The "good death" — it sounds like an oxymoron, an ornamental turn of phrase for the grieving; but since the beginning of the palliative care movement, the concept has guided how doctors and nurses provide care.
It's a phrase that also has meaning in the Chinese-Canadian community though the interpretation may have more layers.
Over the past decades, Canada has had an open door immigration policy. For example, from 1991 to 1996, according to the Canadian Consulate in Hong Kong, approximately 30,000 people from Hong Kong immigrated annually to Canada.
Today, 20 years later, many of these early Hong Kong emigrants have reached retirement age and beyond. Their rite of passage into a new stage of a life has fostered an increased interest in end-of-life care from a Chinese-Canadian perspective.
According to Kerry Bowman, a bioethicist at Mount Sinai Hospital in Toronto, the "good death" from a Chinese viewpoint generally places less emphasis on autonomy. "I don’t pretend I can speak for all Chinese-Canadians," said Bowman but overall, value is placed on "inter-relationships and interdependence rather than independence."
For example, when it comes to end-of-life decision making — an important element of the "good death" in terms of being prepared — it’s not a question of "what would your mother want if she could speak for herself" but "how do you think your mother would want a decision like this to be made?" said Bowman.
Goal of a good death
In her research, Dr. Bethne Hart, a nursing and midwifery lecturer at the University of Newcastle, has found that the precepts for a "good death" are often based on a goal of pain-free dying and a high level of awareness, acceptance and preparation for death.
The difference is fairly nuanced, he said, but essentially family members, more so then the dying person, become an integral part of the "good death" process.
Another element of the Chinese understanding of the "good death,"adds Bowman, is the level of open communication and awareness that’s practiced in institutions.
"There’s a strong current in Western culture and in health care in which overt direct communication about death is valued because ultimately the ‘truth shall set you free.'" But in Chinese culture, forceful discussions of an approaching death is often unacceptable, and in fact, can be seen as destructive and harmful, said Bowman.
"So what you get are vague discussions between the dying person and the family that may appear like an aversion to end-of-life planning."
Bowman stresses, however, that many Chinese-Canadians, at least the families he’s worked with, are highly cognizant that they live in a Western society. And so "when we’re talking about a Chinese understanding of the ‘good death’ we have to recognize that it’s a fluid concept."
At the Yee Hong Centre for Geriatric Care, a network of four facilities in the Greater Toronto Area for seniors at all stages of life — from long-term care to palliative — there’s an emphasis placed on the role of the family. "We chose Yee Hong because here, the family is just as important as the parent," said George Ho Sue.
Ho Sue’s mother, Violet, is a resident at the Markham location. He admits a part of the reason his family and his mother chose Yee Hong is because of the food and lifestyle. "My mother grew up in Jamaica but Chinese culture was and still is very much a part of her life."
Of course, it’s not just the menu that families like the Ho Sues appreciate. The children, the grandchildren, the aunts, the uncles with loved ones at Yee Hong also value the fact that they’re kept abreast of and are involved in the care of the resident, said Ann Chan Lo, a social worker with the Centre.
"My mother has dementia," said Ho Sue. "She’s been in and out of palliative care recently. What’s nice about the nurses is that they keep you up-to-date with the treatment and any small changes." And Ho Sue knows that when it’s time to switch to full-time palliative care, his mother will not undergo any type of aggressive treatment. "It’s a discussion we had prior to entering Yee Hong."
And as more and more Canadians are entering their advanced years, workers like Kerry Bowman and Ann Chan Lo are actively engaging with families and patients to realize their understanding of a "good death."
A combination of many approaches may well be the answer.