations, to deliver free, culturally responsive resources.
These changes would ensure that individuals, rather than the health care system, define what a good death is and where it will occur.
Justin Howell Decatur, Ga.
To the Editor:
As a hospice and palliative care physician, I agree with Dr. Daniela J. Lamas that the hospital can be the best place for some patients to die comfortably. I frequently counsel families that rapidly changing symptoms may be too challenging to manage at home, or that their loved one is unlikely to survive transport.
But are clinicians prepared to care for dying patients? Access to fast-acting intravenous medications and nurses down the hall cannot ensure a peaceful death if clinicians hesitate to treat suffering. Unfamiliarity with end-of-life care and fears that opioids will hasten death can delay symptom relief.
We must prepare clinicians to understand the dying process, treat pain and shortness of breath, and communicate with families about comfort-focused care.
A hospital death does not mean that medical teams have failed. But accepting medicine’s limits does not end a clinician’s responsibility. Skillfully caring for patients at the end of life and supporting their loved ones are among our most sacred obligations.
Lindsey Ulin Dallas
To the Editor:
I’m a nurse who provides end-of-life care in the I.C.U., and I read Dr. Daniela J. Lamas’s essay with real recognition. Helping family members through a peaceful death — teaching them what to expect, weaning support so the end is calm, listening to hours or days of stories, coping with tears and fears — is the most meaningful part of my job.
But far more often I’m with families who, as Dr. Lamas puts it, have already “kept escalating through interventions,” and now they can’t bring themselves to allow a peaceful death.
Once a dying patient is dependent on a breathing machine, 24/7 dialysis, an aortic balloon pump or other intense life-support measures, there’s often no good way back. Families can come to feel that stopping these interventions, or not escalating, means failing their loved one.
A peaceful death in the I.C.U. is certainly not a failure. But a more effective change would be to keep many patients out of the I.C.U. by intervening earlier. Palliative care and ethics consultations in the emergency room, before admission, could route more to inpatient hospice, where they’d get the comfort care without the pull toward interventions that end up causing more suffering than they prevent.
Etan Yeshua Washington
To the Editor:
I am one of many older Americans who find that dying either in an I.C.U. or at home presents too many variables. Hospitals are too invested in maximizing care, even in the face of patient directives. At home, family members whose beliefs about death diverge could thwart a loved one’s preferred way to go.
How many Americans over 80 succumb without warning to debilitating injuries that render them dependent on help for daily activities? I have no plans to follow my forebears into their 90s.
I will select the finest hotel with view of sea and sky. My bottle of rosé Champagne will be of the finest vintage. And I will leave the grandest tip to the concierge and housekeeping.
I intend life’s end to be as simple, for me, as “Do Not Disturb.”
Ted Gallagher New York
The post The Path to a ‘Good Death’ Starts With a Plan appeared first on New York Times.
