Dying, as a process or function in modern society, has metamorphosed over the years, partly resulting from societal changes and the individualisation of life we now live. According to Clark (2002), dying is understood as a gradual process of irreversible decline of our functionality and was once part of the whole community. This view later changed and remained the business of the family of the dying person, with the support of a family physician. However, today we see a different picture of death, with the dying person often removed from their family home and placed in an institution surrounded by strangers, with different healthcare professionals treating and caring for them.
It is crucial that we consider the needs of dying people; for example, being free from excruciating pain, avoidance of nausea and vomiting, being in the right place to die — physically and mentally. With different pharmacological and non-pharmacological interventions, these aspirations can be achieved, enabling people to continue to live and die in comfort and with dignity. However, one of the most difficult balances to achieve is ensuring that treatments/interventions we prescribe can still afford the dying person awareness and sobriety. Sobriety comes with multiple nuances and defining all of them here is beyond the scope of this comment.
However, the significance of sobriety for the dying person is multi-faceted, and Yun et al (2018) reported that the dying person tends to develop new realisations and meaning to their life. For example, the self-realisation of their beliefs (religious importance/influence) and acknowledgement of limited possibilities with the impending end (nonexistence) of their life. Yun et al’s (2018) research reported:
‘… in dealing with death in some persons a new sense of meaning may emerge, which is essentially a receptive experience of connectedness with an ego-transcending reality, such as mankind, nature, or God.’.
From such realisation, it can be argued that the dying person may experience reduced fear of their own death/mortality and embrace the reality that this is how their life is going forward.
Central to all these realisations is the presence of awareness and sobriety, which helps give meaning to the dying person, who desires to remain part of the decisionmaking process until the end. This can only be possible and facilitated through understanding from healthcare professionals who provide care and treatment. The dying person wishes to remain communicative with family and friends right to the end, and my own mother, as she was dying at the age of 105, told me how blessed she was to still be able to talk to us.
The balance between medication to control pain and the need to remain aware and cognitively conscious/functional is something all prescribers must consider. It may be possible, through discussion with the dying person, to reduce pain-killing medication on the understanding that they may experience some pain but will retain awareness and sobriety.
What is essential to remember, which can be hard for healthcare professionals, is to always work with and consider the wishes/desires of the dying person over our own. This might mean tailoring our treatment and support options to fit those of the dying person. The dying person may prefer awareness and consciousness over total freedom from pain, and as healthcare professionals, we should promote sobriety for the sake of the dying person and benefit of the bereaved.