What Ways Can You Die When You’ve Had Enough of Life?

(The author is a patient advocate, founder of Ending Well! Patient Advocacy, and is FEN’s surrogate consultant. She focuses on end-of-life care and planning, aiming to help people have a “good death,” and can be reached at Final Exit Network and LinkedIn. – Jay Niver, editor)

“Every human being of adult years and sound mind has a legal right to determine what shall be done with his own body.” – Justice Benjamin Cardozo (1914)

Imagine your life expectancy is six months. How about a terminal diagnosis where you could expect to live for another five, 10 or more years? Many chronic diseases, such as Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), or dementia can have horrific symptoms such as chronic debilitating pain, loss of movement or ability to breathe, or even a loss of self.  For many, the diminished quality of life and control is the hardest to endure, but their options to end their suffering are limited.

How can we die when modern medicine has so many ways to postpone our death and keep us alive? By pushing life-sustaining but often futile treatments, instead of alleviating suffering, the medical community dangles a longer life – if only for a few days. Perhaps you are among the 30 percent of Americans who created an Advance Directive (AD), spelling out your end-of-life wishes and named a surrogate to speak for you when you cannot speak for yourself.

Unfortunately, even with an AD, more people than ever spend their last days in sterile facilities, incoherent, sustained by ineffective pain medication, and tethered to machines that keep them alive but not living. What’s often worse, these treatments go directly against their explicit wishes. “Nearly 40 percent of chronic illness patients nearing the end-of-life who had physician orders limiting treatment received intensive care that was inconsistent with those orders,” according to a study published in the Journal of the American Medical Association. It is hard to see any benefit when a loved one is kept alive in an ICU with no hope of leaving the hospital.

“Whenever the illness is too strong for the available remedies, the physician surely must not expect that it can be overcome by medicine. To attempt futile treatment is to display an ignorance that is allied to madness.” – Hippocrates

When suffering becomes intolerable, here are ways you can choose to die.

1. Do Nothing – Let nature take its course by withholding or withdrawing life-sustaining treatments such as dialysis, a feeding tube, or a respirator. Refusing CPR (Cardiac Pulmonary Resuscitation) with a DNR (Do Not Resuscitate), refusing hospitalization with a DNH (Do Not Hospitalize), or refusing intubation or use of a ventilator with a DNI (Do Not Intubate) are all permissible medical orders. Consider creating a Physician Order for Life-Sustaining Treatment (POLST) form with your doctor. It is a portable medical order that goes with you and spells out what you do or don’t want in an end-of-life crisis.

You can also refuse antibiotics if you contract a potentially life-ending condition such as pneumonia or a urinary tract infection (UTI).

Recently former President Bill Clinton had a UTI that turned into sepsis; without antibiotics he would have died very quickly.” About half of the patients who develop septic shock will die from it, according to the Mayo Clinic (2021). Antibiotics are the most-used therapies in dying patients, in and out of the ICU, and doctors often use them even when they will not provide CPR.

Pneumonia was once referred to as “the old man’s friend,” because before the widespread use of antibiotics, older people just died in their sleep. Hopefully, by being proactive, you can have a peaceful and dignified death in the comfort of your home rather than hooked up to machines in an ICU. A recent Kaiser Foundation survey found that 70 percent want to die at home, but only 30 percent do so.

Rejecting antibiotics may be your ticket to a quick death in your own bed.

2. Palliative Sedation – For some, no medication can control intractable pain. At this point, doctors often suggest terminal or palliative sedation. They administer enough drugs to put you into a deep coma until you eventually die of your condition, usually within days. It is considered ethical, as long as doctors are not intentionally trying to hasten your death. This legal fiction is called the doctrine of “double-effect,” which allows physicians to treat your pain while knowing it will kill you.

3. Hospice – This ends any curative treatments. Instead, your medical team provides “comfort measures” designed to ease pain and anxiety. The goal is to maximize the quality of remaining life for the patient and family. To qualify, you have to be in the last six months of your terminal illness and agree to allow only symptom management. One benefit of hospice is that with support, you will likely die at home.

4. Suicide – Often a last resort for many, it is often accomplished by violent methods. Recently “Sweet’N Low” CEO Donald Tober, 89 (suffering from Parkinson’s), jumped from the 11th floor of his Park Avenue apartment. Friends surmise he was struggling with the loss of his once active lifestyle. The result of jumping off a building or bridge, using a gun, or hanging yourself (Robin Williams’ choice facing Lewy Body Dementia) leaves loved ones to deal with the fall-out. They are left with guilt that they “should have known” what you planned and done something to help. Sadly, both Tober and Williams had the means to explore less violent, more peaceful ways to exit.

5. Medical Aid in Dying (MAiD) – This requires you to obtain a doctor’s prescription and self-administer life-ending drugs. It is legal in Oregon, Washington, Vermont, California, Maine, Colorado, Hawaii, Washington D.C., New Jersey, New Mexico, and Montana.

A mentally competent adult resident diagnosed with a terminal illness (six months or less to live) can voluntarily request drugs to hasten death. Pain is not the main reason people request MAiD. It’s the loss of control (autonomy) and activities that makes their lives worth living. A third of people who get the drugs opt not to take them. They are comforted just by knowing they are there.

Sidebar – Aid in dying was an accepted practice in Roman times. In “Memorable Doings and Sayings” by Valerius Maximus, the aid-in-dying request had to be voluntary and made by a person providing a rational reason for a quick death. There could be no mental illness and no family pressure. It also required the agreement of legal authorities and required that a physician mix the Hemlock potion that the person had to self-administer. Two thousand years later, most of these same rules apply.

­­­MAiD is not a choice of death over life; it is not suicide. It is an option for those dying that spares them and their witnessing family and friends unbearable suffering and offers a controlled and peaceful ending.

Unfortunately, while MAID is a peaceful choice, it offers a narrow use for many suffering people. Only a few states allow it, and you must be within the six-month terminal window –determined by doctors who are not feeling your pain.

6. Voluntarily Stopping Eating & Drinking (VSED) – This requires you to forego hydration and nutrition until you die. If you opt for this, understand that it usually takes from three days to two weeks, and it takes a determined person to ignore thirst. VSED requires support from family or friends, paid caregivers, an end-of-life doula, and a hospice team to provide family support and drugs for symptom management. The person will likely lose capacity at some point, so the person should name a Surrogate ahead of time.

A friend’s 96-year-old mother was trying VSED, but it took so long that her daughter questioned whether she was eating or drinking. She answered, “Not eating, but I’m still having my 5 o’clock martini.” (Not sure if that included the olive.)

Witnesses describe this as a peaceful way to die, but it is not for everyone. In her book, On My Own, former NPR host Diane Rehm describes her husband’s VSED death as “excruciating and heartbreaking to watch.” (For more VSED information: https://finalexitnetwork.org/preparing-for-voluntarily-stopping-eating-and-drinking/)

7. Final Exit Network – This nonprofit group offers “any competent person unbearably suffering an intractable medical condition, the option to die legally and peacefully.” Their mission is to: “Educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence, and defend their right to choose.” https://finalexitnetwork.org/ FEN provides information on practical and dignified methods to hasten the inevitable and offers trained Exit Guides for education and moral support but provides no hands-on help. Physicians carefully screen the people who contact FEN and will not accept anyone diagnosed with a mental illness. In addition, they require family members to be aware of their loved one’s intentions. (For more self-deliverance information, read Derek Humphry’s Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying https://finalexitnetwork.org/resources/final-exit-by-derek-humphry/)

Conclusion: There are many choices in life; there should also be acceptable choices for death.  When faced with a terminal illness, different options may achieve the best end possible.  Suffering is personal, and how much is tolerable is up to the individual.

The methods described above require a person have mental capacity when choosing them. Still, many also need to have the ability to “self-deliver,” not easy for someone whose muscles may be wasting away. The right method for one person may not be suitable for another; you need an end-of-life plan, especially when facing a terminal diagnosis.

Educating yourself about the available options, talking with your loved ones about your wishes, fears, and concerns, and making the best choice based on your end-of-life goals and values will assure that you have the good ending and peaceful death that hospice professionals describe as “a soft landing.”