A Good Death in Ratnapura : A Qualitative Study

Introduction:  One of the most important goals of medical care in patients having a life limiting illness is achieving a ‘‘good death’’. To achieve this, components of a good death should be identified. Objectives : To identify the components of a good death in Ratnapura, Sri Lanka. Methodology:  A qualitative, prospective serial study was done. The study sample included patients diagnosed as having life limiting illness and being followed up at the ENT, Palliative care and Oncology units at General Hospital Ratnapura. Results:  There were 42 participants in the study. Thirty five (83.33%) of the patients had cancer and 7(16.67%) had non cancer life limiting illnesses. The study identified attributes which fall to 15 categories as common components of ‘‘good death’’. Conclusion:  The main categories of good death in Ratnapura, Sri Lanka, were having a good family relationship, having a good relationship with medical staff, Not being aware of death, Fighting against the disease, Dying at ones favourite place, Having faith, Maintaining hope, Maintaining dignity, Freedom from Pain, Physical & Psychological symptoms, Not being a burden to others and Maintaining sense of control. Home was considered the best place to die. Ceylon Journal of Otolaryngology Vol.4(1) 2015 pp. 20-25


Introduction
One of the most important goals of medical care in patients having a life limiting illness is achieving a ''good death''.To achieve this, components of a good death should be identified.

Introduction
Death has been a subject which has been contemplated often in the Sri Lankan society especially due to its influence of Buddhism.In the Western world death is regarded as a function of old age, a consequence of the failure of modern medicine to hinder or preclude the inevitable, or as a process that can be prevented, reversed, or prolonged 1 .Research findings suggest that contemporary attitudes towards death and dying reflect a degree of trepidation, fear, and denial [2][3][4] .The term "Good Death" was originally used to describe the act of euthanasia.Currently in palliative care management in the Australasia region euthanasia is not considered as a part of a good death.Studies show that terminally ill individuals experienced a "good death" if they actively participated in how, when, and where they chose to die 5 .It was not until the 1980s when researchers and clinicians began to focus on issues related to death and dying (e.g.autonomy, palliative care, and dying with dignity) that the term "good death" moved beyond the confines of a synonym for euthanasia and was seen as a complex and individualized phenomena.Previous findings reveal that the characteristics of a good death differ among age groups 3,6 , men and women 7 , patients 8 and clinicians.But no research has been done regarding what a good death is in Sri Lanka.This study has been planned to fill that void.

Objective
The aim of the study is to identify the components of a good death in Ratnapura.
A Good Death in Ratnapura : A Qualitative Study.

Methodology
This qualitative, prospective serial study was done at General Hospital Ratnapura.The study sample included patients diagnosed as having life limiting illness and being followed up at the ENT, Palliative care and Oncology units.The study duration was 3 months starting from 1 st April 2015.Only patients giving written consent were included in the study.The study included in-depth interviews by trained medical officers while collecting their basic demographic information.Ethical clearance for the study was obtained from the National Institute of Health Sciences, Kalutara, Sri Lanka.
Thirty five (83.33%) of the patients had cancer and 7(16.67%) had non cancer life limiting illness such as end stage organ failures and neurological diseases.
Patient's attributes of a good death obtained through the interview was divided in to fifteen categories (Table 1) Eleven of these categories were mentioned by more than 50% of patients (Table 2).They were "Having a good family relationship", "Having a good relationship with medical staff", "Not being aware of death", "Fighting against the disease", "Dying at ones favourite place or environment", "Having faith", "Maintaining hope" and "Maintaining dignity".The most favoured dying place was home (Table 3), Three patients preferred the hospital and another three said that any place was good for their death.The categories least mentioned (<50%) were "Completion of life", "Appreciating others", "Not to prolonging life" and "Contributing to others"
In this study 90.48% of the patients highlighted the importance of having a good family relationship.This may indicate the closeness and unity of a traditional Sri Lankan family and the availability of psychosocial and monetary support from these extended families.Another important fact identified during the interviews was unlike in western studies the autonomy in decision making was not considered important.They wanted a good relationship with medical staff (73.81%).Many acknowledge their fondness to speak indepth about their condition with their physician and many wanted to continue with whatever treatment plan the physician has recommended.A study done before has shown that majority of Sri Lankan patients had no inhibition of accepting their diagnosis and its complications 22 as such Sri Lankan patients wants to be informed about their diagnosis and prognosis but is happy to let the physician and family take decisions on treatment options.
Fighting the disease was also mentioned in 69% interviews.They wanted taking all the available treatment options,this result would emphasizethat taking all the available treatments is an importantfactor for achieving good death in Sri Lanka.Not being aware of death was another component identified in 69% of the interviews.Many preferred to die during their sleep.Home was considered the best place to die.
Factors like freedom from pain, completion of life, not prolonging life and contributing to others were mentioned but many did not consider them essential for a good death.

Conclusion
This study tried to identify the important componentsof good death in Ratnapura,Sri Lanka.The main categories of good death were having a good family relationship, having a good relationship with medical staff, Not being aware of death, Fighting against the disease, Dying at ones favourite place, Having faith, Maintaining hope, Maintaining dignity, Freedom from Pain, Physical & Psychological symptoms, Not being a burden to others and Maintaining sense of control.One main drawback of the study was the patients interviewed were mainly from a very low educational and socioeconomic level.Their views on a good death might not be the same as the general public in Ratnapura.A larger population study involving many hospitalsmay give a better understanding of a good death in Sri Lanka and its variations with factors such as age, sex and social level.