End-of-Life Options for Hastening Your Death
By Chris Palmer
Author of Achieving a Good Death: A Practical Guide to the End of Life
Dying people face the prospect of prolonging life as long as possible (and perhaps experiencing intolerable suffering and deterioration) or finding ways to die peacefully and gracefully. We are now dealing with a controversial issue: the right of an individual to choose how and when to end their life and how to have access to safe, caring, and legal means of doing so.
Discussions about this are usually held with people with a serious progressive illness that may or may not be terminal, but whose life has deteriorated so severely that quality of life has become (or soon will become) unacceptable and unbearable.
Even with advance directives, more people than ever spend their last days in sterile facilities, incoherent, sustained by ineffective pain medications, and tethered to machines that keep them alive but not fully living.
An intentional death gives the dying person peace of mind, a sense of agency, the chance to die at home, the end of unnecessary pain and suffering, and reduced trauma for loved ones. A full and meaningful life ending with a sense of completeness and few regrets provides a profound lesson in living and dying well. The family has a chance to gather around the dying person’s bedside. Sharing laughter, memories, and healing words can create a sacred and memorable event.
Causing our own death is not a criminal act and can, under certain circumstances, be a profoundly wise and loving thing to do, especially when one’s life is so severely diminished that living is worse than death. If a cherished dog is dying and in pain, the owners ask a vet to end her life painlessly and peacefully. This action is widely viewed as morally decent and merciful. No humane person would let their dog suffer without euthanizing it.
Why are humans at the end of life treated worse than dogs? Advocates like HSSD for the right to choose death like to use the slogan, “I would rather die like a dog.” They mean, “Treat me mercifully, as we treat our beloved pets.”
Here are the various ways of hastening death and shortening the period of intense and intractable suffering caused by illness and disease:
- Withholding and withdrawing unwanted life-sustaining treatments
- Voluntarily stopping eating and drinking (VSED)
- Palliative or terminal sedation (what used to be called “barbiturate sedation”)
- Lethal medication, including medical aid in dying (MAID), and the Swiss option (Voluntary Assisted Dying or VAD)
- Final Exit Network Exit Guide Program (Nitrogen gas inhalation)
Withholding and Withdrawing Unwanted Life-Sustaining Treatments
People facing declining health or dementia who do not want their lives artificially extended can work with their doctors to customize their health-care choices away from extending life. Life-sustaining interventions that can be withheld or withdrawn include treatments and tests, such as mechanical ventilation, intravenous hydration, a feeding tube, cardiopulmonary resuscitation (CPR), and antibiotics. hey can be legally declined or stopped at any time. This decision can be made by patients or by their health-care agents.
Voluntarily Stopping Eating and Drinking (VSED)
Voluntarily stopping eating and drinking (VSED) is a practice in which a very ill patient, facing devastating decline, intentionally hastens death by stopping the intake of all food and fluids until death. VSED is legally available to everyone everywhere (unlike medical aid in dying) and places the dying process in the patient’s control.
VSED is legally permitted in jurisdictions where medical aid in dying is not. Unlike aid in dying, it’s not limited to terminal illnesses or to those with current decision-making capacity. Palliative care can manage symptoms like dry mouth or agitation.
Dying by VSED for a healthy person is agonizing. But for very ill people near the end of their lives who are resolved to end life on their own terms, the process of dying by VSED is entirely different, provided they work with an experienced doctor, medical team, or hospice. As death approaches, bodily changes often take away the appetite. VSED aligns with a natural death but should be medically managed to minimize discomfort.
Death usually occurs within two weeks, assuming the person diligently avoids drinking. However, death can occur within a few days for someone already weakened.
HSSD IS working to create and legally support an advance directive with which competent individuals can specify that their future mentally incompetent self (when they have advanced dementia) can use VSED to hasten their death.
Terminal (or Palliative) Sedation
Even strong medication cannot control severe and relentless pain for some patients. If the suffering from pain, nausea, delirium, agitation, shortness of breath, and other end-of-life miseries becomes too intense and overpowering as death approaches, doctors can sedate a patient with medications to make the patient unconscious.
Medical providers call this terminal sedation (other names are palliative sedation, total sedation, and continuous deep sedation). Terminal sedation is consistent with the Hippocratic oath to do no harm because it’s harmful to patients to allow them to suffer without relief.
Legal everywhere, terminal sedation prevents further physical and psychological suffering and can hasten the dying process. Many people consider it a humane option for a peaceful death and needs to be more widely understood.
The distinction between letting terminally ill people die and intentionally ending their lives can get opaque. A precept of palliative care is not to deliberately hasten death, but this precept is soft and mushy in practice.
Medical Aid in Dying
Medical aid in dying (MAID) is when a doctor writes a lethal drug prescription for a terminally ill patient who self-administers the drug and dies. It is patient-driven, not doctor-driven.
The patient must be 18 years of age or older, terminally ill with a prognosis of 6 months or less left to live, mentally competent, and a legal resident of a state our country where MAID is legal. In the U.S. Oregon and Vermont allow out-of-state residents to access their MAID laws.
MAID allows terminally ill adults to request and receive a prescription for medication, which they may choose to take themselves, by mouth, by a tube inserted through the skin into the stomach wall, or rectally. After taking the fast-acting drugs, patients fall asleep within a few minutes, drift into a deep coma, and then segue peacefully and painlessly into death, typically within a couple of hours.
Strong protections are built into MAID laws and vary by state. Typically, the patient must request MAID three times, including once in writing, with two witnesses. In addition, two medical providers must certify that the person meets the eligibility criteria. Coercion of any kind is strictly illegal and carries severe penalties.
MAID has been legal in Oregon since 1997 and there has never been a credible, documented case of abuse. There is no evidence of a “slippery slope” in which criteria are relaxed, or patients coerced to participate, and there is no evidence that MAID targets minorities or the disabled.
Twelve US jurisdictions, beginning with Oregon in 1997, and including Washington, DC, currently authorize MAID. The MAID laws in those jurisdictions are among the most restrictive in countries with such laws.
For many dying people, having the option of ending their lives is itself a relief. About a third of the patients prescribed fatal drugs never use them but having them available gives patients a sense of control and agency over their lives.
For a list of states and jurisdictions where MAID is legal, click here: https://deathwithdignity.org/states/. MAID is covered by some private insurance and Medicaid in several states (California, Hawaii, New Mexico, and Oregon). It is not covered by Medicare.
Voluntary Assisted Dying in Switzerland
Another MAID option is the Swiss option that involves nonprofits like Dignitas, Pegasos, and Athanasios. Switzerland is the only country that allows noncitizens to access their VAD clinics. If you are interested in this option, HSSD has experienced advisors who can help you. For a complete guide to Voluntary Assisted Dying in Switzerland, including reviews of the clinics click here: https://www.theswitzerlandalternative.com/
Final Exit Network (FEN) and the Right to Die
FEN is a nonprofit organization that offers a free Exit Guide Program providing trained volunteers who educate people on how to comfortably and safely end their lives with Nitrogen gas inhalation. They give information and support to people in their homes at no charge. They do not provide tangible physical assistance in death and do not provide the means to bring about death. Anyone working with a FEN Exit Guide must be able to procure, assemble, and operate the equipment needed without help.
A person can qualify for FEN services without necessarily being terminally ill. For example, FEN works with individuals who are in early-stage dementia and are still mentally capable. FEN’s Medical Review Committee, composed of physicians and health-care professionals, carefully screens applicants to FEN’s Exit Guide Program. The program does not accept applications based on mental illness. In addition, the committee requires family members to be aware of their loved one’s intentions.
Operating under the protection of the First Amendment, FEN exit guides provide nothing but information, that is, speech. Merely advising a patient about how to hasten their death does not constitute ‘assisting’ a suicide within the meaning of state felony statutes.
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Arguably, the greatest of our civil liberties is the right to govern our lives, including the right to choose when and how to die. Those who intentionally hasten their death deserve understanding, compassion, and support.