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For Most Patients, a Good Death Is Dying Naturally

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A separate survey in The Journal of the American Medical Association on what makes a "good death" found broad agreement among patients, families, doctors, and other care providers that pain control is the most important aspect of a "good death."

Nonetheless, with depression linked more strongly to patients' interest in assisted suicide than pain, Emanuel emphasizes that doctors need to better recognize and treat depression among the terminally ill. Feeling unappreciated and needing significant help with basic daily activities were two other factors that caused patients to consider suicide.

Emanuel points out, however, that patients' views on assisted suicide were unstable in general. In his study, half of those who initially considered suicide later changed their minds, and follow-up interviews with other patients revealed support for assisted suicide where there had been none earlier.

Therefore, Emanuel and his fellow researchers warn doctors who receive requests for physician-assisted suicide to "not take such requests as settled views." Instead, doctors should look for and treat "depression and other psychological stressors": The study found that depressed patients were five times more likely to change their minds to favor assisted suicide for themselves.

In the "good death" survey, Karen Steinhauser, PhD, the study's lead author and a health scientist at the VA Medical Center in Durham, N.C., found that freedom from pain was ranked as the most important attribute among all the groups -- patients, families, doctors, and other care providers. From there, she said, the groups varied in their end-of-life priorities. Doctors put less emphasis than patients, for instance, on the importance of being mentally aware.

Steinhauser and her co-authors were surprised that dying at home was ranked of low importance among the groups, especially among patients and families. "The notion of dying at home may be romantic among health care professionals," they wrote, but "some patients and families may feel overwhelmed by concerns about symptom control or a dead body in the home."

Overall, Steinhauser commented, "Physicians tend to focus on the physical aspects, [but] patients and families tend to view the end of life with broader psychosocial and spiritual meaning, shaped by a lifetime of experiences. ... Quality care at the end of life is highly individual and should be achieved through a process of shared decision making."

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