A toast “to life” may include the wish for a peaceful death

Nearly everyone hopes for a peaceful death; yet such an end can be elusive. Many of us face both philosophical and practical questions as we do what we can to make our own deaths peaceful.

Some of us may have religious questions. Judaism, like many other religions, is all over the map in its thinking about ways to achieve a peaceful death. Orthodox doctrine, like strict Catholic or Islamic thought, decrees that everything must be done to preserve life. The belief that only God can take a life is at the core of much deeply-held religious doctrine. It means that suffering at the end of life brings one closer to God, or as the Christians say, to the sufferings of Jesus.

Some orthodox Jewish writing says that prayer is the only way to stop the suffering. I remember when an orthodox Jewish doctor brought the Chief Rabbi from Los Angeles to speak to a meeting of the San Diego Medical Society. The Rabbi insisted that no doctor should ever follow directions in a Living Will that indicate stopping treatment. That wish, he insisted, should always be disregarded and all treatment available to keep a person alive be instituted. Not surprisingly, most of his audience left the room.

Most doctors today follow their patients’ wishes when they are in accord with secular law. They also understand that quality of life often takes precedence over how long one can live.

Further, although many religions retain their strict adherence to maintaining life, their followers may have a more pragmatic view. Even a Papal decree now accepts that treatment can be stopped when the burdens outweigh the benefits; Conservative Jewish doctrine too permits that balance to be weighed in end-of-life decision making.

Jewish people have still other reasons to balance reduction of suffering with reverence for life. Despite a conservative heritage, Jews are known for their acceptance, even welcoming, of new ideas, especially ideas that are intended to reduce suffering and to benefit the family and humanity. And death in Judaism is not the enormously fearsome prospect that it is in some religions, which teach that sinners pay the price for their sins in a horrible afterlife or a terrible reincarnation. These are powerful forms of social control which keep people in line, doing the “right” thing for fear of consequences in another life.

Most Jews live instead by natural law and understand that the consequences of bad behavior usually occur in this life, so death becomes a more natural fact of living. As the great Jewish philosopher Woody Allen said, “I’m not afraid of dying. I just don’t want to be around when it happens.”

That quip brings us to the realities of modern dying. We are fortunate to live in an age and a location where the miracles of modern medicine enable us to survive some of the most deadly illnesses and conditions. Our life expectancy is, statistically, 79; and celebrations of 100 birthdays are not uncommon. But some say we have, in many cases, not extended living so much as we have prolonged dying. Our risk, for instance, of dementia increases with age, as it does for many of the other disabling neurological diseases, lung diseases, cancers, etc., that might have ended our lives earlier. Most of us have seen deaths that are prolonged and agonizing – situations that we would never want to be in – and many have cared for loved ones in that situation. We hope for a different sort of death.

I am president of the Hemlock Society of San Diego, now in our 30th year, which educates the community about achieving a peaceful death. Too often, dying people lose control, choice, and dignity at the end of life. We believe people should die in ways consistent with their own values and beliefs, peacefully and without violence, and in the company of their loved ones. This goal is not easy to achieve, even with all the legal changes that have occurred in the past 30 years, including the development of a variety of medical directives by the states. Though these are a bit complicated, following is a brief review of the choices, both practical and legal, that are available now to many of us.

ADVANCE DIRECTIVE(S): This includes your Living Will (also termed a Directive to Physicians), in which you can state your preferences for the medical treatments you would want or not (depending, of course, on your prognosis and quality of life). It may include a Durable Power of Attorney for Health Care, which designates a surrogate, a very important person you want to make your medical decisions for you if you cannot speak for yourself. Many legal versions can be downloaded and copied.

POLST (Physician Orders for Life Sustaining Treatment, which are not available in all states): This directive is designed primarily for people with a year or less to live. It is a legal document and must be signed by your physician. It is often printed on a designated bright-colored stock (pink in California) and designed to follow you in the hospital or care center and allows you to say if you want CPR and other kinds of treatment. It also can be downloaded for your review.

DO NOT RESUSCITATE (DNR) ORDER: This is also a legal document that must be signed by your doctor. If your heart stops or your airways are blocked, it allows the Emergency Team to not administer CPR. A copy of the DNR can be used to order a medallion or bracelet that indicates your DNR status. Many people place their directives on their refrigerator, which is OK if you are home bound, but would not help if you are away from home.

STOPPING OR REFUSING TREATMENT: In 1990, the U.S. Supreme Court affirmed that every American has the right to refuse unwanted treatment, even if it should lead to death. You can stop or refuse dialysis, chemotherapy, artificial feeding or breathing, amputations, etc. Or your health care agent can do it for you if you cannot speak for yourself.

STOPPING EATING AND DRINKING: This is a legal method to end your life by dehydration. It may take up to two weeks from the last fluid intake. It may be difficult and should be done only with medical or nursing assistance and the agreement of loved ones and caregivers. Hospice will often provide medications that make you more comfortable, though some will not because they oppose this choice.

HOSPICE CARE: These organizations, some for-profit and some non-profit, provide comfort care and symptom relief for those with a six-month prognosis. Care is usually provided in your home. However, it is not a substitute for home health care since it is provided just a few hours a week. It cannot relieve all symptoms experienced when dying. Medicare pays for hospice in most cases. Hospice neither hastens nor prolongs death. It is a good way for most people to die but will not make death come any faster. Most hospice programs follow a method of comfort care termed “palliative care.”

END OF LIFE OPTION ACT (EOLOA) (called Death With Dignity Act in some jurisdictions): This law permits a doctor to prescribe lethal medications that a dying patient can take to have a peaceful death. The EOLOA is for adult California residents who are mentally competent and expected to live six months or less. Two doctors must sign off on the patient’s first request; then there is a 15-day waiting period during which another oral and one written, notarized request are made. The doctor can then prescribe medications that, if ingested, will peacefully produce sleep and death. The official cause of death is the underlying disease. It is not suicide for insurance or any other purpose.

SWITZERLAND: This country permits physician aid in dying for all people with unbearable suffering who are not necessarily terminal and who do not have to be Swiss citizens. There are at least two organizations that do this reliably. Both require paperwork and documentation of one’s condition and both charge around $10,000 in addition to air fare and other expenses.

FINAL EXIT NEWORK (FEN): This national not-for-profit volunteer organization provides Exit Guides to its members who are suffering from a severe chronic illness or early Alzheimer’s and are considering a hastened death. Following appropriate documentation and phone interviews, Guides come to the home (almost anywhere in the country) and advise members on what they would need to die peacefully. They can also be present in the home if the member chooses to use the method. Guides provide only information and support; the members must be able to carry out the method themselves. It is a non-medical procedure, generally using inert gas.

All of these options are legal in California and most other states, except for physician-assisted death, which is available also in Oregon, Washington, Vermont, Colorado, Montana (by judicial decision), and the District of Columbia. Currently, there is no “peaceful pill” that can make ending suffering an easy process. Since all of us are going to face death, it is helpful to know what our options are, what is acceptable to us and our loved ones, and how we can access the options. One person dying a slow and agonizing death remarked, “I didn’t know dying is this hard.” It can be, but may not have to be. Know your choices and discuss them with the people who care about you.
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Faye Girsh is the President of the Hemlock Society of San Diego, Past President of the World Federation of Right to Die Societies, and a member of Final Exit Network’s Advisory Board. She has a doctorate from Harvard and practiced Clinical and Forensic Psychology in San Diego for 18 years.