'How people die remains in the memory of those who live on," said Dame Cicely Saunders, founder of the modern hospice movement. While she achieved an enormous amount, her ambition that everyone should be able to die in a safe, peaceful and pain-free environment has yet to be realised.
Dying is life's one certainty, yet often we fail to plan for it and go to great lengths to avoid discussing it in polite company. Is there such a thing as a good death and, if so, do we have the power to arrange it?
Trea McNally, a senior nurse working in oncology at a London teaching hospital, believes that most people's deaths could be far better managed. "Often medical professionals don't focus enough on people who are dying. Much more could be done," she says.
This is a sentiment reflected in the Department of Health's End of Life Care Strategy that was published last July. The document states that many people do not have a good death, and that there is insufficient training among health and social care staff to deliver the best care.
Since then, not enough has been done to tackle the problem. Hospices provide an excellent model for end-of-life care but, due to space and funding issues, only 4% of people are admitted to one, while the majority - 58% - die in hospital and 18% end their lives at home.
Seventeen per cent die in care homes and 3% elsewhere. With around half a million people dying in England each year, the lack of attention paid to the process is something that McNally feels needs addressing.
"When you arrive in the world you are guided in, looked after and physically held by an expert, a midwife. This is a person who is a specially trained multitasker who can ensure that a new life begins in the safest, most positive way possible," she says. "But there is no equivalent person to gently lead you out of the world, to hold you when you are departing and to make you feel safe when you cross over from life into death."
She has nursed hundreds of dying patients and has seen a huge variation in the ways people take their leave. Some die calmly and peacefully, others are contorted with pain, some have capitulated to the inevitable while others have not. "I believe that what we need to do is to train the equivalent of midwives to support those who are dying. Caring and compassionate professionals who are in control of a situation that is unknown and can be terrifying to the person who is dying, and their relatives gathered round the bedside, makes all the difference."
Dylan Thomas famously wrote: "Do not go gentle into that good night ... Rage, rage against the dying of the light." Spirited words but not, according to McNally, the best way to approach one's imminent death. "So often I've seen a moment of surrender in people who are dying. They have accepted that they're not going to win. When people die peacefully they have a beautiful expression on their faces. I get a sense that they are 'home' now, and, particularly with cancer patients who have been through so much, it's lovely to know that they're not going to suffer any more. One of the most important things for the person who is dying is to leave the world feeling they are surrounded by kindness. And it's that kindness that the relatives remember, too."
How to make death better
Do the groundwork
People who put their house in order on every level - practical, financial, emotional, spiritual - generally die more peacefully. Plan the venue for your death and your funeral.
Consider the alternatives to hospital
End-of-life nursing care and treatment tend to be given lower priority in hospitals because it is considered that there's not much that can be done - so fearful patients and their loved ones may be left to their own devices. Nurses are often distracted with caring for those who aren't dying, while pain relief at the end of life can be effectively managed outside a hospital setting.
Create a soothing environment
It is important to ensure the environment is suitably tranquil. Phones ringing, children running around and upset relatives prevent the transition from life to death happening calmly and peacefully. "If a relative is very distraught I remove them from the bedside, give them a cup of tea and try to calm them down. People need permission to die and it's much harder if someone is begging you to stay," says McNally.
Find the right person to help you
People need to feel that they're safe and supported when they're dying. Having a calm, kind, competent and professional person around who is in control of the situation can make a huge difference to both the person who is dying and their loved ones. Try to find a friend, relative or professional carer who has experience of supporting those who are dying to help out. "Death doesn't scare me at all," says McNally. "People see that I'm in control of the situation and think, 'I'll go along with what she says.'"
Touch is important
Like hearing, touch is usually one of the last senses to go. So gently holding someone, or their hand or arm, or stroking their forehead can really help. "It makes a big difference if you can hold somebody's hand, be kind to them and, without patronising them, assure them that there's nothing to be scared of."
