In my 30 years as an Emergency Room physician, I have watched many people die. I've learned from them that the modern American death is often a chronic illness, spanning some five to 10 years, in which a person slowly looses their mobility, their independence, their ability to perform basic activities of daily living, their intellect, and all ability to enjoy life. At some point in this decline, many of us would choose to say, "enough suffering, just let me die."
Today, the act of letting nature take its course at the end of life - of allowing a natural death - is mostly unobtainable. When someone at the end of life takes a turn for the worse, their loved ones and caretakers will reflexively call 911 and seek medical care. Off to the emergency room they go, where I will once again treat their acute illness - their possible exit event - for cure, and prevent their natural death. While most people would prefer to die at home, 80 percent of the deaths in this country occur in hospitals or nursing homes, as the technology that keeps us alive grows ever more complex.
Prior to the advent of antibiotics in 1933, elderly people tended to take to their beds, contract pneumonia or another infection within a year or two, and quietly pass away. Any doctor over the age of 50 will tell you that pneumonia used to be called "the old man's friend," as it brought an end to suffering and allowed a natural death to occur at the end of a person's span of years.
Refusing antibiotics to treat pneumonia or other infections is one option available in pursuit of a natural death. Other choices include discontinuing one's usual medications, foregoing trips to the emergency room for life-sustaining procedures, or refusing to receive artificial nutrition or hydration.
At the end of life, the body and mind naturally lose interest in food and fluids. When I reach the end of life, I want food and drink to be set by my bedside to take if I want it. My caretakers will know that I don't want to be reminded to eat or drink, and certainly not forced to - this may be my most powerful way to find a painless, peaceful natural death, particularly in the case of Alzheimer's Dementia.
The choice for a timely natural death begins with education and communication. First, you must know your options - exactly what steps you can take if you arrive at the point where you would prefer death to continued suffering. Second, you must communicate your choices to your loved ones, your caretakers, and your physicians, and enlist their commitment to helping you achieve your goal. After all, it is they who will probably make your choices for you, at a point where you are no longer able to communicate effectively. Even an Alzheimer's patient who is in early diagnosis, who is still fully sentient, may precisely outline for his Healthcare Decision-Maker his conditions for when assistance with food and liquids should cease, for example, when he no longer recognizes his family, when he is bed-ridden, or when he is no longer able to feed himself.
When that patient reaches his personally-defined milestones, his Healthcare Decision-Maker, doctor, and family can stop forcing food and liquids and allow him to die a natural, relatively painless death--without raising all the serious ethical concerns of physician-assisted suicide or euthanasia.
The currently available Advance Directives fall far short of allowing the kind of choices outlined here. New forms will be needed that let us prospectively choose a natural death at the end of life. Everyone - even the young and healthy - should use these forms to exercise control over their death.
The baby-boomer generation has changed societal norms as it's passed through every stage of life. It is inevitable that they will change how death is managed, also. The change will come by knowing what their choices are, and controlling how those choices are made.
The natural death movement has much to offer the current healthcare debate. There can be fates worse than death, and many of us know exactly how we do not want our lives to end--drooling on for years in a nursing home, lost to ourselves and our families.
In the overheated rhetoric of various interest groups, knowledge is power in the hands of the patients whose choices should, ultimately, drive the system. Know your options for end-of-life medical treatment, including the choice to refuse treatment.
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