[MUSIC] So what defines a good death? Well, it depends on who you ask. Patients, their families, or the healthcare professionals. We are all in agreement that ideally the patient should have control over the dying process, where, when and with who. And that they should be free from pain and suffering at the time of death. Some elements of a good death, such as death with dignity and living in hope until the end, are more important for family members than for patients. The sentiment is that we should burn as brightly as we have done in life, right up until that final moment. My favourite poem by Dylan Thomas, written to his dying father, has the timeless refrain. Do not go gentle into that good night, old age should burn and rave at close of day. Rage, rage against the dying of the light. For patients at the end of life, feeling empowered, spirituality, having a sense of life completion, and being able to say goodbye are most important. Unfortunately, dying often involves a loss of control. 95% of deaths in ICU involve unconscious patients. And invariably, there is a degree of pain and suffering. Often, advanced medical directives, or living wills, are not in place, or not clear enough to cover all situations. For example, I don't want to be on prolonged mechanical ventilation. How long is prolonged? Two weeks, two months, six months, a year? Families are frequently asked to be surrogate decision makers for patients at this critical point. Added to this is the fact that the medical team can't predict with complete certainty what will happen. They are, however, in the best position to give advice on what the treatment options are. And what the likely outcomes could be. Differences of opinion between patients and family members and medical teams can lead to conflict and much unhappiness and angst. At the center of this, there is always a patient. You cannot read the cases of Terri Schiavo, Baby K and Karen Quinlan at the end of their lives and not feel for all of those involved. Each was the patient at the center of a family trying to come to terms with terrible circumstances. The key to successful end-of-life care is effective communication and the establishment of realistic goals. The patient's best interests and wishes must be at heart. There may, however, come a point when the best medical therapy can no longer offer a meaningful chance of recovery. And can be prolonging a patient dying with no quality of life. Merely adding days to the patient's life cannot be the sole measure of success. It is the quality of those days that is the true measure of success. And these must be in keeping with the patient's own goals, not the doctor's or the family's. The term medical futility has been used to describe treatments with no or extremely limited chance of success. This term is, however, open to broad interpretation. Some guidelines now use the term potentially inappropriate treatment, instead of futile treatment. I prefer to term non-beneficial, because it forces us to give the rationale behind the treatment. All treatments are a balance of risks and benefits. And when the benefits are no longer achievable, or come at too great a cost, we must reassess. Medical care in the hospital in ICU is primarily geared to save people's lives, and not to facilitate the dying process. The hospital environment is not conducive to a good death. This is why terminal cancer patients are referred to hospice, where the unit of treatment is the patient and their family together. And the primary focus is on preventing suffering and providing all the support required for a good death. A dying patient is not always a failure of the medical system, but not supporting the dying process absolutely is. To recap, the majority of patients dying in ICU will have treatment withdrawn or withheld. A good death depends on many factors, which everyone involved, patient, family, healthcare professionals, needs to actively address. Communication is key. Ideally, advanced medical directive should be in place to help the family and clinicians honor the patient's wishes. [MUSIC]