For the last couple weeks, converging events have prompted me to assess my situation.
In another instance of maddening bad luck, my new power generator crapped out on me and will have to be replaced. I don’t like the prospect, but I am prepared to do it.
More ominously, however, I have been popping nitroglycerine tablets to stave off chest pains, and doing so with greater frequency than ever before. The nitro trick has been delivering effective and immediate relief, yet I cannot fail to consider that a day will come when it will no longer work and I will find myself at the end of my days.
I don’t think this will happen anytime soon, but the other night I did reflect on how my health is less robust than a year ago; I found myself wondering when the day will come when the only constructive thing I will be able to do is to simply die a good death, and go out with dignity, on my own terms.
I will admit to the thought that death would obviate going through the hassle of ordering yet another power generator. (But that quickly passed.) Nevertheless, I was sufficiently interested in the subject of facing death on one’s own terms, that I reviewed recent articles on the subject.
The ultimate expression of this value, of course, is choosing the time and means of one’s own death. Physician-assisted suicide is legal in only a handful of states, including Washington, Oregon, Vermont, Montana, and most recently, California. California Governor Jerry Brown signed a “right-to-die” proposal into law last October. In the five US states that allow physician-assisted suicide, laws limit the practice to patients with terminal conditions.
But it is also meeting with ardent resistance, especially in cases where people are clinically depressed, schizophrenic, or suffering from some other mental disorder. Legislators and health workers are especially wary of complying with the wishes of patients who may be psychologically impaired. In a study led by Dr. Scott Y. H. Kim, a psychiatrist and bioethicist at the National Institutes of Health, researchers reviewed 66 euthanasia or assisted-suicide cases of patients with psychiatric disorders from 2011 to 2014. Seventy percent of this group was female. Over half of patients had depressive disorders, and nearly 70% had a psychiatric history of at least 11 years. In 56% of cases, social isolation or loneliness was mentioned in the case report, prompting a concern that “physician-assisted death served as a substitute for effective psychosocial intervention and support,” wrote an editorialist.
One of the most common reasons that people choose to die is to escape chronic pain associated with an underlying trauma or pathology which, for one reason or another, is allowed to persist. Depression is a normal reaction to pain. It is situational and healthy as long as it doesn’t go on too long.
Modern medicine is supposed to treat injury and pathology to support and speed healing; it is supposed to treat symptoms like pain to relieve suffering during treatment and healing. When a painful injury or pathology is resistant to treatment and persists, when pain persists after the injury or pathology has healed, and when medical science cannot identify the cause of pain, the task of medicine is to relieve suffering. Unfortunately, undertreatment of pain is commonly experienced by people of all age groups. In the United States, for example, women and Hispanic and African Americans are likely to be undertreated.
In September 2008, the World Health Organization (WHO) estimated that approximately 80% of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world—including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives—suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. Undertreatment in the elderly can be due to a variety of reasons including the misconception that pain is a normal part of aging. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Other reasons may have to do with inadequate training, personal biases, or fear of prescription drug abuse.
Chronic pain is one of the most commonly cited reasons for the use of medical marijuana. A 2012 Canadian survey of participants in their medical marijuana program found that 84% of respondents reported using medical marijuana for the management of pain. Evidence of medical marijuana’s pain mitigating effects is generally conclusive, yet it continues to be illegal in most jurisdictions in America. This is nuts.
Since coming to West Texas and knowing a number of people who experience debilitating chronic pain, I have come to the conclusion that the government and medical establishment have reduced the discipline of pain management to medical quackery, financial exploitation, patient victimization, and malpractice. Some people in West Texas are being unnecessarily driven to their deaths.
Thankfully I do not experience chronic pain, but I am trying to be in a mind-set in which I will not be surprised by my own demise and even welcome it. So I reviewed the writings of Dr. Charles Garfield, who is a clinical professor of psychology in the Department of Psychiatry at the University of California School of Medicine at San Francisco (UCSF). Dr. Garfield has been recognized internationally as the founder of Shanti, which has been at the forefront of a growing national movement to enhance the quality of life for persons living with life-threatening or chronic illnesses by providing volunteer-based emotional and practical support. He has published ten books.
These are the seven factors which, according to Dr. Garfield, are the keys to a good death:
1. Experience as little pain as possible.
When Garfield speaks of being pain-free, he means physically, psycho-socially, and spiritually pain-free. Nowadays, there are medications that can manage most people’s physical pain and make them far more comfortable, and these should not be denied to any patient. Spiritual pain can occur, too. In fact, Garfield has sat with several clergy who had crises of faith on their deathbeds. Sometimes, easing spiritual pain can be accomplished by the presence of a person of faith or readings from sacred texts; other times, it’s better to have someone who can engage in spiritual questioning. Either way, spiritual issues are common at the end of life, and they need attention.
2. Recognize and resolve interpersonal conflicts.
We must also recognize psycho-social pain, the residue of life’s unresolved conflicts with other people. There are almost always interpersonal issues within families, and sometimes between close friends, when one is dying—people who’ve become estranged, “I love you”s that were never expressed, and more. Ira Byock, a palliative care doctor, wrote in his book, The Four Things That Matter Most, that there are four basic messages a person needs to communicate at the end of life: “I love you. Thank you. I forgive you. Please forgive me.” These are a good start. A good death creates a space for people to say those words.
3. Satisfy any remaining wishes that are consistent with their present condition.
Some people want to live long enough to go to a grandson’s graduation, to see a book published, to see a cousin they were close to who lives 3000 miles away. But, be careful that these are the wishes of the patient and not just the patient’s significant others. There’s a difference between a good death and an appropriated death—one that’s stolen from the dying person by other forces, including the agenda of close family members.
4. Review their life to find meaning.
There are two main ways that people on their deathbeds find meaning: in the recognition of all of the people they have loved and who have loved them, and in the work that they’ve done that has contributed to the greater good. In some cases, contributory work will be obvious; in others, it may be less so. But, helping the dying to articulate what brought meaning to their lives will help them feel more at peace with their death.
5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
The whole issue of deathbed conversations—asking a person what he needs or wants—is very important. What does the dying person want? How can they get that? Is it reasonable? Sometimes it’s not reasonable: A friend’s dying mother wanted help in ending her own life; well, that wasn’t going to happen. Sometimes you can have the conversation without acting on it, and any conflicts or issues can be addressed.
6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
Emergency rooms, ICUs, and 911 are set up to preserve life and are not typically supportive of the conditions for a good death. If a person is suffering tremendously, there may be cause to get emergency help; but for most situations, when you throw a person into the larger healthcare system, the prevention of death becomes the imperative, and that can serve to increase suffering for the dying person. One has to be very persistent and clear to avoid procedures that are unwanted—to insist on palliative or hospice care, instead. It can help to have an advanced directive or a “physician-orders for life sustaining treatment” in writing and communicated to loved ones; but often a person also needs a vocal advocate—a family member, friend, or volunteer caregiver.
7. Decide how social and how alert they want to be.
Sometimes a dying person wants solitude; sometimes he or she wants friends and family around. Whatever the case, the dying person should decide. And, though trickier, dying people should be allowed to decide how much consciousness they want. Some people want to sleep all of the time; others want to be alert as much as possible. Once these wishes are known, an advocate can help make that happen.
Garfield says that the key is listening to people who are dying and to try and address the issues that are important to them. The potential for growth through dying is definitely there. It doesn’t mean it will automatically happen, though.
Death can bring out our goodness—our capacity to transcend, love, and grow—or it can bring out our capacity to hate, create enemies, and deteriorate psychologically. To help promote the former, we should create sacred spaces for those who are dying so that they can benefit most from the experience. If we know the conditions for a good death, we are more apt to prepare ourselves and the ones we love to die with dignity and the sense of a life well-lived, rather than treating death as a calamity requiring a trip to the hospital.
A good death, says Garfield, is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage.
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