Take our Positive Aging Test

Find a therapist specialized in aging concerns

When quality of life is undefined, medical care defaults to aggressive interventions.

Early goals-of-care conversations reduce family anxiety and decisional regret.

Surrogate decision-makers face higher stress when wishes aren't discussed in advance.

Defining care preferences early aligns treatment and reduces unnecessary suffering.

As a young oncology nurse, I cared for a woman in her late 80s whose cancer had overtaken her body.

She was scheduled for exploratory abdominal surgery.

When I entered her room to perform my assessment, I couldn't even find a place to place my stethoscope. Tumors were visibly protruding across her abdomen. Her disease was advanced beyond medical intervention.

Her family sat nearby, nervous and hopeful. I'm not a doctor, but even I knew that this surgery would be futile. The surgeon proceeded.

He opened her up-and closed her back up.

There was nothing medically that could be done.

I remember standing there asking myself: Why did this happen?

It wasn't because her family didn't love her.

It wasn't because the physician lacked skill.

It wasn't because anyone was indifferent.

It happened because this beautiful, sweet woman had not clearly defined what quality of life meant to her.

When quality of life is undefined, medicine defaults to intervention.

The Default Toward "Doing More"

Modern medicine is structured to treat, extend, and attempt to fix. Doctors are trained to offer options. Families are told, "This is what we can do".

But "what we can do" is rarely defined. And neither is the clarity of how truly advanced the patient's disease process is.

In the absence of clearly stated goals, escalation often becomes the default path — particularly in moments of fear and crisis.

Psychologically, this is predictable. Under acute stress, the amygdala becomes more active, narrowing cognitive flexibility and increasing threat-based decision-making. Families and patients confronted with sudden decline often experience what researchers describe as "decision conflict", a state associated with heightened anxiety and impaired clarity.

Without a predetermined benchmark, fear hijacks the situation.

The Question That Changes Everything

There is one question that shifts this trajectory.

What does quality of life mean to you, and when would you consider it no longer acceptable?

Quality of life is subjective. For some, it means being able to recognize loved ones. For others, it means independence, mobility, cognitive clarity, or freedom from pain.

There is no universally correct answer. This is a subjective one. But there must be an answer.

Research on advance care planning consistently shows that when individuals clarify and communicate their wishes in advance, end-of-life care is more likely to align with their values. Patients and families experience less stress, anxiety, and depression when preferences are known ahead of time.

Once a person defines their quality of life threshold, it becomes a decision-making benchmark. When that benchmark is no longer attainable, care can pivot — from prolongation at all costs (and those costs are high ) to comfort, presence, and alignment.

Without that clarity, families are left to decide under pressure. Studies indicate that surrogate decision-makers often suffer long-term emotional consequences, including symptoms consistent with post-traumatic stress, when making high-stakes decisions without prior guidance. I have seen this many times in my career.

Take our Positive Aging Test

Find a therapist specialized in aging concerns

In my experience, serving over 1000 people at the end of life, most traumatic grief is not caused by death itself; it is caused by unplanned medical escalation that conflicts with what the person might have truly wanted—had they shared this ahead of time.

Why We Avoid the Conversation

Culturally, we treat death as a medical failure rather than a natural, human experience. Conversations about decline are often postponed out of fear that discussing limits will diminish hope.

But evidence suggests the opposite.

Studies of patients with advanced illness have shown that early goals-of-care conversations are associated with improved quality of life and, in some cases, even longer survival compared to aggressive late-stage interventions.

Planning does not extinguish hope. It clarifies it.

It reframes hope from "cure at any cost" to "care aligned with my values and my choices."

Psychologically, anticipatory dialogue reduces uncertainty. Research in behavioral health consistently shows that perceived control — even when outcomes cannot be changed — reduces anxiety and increases emotional resilience.

Avoidance, on the other hand, transfers the burden forward to a future moment of crisis.

Most People Want to Die at Home

National surveys repeatedly show that most Americans would prefer to die at home. Yet the majority still die in hospitals or other institutional settings.

Preferences without planning are unlikely to be honored.

If someone wishes to remain at home, that requires logistical preparation, caregiver education, and medical coordination. Without that groundwork, hospitalization becomes the default during acute decline.

The system moves quickly. Fear moves even faster.

A Good Death Begins Earlier Than We Think

A good death does not begin in the final days of life.

It begins the moment someone defines how they want to live.

Answering the quality of life question does not hasten death. It anchors care in clarity. It protects families from guessing. It provides doctors with instruction.

Most importantly, It restores subjective agency.

We cannot avoid death. But we can reduce the amount of unnecessary suffering around it.

And often, that reduction begins with one conversation and one question:

What does quality of life mean to me?

And when would you not want extended measures to keep you alive, when that quality is no longer there.

© Psychology Today