ozarque: Death and dying; part seven....

ozarque (

ozarque) wrote,
@ 2007-01-18 08:53:00

Death and dying; part seven....
I went Googling for definitions and discussions of the concept of "a good death," and found a great deal of material, including this paragraph from a British Medical Journal editorial by Richard Smith (titled "Death, come closer"), at http://www.bmj.com/cgi/content/full/327/7408/0-f :

"What is clear from reading this theme issue on a good death is that one size won't fit all. We want to be as different in dying as in living. Different cultures, times, and religions have different concepts of a good death. Some want it sudden, some slow. Some want a quiet death with minimal medical involvement. Others want to follow Dylan Thomas and 'rage, rage against the dying of the light,' squeezing every last drop from life."

This is surely true; there seems to be no way to construct a consensus definition of a good death that will work for every individual in every culture. I thought, therefore, that what I'd do in this post is describe what I would consider a good death for my own self, if I had a choice in the matter, just as an example.

I have two personal advantages in this context. It is of course possible that as the years go by some dementia or other medical misadventure will take them both away from me, but at the moment I have them. The first is my firm religious faith, which includes an absolute belief in an afterlife (and in eternal life) and an absolute disbelief in the existence of any form of "Hell" in that afterlife. The second advantage I have is that I've been through childbirth four times -- I'm already very familiar with a physical process that is natural, that is going to happen for sure whether you like it or not, that cannot be reversed once it begins, that is going to be messy and to some degree uncomfortable, and that has nevertheless all four times had a happy ending. These two things make it possible for me to accept the prospect of death and dying with a certain amount of serenity, and they let me reject that Dylan Thomas version in the quotation.

Suppose I knew that I was dying....

I would keep that information to myself for as long as I possibly could. For me, two or three days of the "saying goodbye" process are plenty, and I believe that dragging it out only causes needless pain for those left behind.

I would do everything possible to avoid going into a hospital. I realize that I might be unable to prevent that, but I would do my best. And if in spite of my efforts I did find myself in a hospital I would do everything I could to refuse any medical heroics or interventions to delay my death, and everything I could to accept only palliative care. I have gone out of my way to make sure that my doctor, my lawyer, and all my family members know that that's what I want, and the moment I arrived at any hospital I would start making sure that every hospital staffer I encountered was made aware that that's what I want.

If I perceived that staying at home to die -- my preference -- was going to become a burden for my family or other caregivers, I would go into a hospice if that was available as an option. If that wasn't an option, I would stop eating -- which would simplify matters -- and do everything I could to make that burden less.

I would spend my final days and hours in music, reading, walking (if I were able to walk), meditation, and prayer, at home or in hospice -- with the members of my household who wanted to be with me allowed to be there, and those who preferred not to be with me not expected to be. And at the end, I would hope to have strength enough not to make a fuss.

With all that said, I have to take a great deal of it back if I am to be totally honest. Suppose I really were in complete control of my death and dying: I would choose an appropriate time and place, I would simply walk away to the chosen place at the chosen time, and I would sit down there and die. Without making a fuss. If I thought I could do that, it's what I would do. In contrast to a good death, which I hope for, I would call that a "best" death. I set that option aside only because I believe that it's probably impossible for the average human being to do that, and I am very much an average human being.

Notes

1. All the articles in the special issue of BMJ are available free on links at the end of the editorial.

2. See also "Defining a good death" -- which provides a number of links to other resources -- at http://dying.about.com/b/a/000137.htm .

(Post a new comment)

Choosing when and where to die...

dpolicar
2007-01-18 03:25 pm UTC (link)

So... I realize this is a potentially touchy question, and I want to be clear before I ask it that I'm asking it out of a genuine desire to know your (and perhaps other people's) answer.

Why do you dismiss the option of choosing the time and place to "sit down and die"?

From the way you talk about it being impossible for the average human being, I infer that what you have in mind here is a kind of psychosomatic feat where you simply decide to stop breathing as an act of will, and I agree with you that that's impossible for most (perhaps all) people.

But of course a variety of technological aids are available that allow even average human beings to do precisely that, and indeed many people do so every year.

Granted, we tend to consider it tragic and socially unacceptable when they do, and I would have a hard time choosing that option in the face of how the people who love me would feel afterwards.

But I'm not at all convinced we're right to do so.

Sure, it's one thing for someone to take their own life in order to stop a pain (physical or emotional) that could have been addressed by other means, or more generally when their life isn't "done".

But if we mean it when we say what you describe above is the "best death" (and I share your sentiment there)... well, it seems like we're running up hard against an unnecessary paradox that it would be valuable to un-knot.

(Reply to this)(Thread)

Re: Choosing when and where to die... response to dpolicar...

ozarque
2007-01-18 03:44 pm UTC (link)

It never entered my head that what I said in the post about choosing a time and place to die would be interpreted as meaning suicide -- which just demonstrates how hard it is to be clear about these matters. I was in fact talking about the option of simply deciding to die and doing it, by act of will. I wouldn't call that a "psychosomatic feat," but I think I understand what you mean by that.

Suicide is not an option for me, because of my religious beliefs. I do believe that when you are already dying you are free to stop eating, and to refuse medical interventions; I perceive that as cooperation rather than as suicide.

I apologize for creating confusion; it wasn't done deliberately.

(Reply to this)(Parent)(Thread)

Re: Choosing when and where to die... response to dpolicar...

dpolicar
2007-01-18 04:42 pm UTC (link)

Sorry... I think the confusion is my doing rather than yours, actually.

I understood what you were talking about (choice of phrasing notwithstanding), but I don't draw an important moral distinction between deciding to die by an act of will and deciding to die by (for example) taking poison, and failed to consider the possibility that others might draw such a distinction.

In any case, you've answered my question, at least in broad strokes... thanks. (I'm curious about the basis for the distinction, but that's a different topic and a potentially landmine-seeded one.)

For my part, I think that if I reached a point where I felt comfortable with deciding on a time and place to die in the first place, I would have no objection to using external tools as a way of implementing that decision (as opposed to relying on my unaided will).

That said, at this point in my life I can't really imagine reaching that point, so my intuitions about what I would or wouldn't consider acceptable then aren't especially reliable.

(Reply to this)(Parent)(Thread)

Re: Choosing when and where to die... response to dpolicar, continued...

ozarque
2007-01-18 05:19 pm UTC (link)

"I understood what you were talking about (choice of phrasing notwithstanding), but I don't draw an important moral distinction between deciding to die by an act of will and deciding to die by (for example) taking poison, and failed to consider the possibility that others might draw such a distinction."

Understood. The vocabulary of English makes it cumbersome to explain the distinction I would make, but I'll do my best: For me, there is a distinction between "to voluntarily stop living, when dying has already begun" and "to commit suicide."

(Reply to this)(Parent)(Thread)

Re: Choosing when and where to die... response to dpolicar, continued...

dpolicar
2007-08-21 07:30 pm UTC (link)

So, I've been digging through old emails that I meant to respond to and fell off the radar screen, and came across this one.

It pleases me that, reading it now, I think I have a clearer sense of what you're saying than I did back in January. Specifically, the "when dying has already begun" clause seems key... somehow I missed the importance of that the first N times you said it.

Just to double-check that I'm in the right ballpark, here... in a situation where dying has already begun (however we establish this), do you draw a distinction of this sort between:
a) voluntarily stopping living by stopping eating
b) voluntarily stopping living by stopping breathing, without any external aids (supposing you were physically able to do this)
c) voluntarily stopping living by stopping breathing, with external aids (eg, suffocating yourself)
...?

(Reply to this)(Parent)(Thread)

	Re: Choosing when and where to die... response to dpolicar, continued... ozarque 2007-08-21 08:02 pm UTC (link)
	Response to dpolicar, continued again.... In a situation where dying has already begun, only your alternative (c) would -- for me -- constitute committing suicide. (Reply to this)(Parent)(Thread)

	Re: Choosing when and where to die... response to dpolicar, continued... dpolicar 2007-08-21 08:15 pm UTC (link)
	Ah. And here I thought I had it. Oh well. Thanks for the response! (Reply to this)(Parent)(Thread)

	Re: Choosing when and where to die... response to dpolicar, continued... ozarque 2007-08-21 09:12 pm UTC (link)
	Response to dpolicar, yet again... Now I'm confused -- I also thought that you "had it." I went back and re-read the post to be sure I had a reasonable grasp of the context of your question, but that doesn't seem to have helped. I'm sorry. (Reply to this)(Parent)(Thread)

Re: Choosing when and where to die... response to dpolicar, continued...

dpolicar
2007-08-21 09:25 pm UTC (link)

You answered the question perfectly cogently and in-context.

The thing that had been perplexing me in the first place was trying to understand drawing a distinction between tool-using and non-tool-using ways of cooperating with one's own death.

On rereading, I thought perhaps I'd completely missed the point, and you weren't drawing that distinction at all, but rather the distinction between ending one's life when already dying, vs. when not already dying. That distinction makes perfect sense to me.

But it's clear from your response that, no, the tool-use distinction I'd originally thought was there is in fact there.

Which is not in any way ambiguous, you're perfectly clear and cogent about it... my problem is that I can't quite seem to wrap my brain around in a Miller's Law kind of way, and I'd rather like to.

(Reply to this)(Parent)

Re: Choosing when and where to die... response to dpolicar...

voxwoman
2007-01-19 04:48 pm UTC (link)

I have a similar mindset to yours, and I also would be interested in discussing that landmine-seeded topic :)

I had read a story written by the son of a man, diagnosed with a terminal illness, who decided to stop eating and end his life, it was not what I would call "a good death" as it took weeks, and was intensely painful. Seeing the photos in the article didn't help, either.

(Reply to this)(Parent)

A good death.

ketaki
2007-01-18 03:40 pm UTC (link)

I've got the example of my grandmother to follow.

She was cooking (what she loves doing best) dal in her Mumbai flat while gossiping with my aunt - her duaghter who came to visit from Canada, when she suddenly cramped up for a second and fell to the floor without fuss or dramatics.

I remember you talking about the process of death very early on in the discussion and someone mentioning that the process of dying continues long after the body ceases to function. This was the case with my grandma. The whole extended family came together from different corners of the globe to go on a little pilgrimage to all my grandma's favourite temples and places. Even today, whenever we get together and someone is struggling in life, we remind each other of grandma's strong spirit and how she battled through the toughest of times with good humour.

I feel too inexperienced to tell you exactly how I want to go, but if I had an option, something like the above with my closest and dearest just chatting and me busy doing something would be best.

(Reply to this)

	hilleviw 2007-01-18 03:51 pm UTC (link)
	It's a grief to me that he's gone, but this makes it sound as though Art Buchwald had a good death: http://apnews.excite.com/article/20070118/D8MNPB480.html (Reply to this)

saoba
2007-01-18 05:45 pm UTC (link)

I know that over the years I have ferreted out one part of what a 'good death' would mean to me, based on three examples.

1) My grandfather, who held off announcing his diagnosis of inoperable cancer until a major family milestone was past, asked his son-in-laws for just one thing. "If they try to bring the crash cart in here against my express written orders, I want you to block the doorway with your bodies and let me go."

2) A young boy I knew was hit by a car and died at the scene before his family could be summoned. A witness got out of her car and held his hand and told him that he was a good boy and that he was loved and that it was going to be all right. She said to me later "I knew he was dying. I just didn't want him to be alone or afraid."

3) A friend, who fought on for years past any one's expectations until she was fighting by reflex. In a long conversation one day she admitted to me she was doing it for everyone else and that she wanted to die. I told her to do what she needed to do. Three days later, after final visits or phone calls with friends, she went to sleep one afternoon and died. I got in terrible hot water with people for 'telling poor A it was okay to die!'. Being a prickly bitch I asked what exactly they thought the alternative might be.

"I knew he was dying. I just didn't want him to be alone or afraid." That gift, that would be one part of a good death for me.

(Reply to this)(Thread)

getting to Okay

maggieno
2007-01-19 01:31 am UTC (link)

When my mother-in-law had collected an "It's okay to die," from all her kids and from her husband, she stopped the chemo, went into hospice, stopped eating and drinking, and died within the week. Her eldest daughter was appalled that she had really meant it and her husband was angry for years that she had "fooled" him. But I was there during the discussion with my partner and Pat was quite clear about what she was asking. We both thought it was right and proper and rather neat. Her daughter moved to angry over the years and has stayed there; her husband still thinks he could have found some what to have the 1930s movie death, with Pat fading away with a smile as she in lay on a recliner under the wisteria terrace and resents that such a scene was taken away from him.

(I *really* have issues with all those sweet and delicate and unmessy movie scenes that create such usually unfulfillable visions for people...)

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sighkey
2007-01-18 05:53 pm UTC (link)

I think that your 'walking away and sitting down to die' is possible under some circumstances, either literally or metaphorically. But you need to be either at the tail end of terminal illness or fortunate enough to be old enough that your vital organs are so worn out that they gently just stop working. My father was in the first of those situations. Although he physically could not just walk away to die because he was bedridden, he metaphorically did just that. He went to see the doctor about neck pain, was told he had 6 to 8 weeks to live, came home, spent abour 2 weeks quietly winding up his life, took to bed and 'walked away' over the next 4 weeks, pausing every now and then to speak to those of us who walked part the way with him. I don't remember him seeming to be afraid at all although he did not believe in an afterlife. He liked the idea of his mortal remains becoming nourishment for other living things and would have liked to have been simply buried in our backyard with our years of non-human family members. (Unfortunately in NZ you can't do that - we did actually inquire - and we did point out to him that even if it were possible someone 50 years in the future might be digging up the backyard and get a nasty shock when finding human bones among the dog and cat bones.)

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	voxwoman 2007-01-19 04:54 pm UTC (link)
	Our friend Joe was cremated and his ashes planted on the grounds of his widow's home (in the front flower garden of the place they were in the process of building when he got his terminal cancer diagnosis). I plan to do something similar with my mother's ashes, keeping some to co-mingle with my father's when it's his time. (Reply to this)(Parent)

	lyonesse 2007-01-18 07:17 pm UTC (link)
	if you're willing to settle for switzerland as the appropriate place, it is apparently possible to select one's appropriate time, and take sodium pentothal. (Reply to this)

cheyinka
2007-01-18 09:05 pm UTC (link)

The more I think about it, the more I realize that what I'm afraid of is dying without warning. I don't want a sudden death, or to suddenly fall into a coma from which I never awaken. Even dying in pain or dying alone don't scare me as much as either of those two - and "dying without pain, with family" seem to be constants across the definitions linked to by the link you provided.

I wouldn't mind the ability to know exactly the time of my death, for that matter, much like, I think, you would want the ability to choose when and where you would die. It's not a suicidal impulse: I see this life as something of which I am the caretaker, not something I own, with which I can do whatever I please, so I suppose what I want is to know exactly the date stamped inside my front cover by the librarian.

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sapience
2007-01-18 09:50 pm UTC (link)

Suppose I knew that I was dying....

I would keep that information to myself for as long as I possibly could. For me, two or three days of the "saying goodbye" process are plenty, and I believe that dragging it out only causes needless pain for those left behind.

I would be deeply hurt if someone I were close with made that decision for me (i.e. withholding such vital information to spare me "needless pain"). Given the opportunity, I would want much more than two or three days. But then, given the nature of my close relationships, I have no doubt that such an omission would feel like a lie to both of us, and would not occur.

(Reply to this)

(Anonymous)
2007-01-18 11:00 pm UTC (link)

I have two personal advantages in this context. It is of course possible that as the years go by some dementia or other medical misadventure will take them both away from me, but at the moment I have them. The first is my firm religious faith, which includes an absolute belief in an afterlife (and in eternal life)

That's certainly a comfort. I wish my own faith were entirely firm. Unfortunately, I am sometimes plagued by doubt. I'd really like to find away to firm up my faith.

Doug

(Reply to this)

idiotgrrl
2007-01-19 03:44 pm UTC (link)

I noticed once again your deep concern for not wanting to be a burden and not wanting to make a fuss. I think this is deeply engrained in us by a childhood where the best thing we could do was (as I've said before) "sit down, shut up, make yourself useful, and for heaven's sake, don't make any trouble. I'm burdened enough as it is." (Insert voice according to your experience.)

Those of us who were reared that way will either continue in that self-effacing way, or revolted against it flamingly in midlife, and ion some cases might have returned to it. Those who were not will probably either fail to understand, consider the attitude to be saintly, or consider it to be nuts.

Anyway, just to assure you I understand and have a fair idea where it comes from.

Pat

(Reply to this)(Thread)

	Response to idiotgrrl... ozarque 2007-01-19 04:04 pm UTC (link)
	Thank you, Pat. However, this is not an example of yet another woman who's been socialized into being "a nice lady." In this one case, it's an example of a woman who has been on the receiving end of the fuss so many times that she has decided not to impose that hardship on others if she can manage not to. (Reply to this)(Parent)(Thread)

	Re: Response to idiotgrrl... voxwoman 2007-01-19 04:58 pm UTC (link)
	I think this is the nail on the head. I see this with my father (and also with my mother). They both were and are very angry with the progressive incapacity of old age/infirmity. Neither enjoy being dependent upon others for "everyday" activities. And, also having been on the receiving end of the fuss as well, I would not want to impose that on anyone else, either. (Reply to this)(Parent)

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