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Planning A Dignified Death

In my line of work, we get inured to talking about death and how to plan for it.

I have been in meetings about business succession planning, which included discussions of my own potential demise, with the management team that includes my wife and found myself taken aback when the subject made her emotional. In the midst of crafting an estate or succession plan, you can forget what it is you’re really talking about.

But in all professions that touch the end of life - medicine, funeral direction, estate planning and others - you come to see death as life’s natural final act. Even then, however, the last thing anybody wants to witness is a pointlessly painful or prolonged death, particularly one that is not wanted by the person experiencing it.

There is nearly universal agreement in our culture that if an animal, particularly a beloved pet, is suffering with no hope of recovery, it is an act of compassion to end that suffering through euthanasia. Yet very few of us are willing to countenance the concept for humans, largely because we recognize that our fellow men and women are capable of exercising free will. For situations where injury or illness takes away our capacity to make choices, we have time-tested legal instruments to guide us, including advance health care directives or living wills, and health care proxies that delegate the power to make decisions to others close to us.

Ultimately, though, the choice to go on living is one that all of us implicitly make for ourselves every day, until and unless we choose otherwise. Yet the law in most parts of the United States does not fully recognize or endorse the idea that living, or dying, is an act of free will.

The Washington Post recently ran a story about Brittany Maynard, a 29-year-old who had been diagnosed with a stage 4 malignant brain tumor. Maynard was living with her husband in California when she was diagnosed, but they relocated to Oregon in order to be able to legally choose doctor-assisted death rather than prolonged treatment for her terminal condition.

In an op-ed for CNN, Maynard described coming to “a heartbreaking conclusion: There is no treatment that would save [her] life, and the recommended treatments would have destroyed the time [she] had left.” She considered alternatives such as hospice care with only palliative medication, but ultimately decided that even this would prolong her family’s suffering, and her own, to no good end. So she took the steps to establish residency in Oregon in order to take advantage of the state’s death with dignity laws, unavailable in California.

Maynard had previously announced her plan to die on November 1, and she took her prescribed lethal dose of medication at her home in Portland this weekend, the Post reported.

Before her death, Maynard also spoke out as an advocate for wider availability of death with dignity in the U.S. through the organization Compassion and Choices. “I would not tell anyone else that he or she should choose death with dignity,” Maynard wrote. “My question is: Who has the right to tell me that I don’t deserve this choice?”

Physician-assisted suicide is still prohibited in most states, and opponents are quick to demand that it stay that way. Some express moral or religious concerns about the practice. Those who oppose allowing patients to choose their own end also sometimes express concern that such options will be exercised by those with nonterminal mental illnesses. It would be a horrible mistake to enable people suffering from treatable conditions such as depression to make the choice to end their lives as a symptom of those illnesses.

But that is not what we are discussing in a case like Maynard’s. When, as in Maynard’s situation, a cognizant human being makes a deliberate choice not to have her life end in a spiral of suffering for herself and her loved ones, why would we not honor and empower that decision?

Our society has begun to move toward discussing death more frankly and re-examining many of our existing suppositions about what a good death looks like. A study released early this year found that most doctors surveyed would prefer a do-not-resuscitate, or “no code,” order for themselves should they be diagnosed with terminal illness, though by default, most patients receive all available measures unless they specifically indicate other wishes. VJ Periyakoil, the study’s lead author, observed that, “Our current default is ‘doing,’ but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself.” Identifying this tipping point cannot be easy for doctors or loved ones, but surely when patients still have the capacity to do so, they deserve the power to make this call.

Oregon is one of only five states in which physician-assisted suicide is legal. Oregon’s law, the Death with Dignity Act, sets certain requirements, including soundness of mind and two doctors confirming a terminal diagnosis, before a person may request a prescription for a lethal dose of medication. Washington and Vermont have based their statutes on the Oregon model; Montana and New Mexico are the other two states allowing the practice, after courts established the legal right to assisted suicide. Several state legislatures have bills under consideration to allow the practice in at least some cases.

The idea has also had a slow start in other industrialized countries, but is gaining popular support. British author Terry Pratchett, who announced his diagnosis with early-onset Alzheimer’s disease in 2007, hosted a 2011 television documentary about terminally ill Britons who travel to Switzerland in order to take advantage of an assisted dying organization based there. A bill before the House of Lords this summer proposed to make such options available in the United Kingdom itself. If it eventually passes, it will be less broad than Switzerland’s, closer to the laws of Luxembourg, Belgium and the Netherlands, which allow the practice under specific circumstances. Other countries are also considering legislation to address the issue.

There is some evidence that simply having the option of to choose one’s own end can be helpful. Barbara Coombs Lee, a lawyer and former intensive care nurse who helped to write Oregon’s law, observed that choice itself is palliative. “People experience improved quality of life when they have the means to avoid their worst nightmare,” she said. And since patients administer the lethal dose themselves (distinguishing physician-assisted suicide from euthanasia, which is still illegal in Oregon and other places that permit the former practice), the patient can change his or her mind at any point. In Oregon, one in three patients who fill the prescriptions don’t use them. This emphasizes the fundamental point that these laws are about choice.

Doctor-assisted suicide in cases like Maynard’s is an extension of the compassion we show to other creatures and the consideration we hold for the bodily autonomy of the patient, and for the feelings of the survivors he or she leaves behind. The entire field of estate planning, where I practice, is based on the reality that we don’t make such plans for ourselves. We engage in estate planning to make life easier and better for the people who will be left after we go.

We can only have the deepest sympathy for Maynard’s family. We know how much they must be hurting from the loss of this promising young woman. But they would have hurt just as much if nature had been allowed to take its course - only with additional suffering first. That would have been pointless and cruel.

With the appropriate safeguards in place, Oregon’s approach is a model of compassionate legislation, one that shows the proper respect for our right to control our own bodies. It enables people to choose, if they wish, a relatively painless and dignified way to exit a situation that can have only one end.

Larry M. Elkin is the founder and president of Palisades Hudson, and is based out of Palisades Hudson’s Fort Lauderdale, Florida headquarters. He wrote several of the chapters in the firm’s book, Looking Ahead: Life, Family, Wealth and Business After 55. His contributions include Chapter 1, “Looking Ahead When Youth Is Behind Us” and Chapter 4, “The Family Business."

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