Evaluating the “Good Death” Concept from Iranian Bereaved Family Members' Perspective

The domains and the components perceived as important by bereaved family members were (1) physical and psychological comfort, (2) dying in a favorite place, (3) maintaining hope and pleasure, (5) not being a burden to others, (6) good relationship with family, (7) physical and cognitive control, (8) environmental comfort, and (9) life completion. The domain perceived by family members as less important was “unawareness of death” (mean = 3.05).

Significant differences were found between some domains of a good death and demographic characters of family members. Older participants were more likely to perceive a good death as “being respected as an individual” and “having good relationships with family members.” Among participants, those who had a higher level of education were more likely to view a good death as “being respected as an individual” and “pride and beauty.” There was a negative correlation between level of education and “unawareness of death” (Table 2).

Discussion

According to the factor analysis, 18 domains contributing to a good death were identified. However, the domains of the “good death” concept that were perceived as important by bereaved family members were similar to those in Japan. This finding thus indicates that these perceptions are foundational elements of a good death, regardless of ethnicity or cultural differences.

The results indicated that most family members are likely to view a good death as “being respected as an individual” and having “control over the future.” According to Murata,¹⁹ approaching death can cause a sense that life is meaningless and a loss of the patient's well-being founded on temporality, relationships, and autonomy. Providing a good death means that dying patients are able and allowed to participate in the same human interactions that are important throughout life and appreciating patients as unique and “whole persons,” not only as “diseases” or cases.²⁰ It means supporting patients' well-being through positive stimulation, for example, offering beautiful views and tasty meals.²¹ A good death is also perceived by family members as “religious and spiritual comfort.” Ghavamzadeh and Bahar¹⁴ claimed that among Iranians religious beliefs strongly and explicitly deal with the fact of death. This finding reflects the result of Tayeb et al,¹¹ who found that Muslims believe that death is closely linked to faith. They appreciated the importance of access to any needed spiritual or emotional support. Steinhauser et al.²⁰ also found that 89% of American patients and 85% of their families emphasize that a good death is “being at peace with God” and “prayer.”

Participants perceived a good death as a “natural death.” Johnson et al²² claimed that death without “machines,” “tubes,” and “lines” is considered more dignified and aesthetically pleasing. Withdrawal or withholding of treatment of the highly invasive and technological sort is conceptualized as restoring patient dignity and, to a small degree, personhood.²² Many deaths were not considered “good” because of inherent problems within a culture of care that usually strives to prolong life and prevent death.²³ Similarly, Miyashita et al¹⁸ reported that most Japanese view unnecessary life-prolonging treatments such as vasopressors, antibiotics, and artificial hydration as barriers to achieving a good death. The domain perceived by family members as less important was “unawareness of death.” This is consistent with Steinhauser et al's²⁰ finding that 96% of American patients emphasized “knowing what to expect about one's physical condition” achieves a good death. This is inconsistent with Tang et al's²⁴ claims that in many traditional cultures (eg, most Asian countries and a few European cultures), in an effort to protect the patient from despair and a feeling of hopelessness, family caregivers often exclude patients from the process of information exchange. This is also in contrast to Miyashita et al's^{[18] and [25]} findings, where many Japanese do not want to know the seriousness of their condition. Our findings could be explained by the other results of this study. The results indicated that the majority of participants had a high level of education. The other findings showed there is a negative correlation between level of education and “unawareness of death.” Since the majority of participants were well-educated, it can be concluded that they were less likely to view a good death as “unawareness of death.” This has also been found by Montazeri et al.²⁶

The results showed that the family members' age was correlated with some aspects of a good death. Miyashita et al¹⁸ also found that the older the family member, the more positively he or she would look on the patient's death. They claimed that death at younger ages tended to be evaluated as a bad death. This could be explained by their earlier study, where they found that age and psychosocial maturity inversely related to death anxiety.²⁷ Based on the results, level of education positively influenced some domains of a good death. There was a negative correlation between level of education and “unawareness of death,” with Montazeri et al²⁶ finding that Iranian patients with a low level of education were more likely to not know the diagnosis.

Conclusion

According to the results of this study, providing a good death requires professional caregivers to be sensitive and pay attention to the preferences of each unique person's perceptions through her or his senses. This includes views, tastes, sounds, smells, and bodily contact. The ability of a dying person to see a sunset may seem petty but is important in providing high-quality care for people at the end of their lives. The same goes for the other senses. These circumstances deserve attention in all educational programs and especially in programs dealing with end-of-life care. In order to implement holistic care, caregivers must pay attention to patients' spiritual needs. Establishing a specific palliative care unit in a hospital and meeting each patient as a unique being and part of a family could be the best way to improve the quality of end-of-life care that is missing in Iran. It requires cultural preparation and public education through the media and by well-educated staff. Since demographic variables influenced the evaluation of a good death from the bereaved family members' perspective, public education needs different strategies.

Limitation

All data in this study were collected by use of self-report questionnaires. The dependence on self-report aspects in this study may have caused an overestimation of some of the findings due to variance, which is common in different methods. The respondents were predominantly female, which limits the generalization of the results for male respondents. Moreover, the convenience sample of Iranian bereaved family members, which is not representative of the entire Iranian population, could weaken the generalization of the findings. Further research is necessary to illuminate the concept of a good death as perceived by the general Iranian population.