A Planned Death

A Planned Death October 21, 2022

Most people cannot wrap their minds around planning to leave this life on their own terms. Have we been programmed to believe that enduring suffering is saintly? In our office, I have seen more deaths due to suicide and tangentially, accidental suicides, this year than any other. Suicides are often attributed to untreated depression, physical pain or other forms of suffering. When you begin to consider the right to die, there are several heavy topics to unpack: 

  • Under what circumstances, if any, would you find suicide acceptable? 
  • What are your religious beliefs, and do your personal views match them?  
  • What are the laws in your state regarding the right to die?  

Surviving an untimely death of a loved one is traumatic; when you lose your parent, partner, or child, it seems a horrific mistake that needs to be explained and justified. It’s a very different ballpark between the death of a healthy young person and that of a chronically ill elder. I often hear people extoll the proverbial phrase, “They are in a better place and no longer suffering.” But, do you believe that? If our society believes it, why would anyone ever live in chronic pain until their body finally sputtered, painfully to its last? Does belief in the afterlife make it easier to end your earthly existence? Perhaps not. While there is no single Christian view of suicide, most strongly discourage it. However, in 1983 the Roman Catholic Church removed suicide from its list of mortal sins. 

A Different Perspective 

I’ve worked in Elder Law for 10 years, and I can promise you that few die naturally at home in their sleep. The reality is that most people die over many months and even sometimes years, some will linger in a hospital bed, at home or in a long-term care facility. Frequently, a series of falls and head injuries begin a sequence of hospital stays until the body eventually has additional complications. Active dying is often “managed” through a medically induced comatose state to prevent pain. Once the body has stopped eating, drinking, as well as relieving itself, Death will likely occur within days. How many days? We don’t know, maybe weeks, and sadly it could be even longer. But the reality is that if you are in a nursing home or medical setting upon your last days you will likely be medicinally comatose. 

What would a death look like that involves the Right to Die? 

Consider the difference if you knew your time had come. You could choose when, where, how and who would be present at your vigil and at the moment of your final breath. Imagine all the things you might want to say or discuss with your family, friends or even that person who hurt you so many years ago.
Perhaps you are wrapped in a warm blanket, lying on a soft, velvet-covered dais outside under the autumnal leaves. You can see the bluest sky and white feathery clouds. The attending guests crunch through the leaves to your bedside to have their own individual sacred moments of intimate, intense interaction. Every breath seems sweeter, and every word has weight. Perhaps you have chosen an IV drip that will quickly and painlessly end your life. Consider having your most beloved people holding and supporting you as the transition occurs, being wrapped in the clear awareness of unconditional love and acceptance for your choice to avoid the random event of a comatose transition, a possibly lengthy death with ramifications.  

After your transition, your body is wrapped and covered. Tears begin to flow and time for expressing emotion is allowed and honored by sharing prayers, singing, keening, and whaling allowing participants time to find closure and acceptance within this sacred time and space. Obviously, this is just one of any number of scenarios. 

The Living Will  

I cannot stress enough the importance of having a Living Will. Not to be confused with a Last Will and Testament, this document states that in specific end-of-life circumstances, you do/do not want to artificially prolong life with invasive procedures.  

We recently had a guardianship client begin a series of falls. The ward has lived for the past several years in a nursing home. The family is unable to provide the intense level of care themselves. The doctors were unable to resolve the brain bleed and recurring build-up of fluid in the brain cavity and so a shunt was installed from the brain to the stomach. In addition, the hospital suggested installing a permanent feeding tube.  

Did your red flags go up at that suggestion? Mine certainly did. In a case where a person had made a Living Will there is the option to remove a feeding tube, but in a guardianship where a person has been deemed to not have the capacity to make their own decisions, they are not capable of deciding. In this case, we deferred to the family to discuss and make the decision and I personally informed them of the possible long-term ramifications. The guardian nor the doctor is likely to remove the feeding tube or other artificial means of life support once in place.  Let’s review the applicable statute: 

“Virginia Code § 54.1-2986. Procedure in absence of an advance directive; procedure for advance directive without agent; no presumption; persons who may authorize health care for patients incapable of informed decisions. 

  1. Whenever a patient is determined to be incapable of making an informed decision and (i) has not made an advance directive in accordance with this article or (ii) has made an advance directive in accordance with this article that does not indicate his wishes with respect to the health care at issue and does not appoint an agent, the attending physician may, upon compliance with the provisions of this section, provide, continue, withhold or withdraw health care upon the authorization of any of the following persons, in the specified order of priority, if the physician is not aware of any available, willing and capable person in a higher class:
  2. A guardian for the patient. This subdivision shall not be construed to require such appointment in order that a health care decision can be made under this section;” https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2986/

In other words, the physician and guardian must agree to remove life support. However, unless the family is present and likely to be involved, neither the attending physician nor the guardian will put themselves in such an ethically questionable position and the person will stay on life support. 

Another similar case to consider was a guardianship where the ward had received head and brain injuries, along with additional complications, in a car accident which resulted in him receiving a ventriculoperitoneal shunt, tracheostomy, and a PEG tube (artificial breathing and a feeding tube). This ward has no family willing to be involved in the case and so we have no way of knowing or proving any prior end-of-life decisions the ward may have voiced. The ward is minimally responsive to stimuli, and no response has been adequate to prove cognizant communication. Now, in the 2nd year in this ongoing state, the ward is on palliative care, is stable and has not improved or declined. While we have had many discussions with the nurses and attending physician, months turn to years and the clock ticks on. 

“God will take me when he is ready for me!”

While this statement above may feel comforting, you are actually avoiding the issue. Physicians are sworn to do their duty to keep your body alive. And without meaning to be accusatory or harsh, if they don’t have a proper document that informs them specifically what your wishes are for yourself, they must assume that you want them to do everything within their power to keep you alive.

Quality of life is an ethical and spiritual discussion they are not going to broach with you or your traumatized family in the middle of an emergency situation. We all know that Death will come, it is not negotiable, but not being prepared for it is actually a choice.~

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