10 Ways to Help Ensure a Peaceful Death

(Editor’s Note: I added a few lines here and there, but most of the content below was provided by Faye Girsh, co-founder of Final Exit Network and founder of Hemlock Society of San Diego. — KTB) 

Prolonged dying can result in pain, dependence, endless procedures, and reliance on others for care. Often it means months and years in a nursing home and/or a succession of caregivers. Many of us have not prepared financially or psychologically for treatments that may keep us medically alive well beyond what we want. Here are 10 considerations to avoid that fate.

1. What is unacceptable to you?

Determine what quality of life is acceptable and what circumstances you consider unacceptable. Discuss this with your spouse/partner, family, friends, doctor, minister, close neighbors – anyone who might be asked if they know what you want.

2. Do Not Resuscitate (DNR)

Do you want cardio-pulmonary resuscitation (CPR) to restore your heartbeat? CPR typically involves chest compression that often results in cracked or broken ribs, which will probably take at least six weeks to heal. If you do not want CPR, ask your doctor to sign a Do Not Resuscitate order and to help you get a bracelet or necklace indicating that you are DNR. You can also shop online. Emergency medical personnel are required to perform CPR unless they see a clear indication that you are DNR or a health care agent or power of attorney is readily available who will instruct them otherwise. The bracelet or necklace will make sure they do not perform CPR on you. 

3. Do Not Intubate (DNI)

Do you want a breathing tube inserted into your throat and windpipe to facilitate getting more air into and out of your lungs? The procedure is called intubation and is sometimes performed in the same circumstances that warrant CPR. It is not uncommon for medical personnel to actually suspend CPR in order to intubate the patient, often with undesirable results.

4. Advance Directive / Living Will

Whatever you decide about medical treatment options, put your instructions into an advance directive or living will. Those two terms mean the same thing but a document with the title most commonly used in your state may be easier to enforce. If you have a lawyer, s/he can provide the best guidance. State-specific forms can be downloaded from this page of the National Hospice and Palliative Care Association (NHPCA). The form has two parts: 1) What you want and don’t want (e.g., CPR, feeding tube); 2) Designation of your health care agent or power of attorney, who will have legal authority to speak for you if – and only if – you are unable to speak for yourself or are legally declared incompetent.

Give your advance directive to your doctor, family, close friends, neighbors, etc. and discuss it to make sure there are no misunderstandings. If you make any changes, sign and date the new version and be sure everyone who has an earlier copy receives the new version and gives the prior one back to you.

5. Physicians Order for Life Sustaining Treatment (POLST)

POLST gives seriously ill or frail people more specific direction over their health care treatments compared to advance directives and more options than DNR orders. POLST forms vary by state and can be found here. A POLST differs from an advance directive in three key ways: 

• POLST forms are medical orders. All medical personnel are legally obligated to follow the instructions of the POLST; they are not required to follow the instructions of an advance directive.
• An advance directive can be filled out at any time and addresses how you would generally like to be cared for at the end of your life. POLST forms are only filled out when you’ve reached an advanced illness and are specific to that condition and situation.
• POLST forms are portable. It moves with you as a part of your medical record and must be honored by the health care professionals in any location.

6. Hospice

The word “hospice” has several meanings. Originally, it was a building where terminally ill patients could go during the last months of life to receive palliative care (also known as comfort care). This is still the common usage in England, where hospice began. In the US, hospice is also a medical designation that means a doctor has determined that you likely have six months or less to live if your illness continues its current progression. At that point, treatments primarily intended to cure your illness are replaced with those that focus on your comfort. Some hospitals and hospice organizations in the US do provide a physical building for hospice care, but home hospice care is often a better option.

Hospice care is funded through Medicare and typically includes palliative medication, hospital beds, walkers, wheelchairs, bathing, massage, music therapy, counseling, and other options for making the end of life more comfortable. A common myth is that hospice patients are not allowed to go to the hospital. That is not true. If you are a hospice patient and you injure yourself in a fall, you can still be treated for the injury.

Many doctors will refer their patients to a particular hospice organization, usually the program run by a hospital where the doctor has admitting privileges. It is your legal right to choose any hospice organization you want. You can find a list of hospice care providers here.

7. Medical aid in dying (MAID)

MAID is available in 10 states and the District of Columbia with similar but sometimes different criteria. It is also known as physician-aided death. Common qualification requirements are listed below, based on the original Oregon Death with Dignity Act.

• You must be a legal resident of the state.
• Two doctors must agree that you are mentally competent and acting voluntarily, and that your condition is terminal, which means you are likely to die within six months.
• You must be able to self-administer the medication.
• You must make two oral requests to the attending physician at least 15 days apart and submit a written request to the attending physician, witnessed by two persons, one of whom cannot be a relative.
• Your next of kin must be informed.
• No medical professionals are required to participate in MAID, so you may need to shop for a doctor who will support your plan.

8. Terminal sedation

In cases where other treatments do not offer sufficient pain relief, medical providers are legally allowed to administer potentially lethal doses of main medication if the primary purpose of the medication is pain relief. This is known as terminal or palliative sedation. The doctor decides if this form of treatment is appropriate and it is usually done in a hospital. If you want the option of terminal sedation, clearly state that fact on your advance directive.

9. Voluntarily stopping eating and drinking (VSED)

VSED leads to death from dehydration and is used by many people who do not have a medical diagnosis of a terminal illness but would like to hasten their death. The process can take up to two weeks from the time of the last fluid intake. It is essential to have a caregiver and access to medical care for relief of pain, agitation, or sleeplessness. Some hospice organizations will help with VSED.

10. Final Exit Network (FEN)

FEN offers education and support to qualified applicants facing an intolerable qualify of life due to intractable illness or pain, including those who do not live in a state where MAID is available or who do not meet its requirements. FEN’s guide services are available in all states and the District of Columbia. You do not need a terminal diagnosis or prescription medication. If you want to ensure a peaceful and painless death on your own terms, contact FEN to see if you qualify.

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