THINK

Have you thought about how you might die?

Unfortunately most of us, even in advanced age, haven’t. We’ve not given serious thought to how life might end. Please, do so before talking to others and writing an advance directive.   Do some research and some thinking about what you might want at the end of life. What are your wishes? And what can you do now to achieve those wishes later?

Man thinkingFrom our newspapers, radio and TV, we know of horror stories about prolonged suffering and death.   We can’t change what our fate will be, but we can ameliorate it. We can change or even refuse the treatments the medical establishment wants to give us. That is, we can choose to die a natural death, or even to shorten a lingering death, and to receive all pain relief possible.

Today we have a problem our forebearers didn’t have. They typically died within days of becoming ill. Today, medical advancements change that—much can be done to keep us alive longer, much longer for many.   Even so, there comes a time when the doctors really can’t do much if anything to prevent death.   There are many stories of a new procedure or a new medicine being offered by a doctor, but it gained, when it gained, if anything, only a few more days of life, often miserable days at that.

To greatly improve your chances of avoiding such a fate, take control. Perhaps start by reading some of the many books and articles and watching videos listed in Resources.   They should get your thinking process started.

One way to start is with Go Wish cards.  Each card gives you an issue to think about; you then sort the cards into three piles according to their importance to you.  You can easily do this on line at the link given above.

A  short, recent, wonderful book on how doctors need to change the way doctors advise aging and dying patients is Dr. Atul Gawande’s Being Mortal. A concise book on the methods of hastening death is Boudewin Chabot’s A Way to Die. Both books are available at Amazon.

End-of-Life Choices

The basic choices that you should consider, discuss, and decide are:

  1. Do Nothing
  2. Seek all medical options so that you live as long as possible
  3. Avoid resuscitation and other emergency treatments
  4. Choose a natural death by halting and preventing medical interventions
  5. Choose to hasten death, through the choices given below

Let us explore these options.

Do Nothing. The doctors are in control. You are passive and do as they suggest.

Seek All Medical Options. Some of us wish to live as long as possible. There are several ramifications of this choice but if made, it will be respected and should be easy to honor since the focus of our medical system is to keep us alive as long as possible.

Avoid Resuscitation (and intubation, etc.). This option is frequently included in many advance directive forms. However we advise against a blanket order for no resuscitation (called a DNR). There could well be times you would want resuscitation. If resuscitation is necessary because the patient has just had an event that is related to his or her chronic illness, then DNR may make sense. But if the need for resuscitation occurs for some other reason, such as choking on food, then resuscitation may be desirable.

Choose a Natural Death. Natural death generally means that under dire circumstances don’t prolong my life with resuscitation, ventilation or any of the myriad interventions that may (or may not) prolong your life, at least for a few days. By law you can refuse interventions, or force them to be terminated or removed if already started. That is to say, under specified circumstances don’t prolong my life— just let me die.

Choose to Hasten Death.   Yes, there are options to end life, but they are not easy to implement.  And any assistance is illegal (a felony).   This choice needs to be planned for, though not necessarily used.   These methods are listed below the next paragraph.

Quality of Life. Instead of focusing on medical interventions and procedures, as most advance directives do, there can be focus on the quality of life in options 4 and 5 (natural death and hastening death. The advance directive form given here takes this approach. This approach is really what quality of life don’t you want?  Think about situations in which you would probably wish to die, such as unrelenting pain with no hope of recovery, or not ever being able to get to the bath room to relieve yourself, etc.  Best to discuss such situations with your proxy and then list them in your advance directive.

Methods for Hastening Death

It is no longer against the law in any state to take your own life. Taking your own life in any these ways is not violent and can be done at home with your loved ones around you.  Note: These methods are not being advocated, nor the options listed above.  We include all these simply because we believe people need to know all the possibilities.

  • PAD. (Legal Physician-Assisted Death) In a few states it is legal for a physician to prescribe but not administer a lethal drug. These websites can give you more information about Physician Aid in Dying: California, Oregon, Vermont, Washington
  • SED. (Stopping eating and drinking)  SED is perhaps the most common of the four non-physician methods.   If done with palliative care (pain and discomfort control), it is not painful. The process takes a week to ten days, and in rare cases even longer.   But after only a few days one is not hungry, and actual thirst goes away too. However, the mouth does get dry, so one thinks he or she is thirsty; swabbing the mouth alleviates the dryness, and hence the thirst.   Doctors say some patients near death unconsciously stop eating and drinking. So it is a natural process, just moved to an earlier time. For more on this read our June and July 2014 blogs, or better, read Dr. Boudewijn Chabot’s excellent book, Taking Control of Your Death by Stopping Eating and Drinking. (Available at www.dyingathome.nl, or Amazon).
  • Inert gas. There is, or was, a speedier way to choose to exit by inhaling helium.  One could purchase helium tanks from a toy or balloon store, make a hood which is connected to the helium tank with common plastic tubes.  One puts on the hood and turns on the gas. It’s that simple. Unfortunately pure helium is no longer used; it is often diluted with 20% air. There is an organization that promoted this method, the Final Exit Network (FEN). Because of the diluted helium, FEN is tending toward using nitrogen.  Nitrogen is just as effective but is harder to obtain and use, and is more expensive.  Under FEN, when the time comes, it will have an “exit guide” advise one through its current preferred method. Courts have held that the guides are not breaking the law (committing murder or assisting suicide) because they don’t directly assist in any way. They only give information, a First Amendment right.   You can join FEN for a few dollars. The FEN website is finalexitnetwork.org
  • Prescription Drugs. Years ago, before helium became so easy to obtain, this was the choice of many. The drugs are usually barbiturates.   If pills are used, rather than injection, many have to be taken, as well as some other drug to assure that the pills don’t come back up.   It has become hard to obtain lethal drugs – but can be over the internet from a foreign country.  Another way is to somehow obtain a prescription for some of these pills, then keep renewing the prescription, perhaps by visiting several doctors.  In any case, most likely you are involved in an undesirable subterfuge.   This method is not recommended for this and many other reasons. However if you are a doctor, this approach is easy: just write yourself a prescription or two.
  • Compression of the Carotid Arteries.  This halts flow of blood to most of the brain.  In short this is self-strangulation. Unconsciousness comes in about a minute, and death a few minutes later.  No special equipment is needed—just something to act as a tourniquet such as a cord or strip of strong cloth (e.g., necktie or stocking) or other material, to tie around your neck, and something to twist it very tight, such as a stick or wooden spoon. The latter must be long enough to give leverage for tightening, and for catching against your shoulder so that the tightening doesn’t unwind once you lose consciousness. This procedure when done correctly does not cut off the windpipe. To avoid that happening, the tourniquet must be placed above the adam’s apple, thus allowing breathing.   This method is attractive because it can be accomplished just about anywhere, such as in a hospital.  It is discussed briefly by Dr. Chabot in his book, A Way to Die (available from Amazon and www.dyingathome.nl).  It is detailed by Chris Docker in his book, Five Last Acts – The Exit Path, available on Amazon.   Docker gives several cases where this method was used in Europe, but apparently there are no documented cases in the United States.

Important Caution: No assistance.   You must be in good mental health and have some physical abilities to choose and consummate any one of the four methods summarized above.   That is, you must be legally competent and able to do the job yourself.   If someone buys the helium or nitrogen for you, or hooks you up, or orders or gives you the drugs, or feeds you medicine, he or she could well be accused of assisting suicide, a felony.   Put another way, you are not committing a crime by choosing an early exit, but if someone helps you, he or she probably is.   As to SED, you need to start the process yourself, but others will need to help with palliative care. So far no proxy or medical person has been prosecuted for helping someone with SED through to the end. (Read our post – “What is Assisted Suicide?)”.

Dementia.  If one is suffering from serious dementia, usually Alzheimer’s disease, and doesn’t want to suffer the middle and late stages of such a disease, one must chose to exit early, while s/he is still able to think and do things. Once one reaches incapacity, no one can implement any of these methods.  It would be wise though to include in your advance directive that you are not to be force fed by spoon, straw, tube or injection. So maybe, even if you are in a severely demented state, you might choose to refuse food and drink.

Now that you have done some thinking and, hopefully, some research, and have some sense of what you want in terms of end-of-life choices, the next step is to TALK — that is, have conversations with your loved ones, your proxy, and perhaps others.

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