CHOOSING
YOUR OWN PATHWAY
TOWARDS DEATH
SYNOPSIS:
I will die; you will die.
Each of us with have a particular pathway towards death.
In retrospect, those who survive us will be able to describe
the exact steps that we took—or
were taken for us—
at
the end of our lives, just before we died.
However, if we grasp this truth about our own deaths,
we can make many important decisions about the exact pathways
by which we will approach our own deaths.
Will we have good deaths? Will we have bad
deaths?
If we could re-write the
deaths we have known,
what would we change about the pathways to those deaths?
OUTLINE:
1.
WE LEARN FROM THE WRONG PATHWAYS 'CHOSEN' BY OTHERS.
2.
WE CAN EXPLAIN OUR IDEAL PATHWAYS TOWARDS DEATH
IN OUR ADVANCE
DIRECTIVES FOR MEDICAL
CARE.
3.
18
SPECIFIC
QUESTIONS WE SHOULD ANSWER
TO CREATE OUR
IDEAL PATHWAYS TOWARDS
DEATH.
4.
WE
MIGHT DECIDE TO AVOID FUTILE MEDICAL CARE.
5.
DISPOSITION OF MY REMAINS:
THE MEDICAL
USES OF MY BRAIN-DEAD BODY.
RESULT:
The
questions raised by this chapter
should inspire some creative thinking for the reader.
Some specific and concrete plans might emerge
as a result of considering the best end-of-life decisions.
CHOOSING
YOUR OWN PATHWAY
TOWARDS DEATH
by
James Leonard Park
While we are in the middle of conducting our own
lives,
we seldom do any planning for our deaths.
This means 'deciding' by default that we will be treated
by standard medical care at the end of our lives.
Perhaps we believe this will result in the best death possible for us.
But we might want to do some planning right now—in the middle of life—
for the last year of our lives.
The pathways of our lives have many branchings.
Each time the pathway before us divides into two or more pathways,
we have to decide which road to take.
Sometimes we can back-track to try the other road,
but usually the decisions we make will lead us inevitably forward.
And if we made a bad decision in the past,
probably we cannot go back to undo it,
but we can make some course-corrections in the future
that will bring us back to the path we should have chosen
originally.
1. WE LEARN FROM THE WRONG PATHWAYS 'CHOSEN' BY OTHERS.
When we think about our own coming deaths,
we might be strongly influenced by deaths we have known.
Which deaths were worth emulating?
And which pathways towards death would we prefer to avoid?
Usually what comes first to mind is the bad deaths we have known.
Perhaps we are haunted by scenes in hospitals we want to avoid.
In modern times, death usually takes place under medical care.
But medicine was invented to prevent
death
—or
at least to postpone death
as long as possible.
This means that at least
some of the suffering at the end of life
is due to the standard procedures of the medical profession
and the modern hospital.
There are routine ways of treating all patients.
Whenever there is some procedure that might help the patient,
that treatment will be considered and possibly tried.
Sometimes there are so many specialists dealing with various problems
that no one professional
is considering the best interests of the
patient.
This leads to an end-of-life pattern of endless
tests and treatments,
each of which might have had some purpose
if that particular disease or condition were the only problem.
But very often as we approach the end of our lives,
we are beset by a host
of medical conditions.
Curing one problem, such as cutting out a cancerous
tumor,
only leaves us in the hospital facing a series of other health problems.
If anyone had really summed up our whole health situation,
we might be more inclined to choose less aggressive treatments
because we know that even if the cancer is 'cured',
we will survive to face the remaining array of illnesses and problems.
If we could read our lives backwards, beginning with
the last page,
then we would know exactly what killed us.
Having read the last chapter,
we could make wiser decisions for the middle chapters.
For example, we would reject expensive and invasive medical
treatments
if we knew we would die of something else within a few months
anyway.
2. WE CAN EXPLAIN OUR
IDEAL PATHWAYS TOWARDS DEATH
IN OUR ADVANCE
DIRECTIVES FOR MEDICAL
CARE.
Probably the best place for each of us to explain
how we wish to be treated at the end of our lives
is in our comprehensive Advance Directives for Medical Care.
Such legal documents permit us to include as much detail as we want
concerning all issues related to our last days alive.
When we have decided how we want to approach our
deaths,
we can describe our ideal pathways in our Advance Directives.
We cannot be certain that our plans will be followed,
but at least we can explain what
we want if it becomes possible.
If we give no
guidance about our preferred pathways,
then we will be given standard medical care at the end of our lives.
Normal and customary terminal care will be provided.
What should we
include to create
comprehensive Advance Directives?
Advance
Directives for Medical Care:
24 Important Questions to Answer
3. 18
SPECIFIC
QUESTIONS WE SHOULD ANSWER
TO
CREATE OUR IDEAL PATHWAYS TOWARDS DEATH.
The following Questions for a comprehensive Advance
Directive
will create specific pathfinding-directions for us in our last year of
life.
Each Question is linked to a more extensive explanation on the Internet.
This enables readers to explore any Question
more deeply.
(The
Questions keep their original numbering system from Your
Last Year.
All 24 Questions—including those
omitted below—are found here.)
Question
4:
What level of personhood
do you wish to preserve thru medical care?
When—according to your own criteria—
would you become a former person?
When
choosing our own pathways towards death,
we should deal with qualify-of-life issues
such as degrees
of
mental
decline.
We might define being a human person by the following four traits:
(1) consciousness, (2) memory, (3) language, & (4) autonomy.
Then, as we lose such marks of personhood,
we might direct some specific actions to be taken or omitted,
which will define our chosen pathways towards death.
Question
5:
Where do you draw the line
between a quality of life
worth preserving and the remnants of biological life
that should be mercifully shut down?
Another way to include quality-of-life considerations
would
be to ask about the likely process of personal decline:
When should our proxies make life-ending decisions for us?
For
example, if we become former
persons
with only some remnants of biological life in our bodies,
should our proxies 'pull
the plug'?
Question
6:
How do you want to be treated
if you get Alzheimer's disease
or some other condition that limits your mental
abilities?
One set of
possible problems could affect our brains,
so that we lose most of our former selves.
We can project specific
plans
for ourselves
if we ever suffer the degrees of mental decline we describe.
Question
7:
If you are in serious pain,
what do you want done?
What amount of pain do we now believe
we would be able to tolerate at the end of our lives?
When such a time comes, when pain is a serious issue,
we should have the right to change our minds about pain-control.
But we will help to establish our own pathways towards death
if we explain as fully as we can
how we expect to handle terminal pain if it happens.
Probably our chosen pathways will tolerate a certain
amount of pain,
especially if we can foresee some relief in the future.
But if pain will be our constant companion for the rest of our lives,
will we choose a shorter pathway towards death?
Question
8:
Do you want to be put into a nursing home?
If
so,
for how long, under what conditions, and for what
purposes?
Many pathways towards death include some time in
a nursing home.
How do we feel about nursing homes now?
Have we selected a nursing home that would be our top choice?
If we agree to live in some sort of assisted-living situation,
how long should such an arrangement continue?
What limits on such terminal care would we establish now?
If our possible pathways towards death were a board
game,
how long would we tolerate being in a nursing home?
And how would the decision be made to move on towards death?
Question
9:
Where would
you prefer to die?
Not all of us
will have a choice about the best
place to die,
but if we were able to choose, where would we like to
meet death?
And if that place is not possible,
what would be the next best location for death?
Just as we were all born at a specific spot on the planet Earth,
so each of us will die at a specific address in a certain city or town.
Question
10:
Will you put financial limits on your terminal
care?
Terminal care
often absorbs huge amounts of health-care dollars.
Sometimes the costs might not seen commensurate with the benefits.
So, how would we decide about the financial dimensions
of our last year of life?
Question
11:
How much do you want to know
about your medical condition and prognosis?
Some of us might wish to be kept in the dark
about
our coming deaths for as long as reasonably possible.
We just do not want to be forced to confront our coming demise.
But others of us might like to participate as fully as possible
in the end-of-life decision-making that will inevitably happen.
We will help to define our own chosen pathways
towards death
by indicating while we are still in good health
how much we want to know about the process of dying
when that unavoidable time comes.
Question
12:
When should all curative
treatments be ended?
Medical care is
primarily devoted to curing patients
who have diseases or other conditions,
some of which might cause death.
After taking part in many medical procedures aimed at cure,
we might decide to change the purpose of our medical care
from cure to comfort.
If we cannot be cured, at least we can be made comfortable.
Who will decide to change course in the hospital?
And how will any such decisions be reached?
Question
13:
When should end-of-life medical orders
be written for you?
Some time between
now and the end of our lives,
it would be appropriate to prepare with our terminal-care physicians
comprehensive written plans for the last days of our lives.
These end-of-life documents should embody
our ideal pathways towards death.
If we are beginning what will turn out to be the
last year of our lives,
which life-sustaining medical treatments do we want
and which forms of medical care do we plan to avoid?
Once we have created our end-of-life medical plans,
and put these into writing signed both by ourselves and our doctors,
then these careful documents will guide
the rest of our medical care.
Here are the details
for creating End-of-Life
Medical Orders (ELMO).
Question
14:
How long should you be
maintained by life-supports?
While we are
still in possession of all of our mental faculties,
we should make some decisions about life-support systems.
If we do not put some limits on such medical interventions,
we might automatically be put
on life-supports
when our vital organs begin to fail.
And if we are put onto life-supports,
should we specify how long
the supports should remain in
place?
If we do not recover in one week or one month,
should the life-supports be removed?
Question
15:
Should food
and water
ever be
withdrawn or withheld
in order to
shorten
the process of your dying?
It used to be
quite controversial to discontinue food and water
with the knowledge that this would inevitably lead to death.
But now this is a choice
that we can all make
in the process of defining our own pathways towards
death.
How do we feel about medical
dehydration as a method of dying?
Question
16:
Do you endorse more active
means of ending your life?
Do you believe you have a right to die?
Voluntary death? Merciful Death?
And in some states of the USA and other countries of
the world
we now have the legal option to choose more active methods of dying.
Just what degree of choice should we exercise at the end of our lives?
And if we can no longer choose for ourselves,
do we give our proxies the authority to choose death for us?
Question
17:
Under what conditions would
you request death?
Even more
explicitly, we might have occasion to request or approve
some measure that will certainly bring death.
How might we come to this decision-point
in our process of moving ever-closer to death?
If we understand our likely decline into death,
what sign-posts would suggest it is time to request
death?
Question
18:
Do you wish to
join the
One-Month-Less Club?
Joining the One-Month-Less Club is definitely a way of selecting
one particular pathway towards death rather than the most common road.
Declaring ourselves members of the One-Month-Less Club
means that we plan to live
well during the best years of our lives
so that we will not miss the last (perhaps pain-filled) month.
Instead of following the standard procedures of
modern medical care,
we who are members of the One-Month-Less
Club
have chosen to shorten our
process of dying by about one month.
Question
19:
Which definition of death
should apply to you?
We might be
surprised to learn that death can be determined
using different sets of criteria and tests.
So if we select one of the most liberal definitions,
we will be declared dead somewhat earlier in the process.
For example, do we endorse using the brain-death criteria
for the purpose of certifying our own deaths?
What about the final loss of consciousness?
What if most aspects of personhood have disappeared?
Question
23:
What philosophical, ethical,
or religious beliefs
do you hold that are relevant
to your medical care and other end-of-life decisions?
Our individual philosophies of living and dying
will affect the choices we make about the last year of our lives.
The default choice might be no choice at all:
We will just do whatever is customary in our cultures.
But we might have very individual ideas about how to
meet death.
This would be a good place to explain our preparations.
Question
24:
Are you ready to die
now? If yes, explain.
If no, what preparations (practical, interpersonal,
spiritual)
would make you more ready to die?
What projects do you wish to complete before you die?
The degree of
our readiness for death will also have
a profound impact on what pathways we choose towards
death.
Do we wish to distribute some of our possessions before we die?
Are there some personal relationships we want to settle before death?
What loose-ends should we tie up to make our lives more meaningful?
If we are not yet ready to die, we might be able to explain
some specific things we want to do before we die.
4. WE
MIGHT DECIDE TO AVOID FUTILE MEDICAL CARE.
Modern medical science has created an ever-expanding
array
of tests and treatments for every possible problem.
And the standard medical choice has usually been
to keep applying medical methods until everything fails.
The patient dies despite
all medical efforts.
This defines a common pathway towards
death.
When we come to the end of our lives,
we have little or no
experience with the physical problems
the doctors are working hard to cure.
So, we easily agree to follow all medical
recommendations.
An alternative pathway towards death would define in
advance
what would constitute futile
medical care.
The medical professionals will be reluctant to discontinue treatment
because there is always a small chance that the patient will recover.
But a more honest and open approach would weigh
the possible benefits
against the known burdens
of each
treatment.
When we are facing our own deaths,
sometimes we are willing to bet on very long odds:
Even when the chances of success are very slim,
we might agree to a treatment that has usually failed in the past
when applied to patients with the same diseases.
Our views of medical futility might change as we get
older.
When we are young, hoping for many years of meaningful
life,
we will accept the greater risks and burdens
of experimental medical
treatments
because we have so much to lose if we die then.
But when we know that we are approaching the likely
end of our lives
because of known chronic diseases or conditions
or just because of advanced age,
we will probably be more cautious about approving medical procedures
that have only a small chance of doing more good than harm.
Unless we make our values clear about
futile medical treatment,
we might be treated-to-death:
We might receive every appropriate medical test and treatment.
And particularly when we are being treated by several specialists
(each perhaps concerned only with one bodily system),
no one of these
professionals will take the larger view
of our whole
process of living and dying.
Another essay proposes creating a new medical
specialty:
Medical
Futility Monitor: Avoiding the Million-Dollar Death.
This
terminal-care physician with many years of experience
will be available for consultation when patients might be suffering
from too much medical care
rather than too little.
If we so desire, we can explain that our own medical ethics
includes consulting such a neutral physician
to ask the question of
medical futility.
We can declare in our Advance Directives for Medical Care
that we do not wish to be subjected to useless medical procedures.
And we can define how such a determination might be reached.
Who will decide when
to 'pull the plug'?
5. DISPOSITION OF MY
REMAINS:
THE MEDICAL
USES OF MY BRAIN-DEAD BODY.
One major problem I face in making my plans for
death—and
afterwards—
concerns what will happen to my body once I am dead.
I would like to donate my body for all possible medical uses,
including uses that might begin after I have been declared
brain-dead.
Medical science and ethics have not yet accepted the
possibility of using
brain-dead bodies for testing medical procedures and practice
surgery.
I have given my full permission for such uses of my body after I am
dead.
And I hope that such a gift will be acceptable after my death.
I have written another essay explaining this
proposal in detail:
"The
Living
Cadaver: Medical Uses of Brain-Dead Bodies".
Perhaps something like this can appear in a medical journal
to start the discussion of how to accept such gifts.
Created
November 15, 2011; Revised 11-17-2011; 11-22-2011;
1-6-2012; 2-24-2012;
3-17-2012; 6-12-2012; 7-28-2012; 8-25-2012;
3-19-2013; 5-31-2013;
6-12-3013; 6-18-2014; 12-23-2014;
4-8-2015; 7-10-2015; 3-23-2016; 11-10-2017; 9-27-2018;
AUTHOR:
James Park is much closer to his death than to his
birth.
He is a philosopher with special interest in end-of-life
issues,
including how we might improve the process of dying.
Much more will be learned about him from his website:
James
Leonard Park—Free
Library
Here are
a few other on-line essays
that might help us to choose the
best pathways towards death:
Losing
the
Marks of Personhood:
Discussing Degrees of Mental Decline
Advance
Directives for Medical Care:
24 Important Questions to Answer
Medical
Futility Monitor:
Avoiding the Million-Dollar Death
The
One-Month-Less Club:
Live Well Now, Omit the Last Month
Choosing Your Date of Death:
How to Achieve a Timely Death
—Not
too Soon,
Not too Late
Choosing
Your
Own Pathway towards Death
Completed
Life
or Premature Death?
One
Million
Chosen Deaths per Year?
Fifteen
Safeguards
for Life-Ending Decisions
Will
this Death
be an "Irrational Suicide" or a "Voluntary Death"?
Will
this Death
be a "Mercy-Killing" or a "Merciful Death"?
Four
Medical
Methods of Managing Dying
VDD:
Why
Giving Up
Water is Better than other Means of Voluntary Death
Voluntary
Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice
Taking
Death in
Stride: Practical Planning
Pulling
the Plug:
A Paradigm for Life-Ending Decisions
Life-Ending
Decisions for Alzheimer's Patients
God
Will Decide
When Life Will End:
We Should Not 'Play God'
WOULD YOU LIKE TO
MEET OTHER
SUPPORTERS
OF RIGHT-TO-DIE
HOSPICE?
If you plan to choose your own
pathway towards death,
consider joining a Facebook Group
and Seminar called Right-to-Die Hospice.
This discussion group is
free of charge.
And members are
welcome to join
from
anywhere on Earth.