Chapter 155
Physician-Assisted Dying
Scientists investigated how dying people are cared for in hospitals, and what they saw was not pretty. Often, not even basic measures were taken to ensure patients’ well-being, contact with the dying was minimal, and the closer death came, the more distance and isolation grew. In one heartbreaking case, for example, a 52-year-old woman had cancer with metastases to the liver; her abdomen was severely distended, she was jaundiced and short of breath, but awake. Her eyes were swollen, and she cried yellow tears. The patient received no help from the responsible nursing staff. In the nursing notes, however, it was stated that her hygiene, pressure sores, mouth care, and eyes had been attended to—but that was all a lie. The only thing she got was a bedside commode, and a nursing aide brought it to her. In the four and a half hours the researchers recorded, she had six minutes of human contact.
What might a good death look like? You retain control, your dignity, and your privacy. You get pain medication, emotional support, and your wishes are respected. You decide for yourself where and how you want to spend your last days. You can say goodbye and go when the time has come, without life being prolonged senselessly.
The best chance to determine the course of your own death is if you get a hospice placement. In palliative care, symptoms are relieved and life is made comfortable, and it can be used at any stage of a serious illness, whereas hospice care is only about making the last days pleasant, because now attention is no longer focused on cure. In the United States, about half of Medicare patients eventually enter hospice care, but many (28%) only in the last few days before death.
For some, hospice means giving up, but patients in hospice tend to live longer than those cared for elsewhere. Patients who choose hospice live, on average, one month longer than comparable patients who do not. In one study, lung cancer patients who were randomized to receive early palliative care lived two and a half months longer than the control group. That corresponds to the survival time you get from standard chemotherapy. In fact, that is one way hospice can extend the lives of cancer patients: by eliminating the risk of overtreatment with chemotherapy and the associated poisons.
Physician-assisted dying
Palliative care has its limits. Even in hospice, where exemplary care should be expected, it happens that people live their last months with uncontrolled pain. Because of this unbearable suffering, patients ask us, despite our greatest efforts, to end their lives prematurely. Physician-assisted suicide, more precisely physician-assisted dying, allows terminally ill people to voluntarily take a lethal dose of medication that a doctor has prescribed specifically for that purpose. In see.nf/aid I discuss the situation, namely that in 40 US states any physician assistance in dying is prohibited by law. Voluntary stopping of eating and drinking, on the other hand, is permitted everywhere in the United States: the voluntary forgoing of eating and drinking (VSED).
The advantages of VSED
Ideally, every terminally ill person in hospice or on a palliative care unit would receive optimal care, so that no one would wish to end their life prematurely. Unfortunately, the reality is that some terminally ill people still suffer despite all efforts, which has led to more and more trying to escape their unbearable situation through voluntary stopping of eating and drinking. In Europe, one to two percent of deaths are attributable to it.
VSED can be defined as a conscious decision, due to persistent, unacceptable suffering, to voluntarily and intentionally stop eating and drinking with the goal of accelerating dying. In see.nf/vsed I talk about its advantages: you die at home, you do not have to wait for any approval, it is legal, you can change your mind at any time, and you do not need anyone’s permission. Simply knowing that there is an “way out” can ease despair and the feeling of being trapped, give control back, and ensure that the patient feels better. It can also prevent people from choosing a more violent route or feeling pressure to end their life prematurely while they are still able to.
What does VSED feel like?
What is it like to die because you voluntarily stopped eating and drinking? You hear a lot about death by VSED being peaceful, painless, and dignified. Fortunately, there are some independent studies that have tested these claims. I discuss them in see.nf/vsed.
On average, one dies about seven days after stopping eating and drinking, but 8 percent of those wishing to die lived longer than two weeks. The last days of life were rated as peaceful, with little pain and suffering—more so than with physician-assisted dying. Most hospice staff said they would consider VSED themselves if they became terminally ill.
In the final phase of dehydration, a certain analgesic (pain-relieving) effect might even occur, presumably because endorphins are released that act as natural painkillers. A systematic review that appeared in a palliative medicine journal therefore concluded that VSED exhibits all twelve characteristics of a “good death,” with particular emphasis on the fact that the dying person retains dignity and control.
One of the most famous reports on VSED appeared in the Journal of the American Medical Association. In it, a physician describes his mother’s death. I asked the journal for permission to reprint two particularly moving paragraphs here. They were glad to accommodate me—for 12 867,28 US dollars. Therefore, I included the excerpts only in my video see.nf/vsed. (Please have tissues ready.)
The dementia trap
Dehydration has other good sides as well. You have to worry less about incontinence, catheters, or bedpans, and you suffer less from nausea and vomiting because digestive secretions decrease. With fewer airway secretions, you have to cough less and are less likely to feel like you are choking or drowning. Swelling, too, which can become a problem in the end stage of cancer, decreases with dehydration. That can also reduce pain, because less pressure is exerted on the nerves. Conscious awareness may also decrease, which can likewise be a relief, but also raises a serious ethical dilemma. What happens if you fall into delirium, forget what you decided, and want to drink something? I address that in the video see.nf/dignity, as well as the question of how to address the topic of feeding in advance in a written directive if you do not want to go through your dementia all the way to the final stage.
Keeping control
Thanks to the 4th Amendment, everyone in the United States has the right to refuse medical care. Critics argue, however, that food is excluded from that, because it is a basic need. But if you can refuse to be connected to a life-saving ventilator, so the counterargument goes, then you should also be able to refuse food and drink. (After all, nothing is more vital than breathing!) In see.nf/dignity I discuss other common criticisms and potential pitfalls, and also how to deal with thirst. The conclusion is that VSED brings most patients a peaceful, gentle death.
4. Dr. Greger’s eight anti-aging tips
Introduction
Anti-aging remedies are as old as the world, but for their explosive increase in recent years, three factors are cited in the United States: 70 million aging Baby Boomers, the availability and advertising of goods on the internet, and the Dietary Supplement Health and Education Act of 1994 (DSHEA).