End of Life: Understanding and achieving a "good death"
A blog written by Dr Samantha Fien (Central Queensland University) and Associate Professor Magnolia Cardona (University of New South Wales)
For many older people approaching the natural end of their lives, the goal is often to live as comfortably and meaningfully as possible, rather than to prolong life at any cost. However, a widespread and concerning issue known as overtreatment or dysthanasia has been recognised for over a decade, yet it continues to affect older adults globally.
This involves administering non-beneficial treatments that may not improve survival and can even cause harm or prolong suffering. Specific examples of these practices include unnecessary testing, multiple concurrent medications, avoidable hospitalisations, extended ICU stays, and resuscitation when not indicated, e.g. against patient’s wishes. This denotes wasteful and costly care, and is often described as a "bad death".
Why Does Overtreatment Happen?
A recent review we conducted sheds light on four main determinants of overtreatment, often intertwined with an overarching theme of inadequate shared decision-making and policy:
- Patient Factors: limited health literacy about the low success rate of CPR, misunderstanding of the concept of a good death, and unclear communication with clinicians about care preferences.
- Family/Caregiver Factors: Family dynamics where perceptions of futility vary, goals of care conflict with patient wishes, uninformed decision-making, rescue culture, restricted access to support to die in the community, and caregiver burden.
- Clinician Factors: Clinical inertia (not reflecting on the patient’s best interest), inadequate communication with patients, and lack of consensus across other specialties on when to stop, which triggers moral distress of accommodating unrealistic goals of care.
- Healthcare System Factors: Normalisation of medicalisation of death, poor availability of community services, low uptake of or dismissal of advance care planning.
How can overtreatment be reduced or prevented?
Fortunately, the medical literature also proposes five solutions focusing on comprehensive improvements across healthcare to help ensure a more compassionate End of Life (EoL) trajectory.
- Advance care planning and conversations on prognosis, values and preferred care are crucial and require improved clinician skills and dedicated time to engage patients and families.
- Healthcare system reform and innovative models of care are needed, advocating for increased investment in community-based health services including after-hours palliative care to provide suitable alternatives to hospitalisation, alongside fostering interdisciplinary collaboration to support and prepare patients for death.
- Competency training on evidence-based decision-making and palliative care promoting the application of assessment tools, algorithms and clinical pathways.
- Holistic patient-centred care emphasises continuity of care, understanding the patient's condition, and responding to their medical, emotional, social, cultural and spiritual needs.
- Evidence-based policy making and public health interventions are vital, involving greater public awareness and education campaigns to inform older adults and families about what constitutes non-beneficial treatment.
Achieving a good death is everyone’s responsibility. By fostering open dialogue among older adults, families/caregivers, clinicians, and healthcare providers, we can empower individuals to make informed choices that align with their personal values, leading to satisfaction with care and promoting a peaceful, dignified end of life.
Explore the updated End-of-Life Essentials module, Teamwork and Escalating Concerns, to learn how to recognise when to advocate for patients, and discover practical steps and tools for managing conflict and addressing concerns in end-of-life care.
Dr Sam Fien
Central Queensland University
Associate Professor Magnolia Cardona
University of New South Wales