What Makes for a Good Death?

During the pandemic, experiences of death and dying were profoundly impacted, bringing into fresh relief the question of what makes a good death. In this post we draw attention to what it might mean in contemporary Western societies to have a ‘good’ death. In particular, we focus on what makes the death of a parent qualify as being ‘good’. We will address some of the features associated with a good death — such as location, timeliness, and the presence of family — which figured in our recent work on parental death (Pearce and Komaromy, 2021) and show how they are interrelated.

The notion of a good death is not new, although how it is defined and by whom has changed over the centuries and will doubtless continue to do so. According to sociologist Lindsay Prior, historically, people have always distinguished between good and bad deaths (1989). Tensions that arise from the qualification of what makes a good death have resulted in modifications of the term to include such variations as ‘appropriate’ (Weisman, 1978), ‘good enough’ (McNamara, 2001, Bradbury, 1993) and ‘timely’ (Kellehear, 2007). The body of multidisciplinary literature that includes the social sciences, medicine, history, and philosophy attests to its diversity, complexity, and attention, and its continuing importance across cultural contexts.

As death study scholars, we are interested in how death in old age might be considered desirable — especially the notion that parents should pre-decease their children as part of the ‘natural’ order of things. As part of this inquiry, we recognise that the notion of ‘naturalness’ is highly contested in the social sciences (Berger and Luckman, 1966). In Western societies, as people live longer, death has been increasingly postponed, taking place in older age (Hockley and Clark, 2002). Further, in modern societies where death has been medicalised and institutionalised, dying in old age – or even extreme old age — might be deemed to be a good death. Yet, the notion that older people are ready for death, as a natural phenomenon to the end of a long life, remains disputed (Howarth 2007).

Another feature of timeliness involves being aware of one’s imminent death but without a clear diagnosis of dying. As is the case for many older people, markers of dying can be difficult to recognise and, consequently, many older people suffer a series of uneven and gradual deteriorations (Komaromy 2010). Some type of episode to mark the proximity of death, such as a fall, fracture, stroke, or infection, can herald that the end is near, but this often means being close to death in terms of weeks or days, rather than months or years. This makes having enough time to provide high-quality end-of-life care difficult. Indeed, older people, especially those in care homes, will be subjected to a rehabilitative regime to counter the induced institutionalisation of being in a care home, even though physically their failing bodies may be unraveling toward death (Komaromy 2010). Whatever marks the beginning of dying, it is often at this stage that decisions have to be made, including such things as whether or not to embark upon curative treatment. And this can create dilemmas, not least about who is making which decisions within families, and can create distress, as our research examples have highlighted.

Being accompanied at the end of life is also often associated with a good death. This means being aware of when the end might be and requires an open discussion of the imminence of death. Our research shows that such preparedness is not always possible. As referred to above, discussions about when to stop curative treatments and focus on the quality of end-of-life care are often in the hands of the medical profession, and negotiating the transition from curative to palliative care requires a degree of power-sharing. These decisions are often both ethical and practical and despite the best intentions, it might not be possible for interested parties to do the right thing.

With the advent of the modern hospice movement, central to a good death is the relief of pain and symptoms, with pain including physical, emotional, spiritual, and social dimensions. This philosophy — a radical movement against death as a highly medicalised event — continues to receive resistance in those conditions without clear dying trajectories, not least among older people. Put simply, the rhetoric of extending palliative care to all is not matched by the reality. Pain and symptom relief is not necessarily available to everyone – and it remains the case that conditions like cancer take priority over more chronic conditions, including multiple morbidity. Indeed, research highlights the way that some end-of-life care is of relatively poor quality, especially in older people. (Tobin et al., 2021).

Research into the desired place of death highlights that most people prefer to die at home (Pollock, 2015). The reality, though, is that most people die in hospital. And no matter how desirable it is, dying at home requires much support. The expression that ‘care at home means care by women’ might be less representative in this millennium, but our examples highlight that caring roles within families can still be gendered. The difficulties associated with care at home, and its dependence on full-time care, means that, for adult children working full time and who are often geographically distanced from other family members, providing care for dying parents is difficult, if not impossible. Therefore, even assuming that conversations about where someone wants to die might have taken place, practical restraints may prevent such preferences from becoming a reality.

From an emotional and philosophical dimension, being ready to die might be seen as desirable. Here, we have highlighted a few of the interconnected strands that make dying well a complicated process. Even assuming that people share notions of what makes a good death, and recognising individual diversity and social and cultural constraints that script types of death, facing death is far from straightforward. The reality that uncertainty is a common feature of illness further complicates how decisions are made. So, not only is achieving a good death for some people difficult, it requires a range of resources on all levels which might not be available. However, by engaging with advanced-care planning and discussion, families and communities can find ways to mitigate some foreseeable difficulties, while accepting the inevitable uncertainties we all will face in older age and at the end of life.