Commentary :
In
writing The socio-political debate of dying today in the United Kingdom and New
Zealand: ‘letting go’ of the biomedical model of care in order to develop a
contemporary Ars
Moriendi (Winnington, Holroyd & Zambas, 2018), the intent was to
highlight that although the right to choice and the right to die debates are
presently hot topics across many Western countries, they remain contained
simultaneously within and constrained by medical and legal practices. The
debate around choice and how we can move forward to achieve a contemporarily
acceptable good
death have, on a number of occasions, been proposed using the Ars Moriendi as a framework for change.
Such approaches however, are most often offered through a medical lens, and can
be seen in the works of Farr Curlin (2015) and Atul Gawande (2014, 2010).
Although these postulations are offered with good intent, and certainly bring
the matter to the fore, they simultaneously hold on to the belief that a
medical worldview alone is sufficient to meet the contemporary model of dying.
While some of this literature is certainly helpful in highlighting the current
discontent with death
and dying for some individuals in Western societies, it does not eliminate
the fact that little has changed for those seeking control over how they will
die. In
raising the potential for a new and inclusive framework for dying we, as the
authors of the above paper and as nursing
professionals, are highlighting the experiences of some patients who have been
caught up in the tangled web of collaborative medico-legal practices which
have, on most occasions, resulted in the loss of control over their death. It
is not surprising that such outcomes occur given the power that medicine and
law have over our lives and ultimately our deaths. There is, however, an
opportunity here for the nursing profession to take true ownership of their
role as patient
advocate to support those in our care whose preferences do not always align
with contemporary medical discourse and, indeed, sit on the
periphery
of such practices. On a simplistic level, this may just be a case of ensuring
that medicine and clinicians of all health
disciplines avoid the trap of labeling individuals who have such ideas as
being non-compliant, deviant or other; as this can be a default option when we
are busy and time pressured. Such an approach suggests a closed framework of
care being practiced. Our
discomfort with choices that are not medicalized
is an issue that we, as clinicians, must acknowledge as being our problem, and
not simply label those seeking alternative interventions is non-compliant.
There has never been a more crucial time for nurses to advocate for the rights
of those entrusted to their care while simultaneously encouraging medical and
legal colleagues to move away from the rigidly constructed ideals of what dying
should look like today; as we demonstrated in the cases of both David Nicholl
and Emma Young from our original paper (Winnington et al, 2018). The patient
voice must be heard if change is to occur to meet the requirements and
attributes for a contemporary Western good death. Nurses are best placed to
support this desire, even if we too have a discomfort with the changes being
sought today. Understanding
and addressing such discomforts can be considered an ideal starting point from
which change can occur. The problem is, however, that as nurses we too can be
caught up in the medicalization of death and dying. Nurses often consider
themselves as being holistic
practitioners. The reality, however, is that clinical tasks often override
the notion of ‘touch, talk, time’ and, as such, erodes the importance of
nursing being a tactile
profession (Molasiotis, 2018). More specifically, there is an apparent
comfort for nurses in being able to speak the language of doctors, to be equals
in clinical practice, with the reciting of pharmacological interventions being
a clear example of this, particularly in palliative
care. It is, therefore, our contemplation, understanding and implementation
of what true holistic practice is that is at the root of the problem. Despite
our intentions to practice with this model of care, it fails to be delivered
when we reject interventions that suggest ‘otherness’, when they fall outside
our scope of practice or field of knowledge. This is seen when individuals
encounter difficulties if they seek to use alternative or integrated
therapies in place of, or even alongside, Western medicine (Molasiotis,
2018). When this scenario is considered in terms of
solely a therapeutic option and not specifically around choices when dying,
this is clearly problematic, as one means of treatment will not suit all
individuals. If, however, we contemplate this discomfort of medical and nursing
professionals and shine that medical gaze (Foucault, 1973) onto the contemporary
dying individual, we can see clearly how individual wishes are often
considered as deviant, odd or other, yet in reality they are merely preferences
for their palliative care. With
the medicalization of many aspects of human life bringing numerous positive
benefits, reduction in disease burden, improved morbidity
and mortality
across the life course for example, modern medicine can be commended for the
gains achieved; yet death is different. Death is death. We stop existing as we
currently experience life. Dying is a transitional process from the known to
the unknown, and so poses profound discomfort in our need for order. For once,
we cannot predict what lies ahead once the cessation of current existence has
occurred, but the ownership of how this should happen must sit with the
individual in question. As nurses, we must trust individuals to make rational
decisions about death and not think them incapable of knowing how they want to
die. Nurses, therefore, need to put aside the notion that otherness is
problematic and support individuals whose contemporary take on achieving their
own good death does not align perfectly with the current socio-medicalized
death. In advocating for this change, nurses can help to actualize
self-determination for the dying. In
considering these issues in the context of re-framing the Ars Moriendi to support the dying in contemporary
society, it becomes evident how the freedom of lives lived are reflected in
the choices made. This is best reflected in the growing momentum of desire to
take back the ownership of our/ their bodies from the medical gaze, and seek
independence in how death will play out. In postulating the notion of a new
framework for dying today, which is open and individualized, where individual’s
decisions no longer sit on the periphery of the currently acceptable medicalized
death, it is clear that nurses are well placed to facilitate the inception of
choice for those in their care. This
is not to suggest that nurses support assisted suicide, nor participate in such
acts, rather they act as a committed advocate for individual choice and not get
caught in the net that only a medicalized death is a good death. Given that a
good death is one that most individuals want and seek; it is not for us to
decide what this should look like, with a one size fits all prescriptive
practice. With medicine currently dominating the landscape of the contemporary
Western death, nurses have a key role to play in being entrusted by the
individuals in our care to die as they have lived, through choices made. References 1. Winnington R, Holroyd E and Zambas S. The
socio-political debate of dying today in the United Kingdom and New Zealand:
‘Letting go’ of the biomedical model of care in order to develop a contemporary
Ars Moriendi (2018) Societies 8: 65. https://doi.org/10.3390/soc8030065 2. Curlin F. Dying in the twenty-first century:
Toward a new ethical framework for the art of dying well (basic bioethics) (ed)
Lydia S (2015) The MIT Press, United States 3. Gawande A. Being mortal: Medicine and what
matters in the end (2014) Metropolitan Books, New York. 4. Gawande A. Letting go (2010) Annals of
Medicine, The New Yorker, New York. 5. Molasiotis A. State of science of CAM –
efficiency, culture and translation (2018) International Conference for Cancer
Nursing, Auckland, New Zealand. 6. Foucault M. The birth of the clinic:
Archaeology of medical perception (1973) RHUS, Pantheon, New York. *Corresponding author: Winnington
R, Associate
Lecturer, University of Plymouth, Drake
Circus, Plymouth, UK, E-mail: Rhona.winnington@plymouth.ac.uk Citation: Winnington
R. Dying for choice: A nurses role in a new Ars
Moriendi to achieve a contemporary good death (2018) Nursing
and Health Care 3: 67-68 Nurse advocate, Patient choice, Death and dying, Ars Moriendi, Medicalization, Palliative care.Dying for Choice: A Nurses Role in a New Ars Moriendi to Achieve a Contemporary Good Death
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