Is dying well as important as living well?

In response to the Salzburg Questions, a new series encouraging a global discussion about the key issues affecting palliative care, Dr Jonathan Koffman of the Cicely Saunders Institute, King’s College London, UK, explores the importance of addressing happiness at the end of life. It’s a timely post given that today, March 20, is the International Day of Happiness.

When did you last ask a patient, “What makes you happy?”

Dr Jonathan Koffman

At first glance happiness seems to be a little bit like love; if you have to ask whether you are in it or not, you probably aren’t. So what is happiness? The subjective, fuzzy, vague feeling of this concept has been neglected in psychology until relatively recently. Is it possible that psychologists weren’t particularly interested in the scholarly research of happiness? I’m not convinced. Achieving quality of life is considered to be one of the main goals of palliative and end-of-life care. A widely presumed component of quality of life is happiness, a concept considered to be so important to human existence that the World Health Organization now recognizes it as an integral component of health.

Given the importance of happiness in quality of life it is perhaps surprising how little research has examined its meanings among people living with advanced disease. Moreover, no research has attempted to understand the meaning of happiness among people living with advanced disease from diverse communities. Addressing this concern is important because increasing globalization has brought with it an unprecedented number of people who have migrated to developed countries.

We recently conducted a study to explore and compare, for the first time, the centrality and interpretations of happiness across two cultural groups. We interviewed 26 Black Caribbean and 19 White British cancer patients living with and, dying from, advanced cancer in London. Beyond providing detailed accounts of how they comprehended their cancer and symptoms, we also asked participants to tell us very simply, in their own words, what made them happy. This is a question that rarely appears in the clinical assessment of patients.

Nearly all participants volunteered views on happiness, which were related to four main themes:

  • Empty lives, a theme associated with lives devoid of contentment.
  • Happiness and the physical form, such as the effect of distressing symptoms on wellbeing.
  • Love and affection, which concerned relationships with family and friends.
  • Realising personal meaning in life, which related to God, prayer and the sacred world.

The findings provide a very evocative account of the presence of happiness even in the darkest moment of advanced disease. For example, we observed that black Caribbean participants often comprehended the inexplicability of their cancer through the lens of their strong religious beliefs, which enabled them to make the successful transition to a state of acceptance and happiness.

We recommend that health and social care professionals be aware that happiness is an important, complex and multidimensional human experience, which at times is also culturally shaped. They must therefore be sensitive and willing to ask the questions that, on the face of it, seem indulgent when compared to the task of treating physical symptoms. This will enable them to better understand their concerns and then to devise therapeutic responses that maximize moments of happiness and subsequent quality of life.

For more information about the study conducted into happiness amongst different cultural groups at the end of life, the full paper can be viewed here.


  • Follow the EAPC Blog for more posts in the Salzburg Questions series.
  • Follow the global dialogue on Twitter. Using the hashtag #allmylifeQs the nine Salzburg Questions will be debated throughout 2017.
This entry was posted in ADVOCACY & POLICY, Salzburg Global Seminar Series and tagged , , . Bookmark the permalink.

One Response to Is dying well as important as living well?

  1. Dr Koffman, I so appreciate asking ‘what makes you happy’. Such a seemingly simple approach, that – as you also pointed out – gets overlooked in focusing on the clinical. As a layperson blogger in this end of life space, I sit on various palliative and end of life steering committees and the healthcare professionals ’round the table are almost always taken aback when I suggest approaching end of life convos with a similar question: what are your small pleasures. I was gratified when one health center did a small study based on the nursing theory of comfort: I will now be able to possible surprise them even more with your question of happiness – backed by evidence! Thank you again.

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