Measuring the quality of dying.

149 IN “A VERY GOOD DEATH: Measuring Quality of Dying in End-Stage Renal Disease,” Cohen and colleagues1 present a case of a patient with endstage renal disease (ESRD) who died after discontinuing dialysis. They describe their research to measure the quality of dying of ESRD patients, and they make the claim that the patient they presented died “an exceptionally good death.” Their article is provocative and suggests three areas of inquiry for palliative care researchers: (1) What criteria should be used to determine that a death is good or exceptionally good? (2) Whose perspective counts? (3) How should we measure the quality of dying? Various researchers have suggested the attributes of a good death. In the ESRD literature, good deaths have been associated with advance care planning that results in respect for the patients’ end-of-life care wishes, psychosocial support by the family, and a stable relationship with a spouse or “spouse-equivalent.”2,3 Singer and colleagues4 in a qualitative study of three groups of patients—those with human immunodeficiency virus infection, elderly residents of a long-term care facility, and dialysis patients—identified five domains of quality end-of-life care that were important to the patients: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, reliving burden on loved ones, and strengthening relationships with loved ones. Using focus groups and in-depth interviews of patients, Steinhauser and colleagues5 identified six major components of a good death from the patient’s perspective: pain and symptom management; clear decision making in which patients participate in treatment decisions; preparation for death in which patients know what they can expect during the course of their illness and are able to plan for events that will follow their deaths; completion in which patients are strengthened in their faith and also participate in life review, resolve conflicts in relationships, spend time with family and friends, and say good-bye; contributing to others; and affirmation of the whole person. In a subsequent study in which they used a cross-sectional, stratified national survey of patients, recently bereaved family members, physicians, and other health care providers, Steinhauser and colleagues6 asked those surveyed to rate the importance on a one to five scale of 44 attributes of quality care at the end of life. In this survey, respondents were also asked to rankorder nine major attributes of a good death identified in Steinhauser and colleagues’ previous study5 from one (most important) to nine (least important). In order of decreasing importance, the top five attributes that patients ranked were freedom from pain, at peace with God, presence of family, mental awareness, and treatment choices followed. From these studies, attributes emerge that patients consistently value as important to them in a good death. In the case presented by Cohen and colleagues,1 some of these attributes appear to have been particularly well handled. The patient was affirmed as a whole person by his health care team, his family was present at his death, the patient had time to say good-bye to family and friends, his treatment choices were followed, and there was not inappropriate prolongation of his dying. On the other hand, we are told that breakthrough pain and in-