Ars Moriendi 10
The concept of a “good death” is not unprecedented. Ars Moriendi (“Art of
Dying”) are Latin texts, most likely authored by Dominican priests, dating to
around 1450, giving advice on how to “die well.”
This period in European history
was one of significant upheaval.
Deaths due to wars and the bubonic
plague continued to be very real
threats. Because death was always
so present, it is understandable why
people turned to faith to cope. The
clergy was expected to perform last
rites for the dying. However, the
mortality rates of the clergy were
similar to the rest of the populace.
Thus, there was not enough clergy
to perform last rites, a situation that
created the need to show the way to
salvation without the presence of a
priest. Ars Moriendi filled this need.
Ars Moriendi texts explained
how to “die well” under the precepts
of the Christian church at that time.
The text is divided into six parts:
1. A series of quotations relating to
death, explaining that death has
a good side. It is meant to console
the dying and explain that death
is not something to be afraid of.
2. Five temptations (avarice, despair,
impatience, lack of faith, and
vainglory) and how to avoid
them. According to the text, these
are gifts from the devil.
3. A series of questions to ask the
dying, which led to consolation
available to him.
4. Prayers and how to die as Christ.
5. Instruction on deathbed behavior
and how to treat family and
6. Prayers for the dying.
The parallels to modern-day
discussions on a “good death” are
interesting. Today, these discussions include comforting and
consoling the dying and spiritual
support when needed.
are living with terminal illnesses for a very long period (e.g., cases of dementia and advanced heart disease), and it is unknown
when death will actually occur.
One can distinguish different types of ailments. Some appear
suddenly, and death is usually imminent once they occur (e.g.,
Ebola). In chronic diseases, the end of life can extend over several years. Thus, we are considering end of life as the the period
when there is no recovery or cure (or the patient chooses not to
pursue a cure), health degrades, and the only exit is death. In essence, it is a process of prolonged death. Beyond that, end of life
is characterized by degradation in the quality of life, or—more
accurately—by the quality of the prolonged death.
Traditional health care systems are curative-oriented and
tend to keep patients alive—even at the cost of pain, suffering,
and reduction in their quality of life, and regardless of the expected eventual success of the care. While death is inevitable, it
continues to be a taboo subject in most cultures. The preparation
or planning for death remains largely unaddressed, leaving the
desires of those who are living with terminal illness unheard
To respond to these issues, various initiatives are undertaken
around the world to focus health care providers, local communities, and family caregivers on improving the quality of death.
But there is much more to be done. According to the Worldwide
Palliative Care Alliance, “more than 100 million people would
benefit from hospice and palliative care annually (including family and care givers who need help and assistance in caring),
less than 8% of those in need access it.” 11
It is worthwhile to consider what is a “good death” and how
to improve the “quality of death,” even though deaths are nearly
as unique as the lives that preceded them, shaped by cultural,
religious, community, and familial attitudes; physical conditions;
the offending sickness; and medical treatments. A “good death”
is one in which a person dies on his or her own terms; in good
terms with, and free of concerns for, those left behind; in a sup-
ported setting; and with minimal pain and suffering. The wide
adoption of advance directives and end-of-life care plans may
improve the quality of death.
To bring the “quality of death” issues to light, the Lien
Foundation commissioned the Economist Intelligence Unit to
develop a “Quality of Death Index” in 2010.12 This index measu-
res the current environment for end-of-life care services across
The index scores countries across four categories:
■ ■ basic end-of-life health care environment,
■ ■ availability of end-of-life care,
■ ■ cost of end-of-life care, and
■ ■ quality of end-of-life care.
The index uses 24 indicators that fall into three categories:
1. quantitative indicators—e.g., life expectancy, health care
spending as a percentage of GDP;
2. qualitative indicators—assessments of end-of-life care in in-
dividual countries (e.g., public awareness of end-of-life care)
3. status indicators—whether something is or is not the case
(e.g., existence of a government-led national palliative care
The scores from each indicator are aggregated and norma-
lized for comparison.
The UK, Australia, and New Zealand are at the top of the
overall ranking. Their high ranks are attributed to the relative
wealth, advanced infrastructure, and established end-of-life
care initiatives that are in place. The bottom of the overall ranking unsurprisingly includes the newly industrialized countries:
Mexico, China, Brazil, Uganda, and India (see Figure 5). The