Tag: Conscious Dying

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Will your life end well? An Oscar nominee and palliative care advocate on what’s new in death

Shoshana Ungerleider, founder of the End Well symposium and the Ungerleider Palliative Care Education Fund

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Shoshana Ungerleider is a leading palliative care advocate as well as a practicing physician at California Pacific Medical Center in San Francisco. In her work as an activist and educator on end-of-life issues, she’s been focused on creating a more human-centered approach to how we die. To this end, Ungerleider has started a philanthropic organization dedicated to education about end-of-life issues, launched an annual symposium on the end-of-life experience called End Well, and helped produce documentary films on the subject, including the Oscar-nominated Extremis and End Game, which was released on Netflix earlier this month. The Business Times spoke to her about what’s behind her passion for palliative care and how a better understanding of death is essential to a better health care experience.

As an internist who works in a hospital, how did you first get interested in palliative care?

Sort of the weird thing is that I never set out to be any kind of advocate for end-of-life issues. But really early on in my residency, I experienced so many patients in the ICU who were dying of lung cancer, of liver disease, of end-stage something and I realized that nothing that we were going to do was really going to reverse their age or their underlying medical problems. But nonetheless we were still kind of doing things to them because we could and not because we necessarily should. It turns out that far too many people spend their last moments of life suffering. They’re in pain. They’re hidden away from their loved ones. And to me it’s coming down to the fact that we’re not doing as a job both as health-care providers but also society at large of having honest conversations early and often about what matters most to us.


 
Are there generational differences in terms of people being open and comfortable about conversations around death?

Millennials are, for whatever reason, really open and honest about mortality and making sure that they get what they want and have some autonomy. There’s a similar thing with baby boomers interestingly, really wanting to have a say and maintain control. There are organizations like Death over Dinner in Seattle, where they kind of helped you curate and facilitate a conversation around the dinner table with friends, family or loved ones. Also, The Dinner Party, which is another group founded by some young women who lost their parents which is more focused on grief, and loss, and creating an open conversation around their table. So it’s fascinating to me just how much innovation is happening around this seemingly very taboo topic.

Many doctors feel that death is ultimately a treatment failure. But have you seen an evolution from the physician and provider side when it comes to end-of-life care?

There’s been, over the last 15 years, a shift in medical education. So people are realizing that teaching doctors how to have hard conversations is really critical. We need to be doing more of it and there needs to be sort of core academic competence models coming out of our national accrediting bodies that haven’t happened yet. But the field of palliative care is brand new. It’s only been a specialty that’s been board certified since 2008. There has been a radical shift in the last 10 years to now being a very much more popular field. They talk about it often and medical students and residents are much more open to the idea that doctors still have a place in healing, even when a cure is no longer an option.

One of your stated goals is to make the end-of-life process more human-centered and less clinical, cold and impersonal. What role is technology playing in that shift?

There’s a few apps out there that are really helping to facilitate advanced care planning, meaning the kinds of documentation and discussion that need to take place to make people’s end of life care preferences known, like Cake out of Boston. There are also a few entities researching the use of virtual reality in terms of both therapeutically helping to treat pain and anxiety, but also for recreational use. So some places in Canada and the UK are specifically using it for patients who are in hospice and want to mark things off their bucket list. So while they can’t travel but they might be able to experience Niagara Falls or go climb Everest virtually.

Are there things that American culture regarding death can learn from other places around the world?

It’s really interesting because everybody always asks if there are countries or societies that do this well, and the answer to that is no. Nobody has figured out the best way to support patients, to support families, to think about caregiving from a civic perspective. The one really interesting case study that I always point to when I talk about this is La Crosse, Wisconsin. It’s a town of about 50,000 people where one leader in the community decided that he was going to make his hometown just like a great place to die. How he went about this was in the mid-2000s he figured out a way to really encourage people to do a lot of advanced directives, so that it became just a commonplace thing. In 2009, something like 95 percent of the people that died (in La Crosse) had filled out an advanced directive. In the United States we have 10,000 baby boomers turning 65 every day. Never in the history of our country will so many people die in such a short time span, so it behooves all of us to start thinking about innovative solutions to caregiving.

So you’re probably the person I’ve talked to who’s thought about these issues the most, how has your perception of your death had changed?

Something sacred is happening. You get to see a very intimate window into someone’s life and really the mystery of what binds us together as human beings. For me, being reminded of my mortality makes my life sweeter. It’s more rich when you know that one day it will end.

Complete Article ↪HERE↩!

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What does a good death look like when you’re really old and ready to go?

David Goodall a day before his assisted death in Switzerland.

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[H]awaii recently joined the growing number of states and countries where doctor-assisted dying is legal. In these jurisdictions, help to die is rarely extended to those who don’t have a terminal illness. Yet, increasingly, very old people, without a terminal illness, who feel that they have lived too long, are arguing that they also have a right to such assistance.

Media coverage of David Goodall, the 104-year-old Australian scientist who travelled to Switzerland for assisted dying, demonstrates the level of public interest in ethical dilemmas at the extremities of life. Goodall wanted to die because he no longer enjoyed life. Shortly before his death, he told reporters that he spends most of his day just sitting. “What’s the use of that?” he asked.

Research shows that life can be a constant struggle for the very old, with social connections hard to sustain and health increasingly fragile. Studies looking specifically at the motivation for assisted dying among the very old show that many feel a deep sense of loneliness, tiredness, an inability to express their individuality by taking part in activities that are important to them, and a hatred of dependency.

Of the jurisdictions where assisted dying is legal, some make suffering the determinant (Canada, for example). Others require a prognosis of six months (California, for example). Mainly, though, the focus is on people who have a terminal illness because it is seen as less of an ethical problem to hasten the death of someone who is already dying than someone who is simply tired of life.

Why give precedence to physical suffering?

Assisted dying for people with psychological or existential reasons for wanting to end their life is unlikely to be supported by doctors because it is not objectively verifiable and also potentially remediable. In the Netherlands, despite the legal power to offer assistance where there is no life-limiting illness, doctors are seldom convinced of the unbearable nature of non-physical suffering, and so will rarely administer a lethal dose in such cases.

Although doctors may look to a physical diagnosis to give them confidence in their decision to hasten a patient’s death, physical symptoms are often not mentioned by the people they are assisting. Instead, the most common reason given by those who have received help to die is loss of autonomy. Other common reasons are to avoid burdening others and not being able to enjoy one’s life – the exact same reason given by Goodall. This suggests that requests from people with terminal illness, and from those who are just very old and ready to go, are not as different as both the law – and doctors’ interpretation of the law – claim them to be.

Sympathetic coverage

It seems that the general public does not draw a clear distinction either. Most of the media coverage of Goodall’s journey to Switzerland was sympathetic, to the dismay of opponents of assisted dying.

Media reports about ageing celebrities endorsing assisted dying in cases of both terminal illness and very old age, blur the distinction still further.

One of the reasons for this categorical confusion is that, at root, this debate is about what a good death looks like, and this doesn’t rely on prognosis; it relies on personality. And, it’s worth remembering, the personalities of the very old are as diverse as those of the very young.

David Goodall died listening to Beethoven’s Ode to Joy.
 
Discussion of assisted suicide often focuses on concerns that some older people may be exposed to coercion by carers or family members. But older people also play another role in this debate. They make up the rank and file activists of the global right-to-die movement. In this conflict of rights, protectionist impulses conflict with these older activists’ demands to die on their own terms and at a time of their own choosing.

In light of the unprecedented ageing of the world’s population and increasing longevity, it is important to think about what a good death looks like in deep old age. In an era when more jurisdictions are passing laws to permit doctor-assisted dying, the choreographed death of a 104-year-old, who died listening to Ode to Joy after enjoying a last fish supper, starts to look like a socially approved good death.

Complete Article ↪HERE↩!

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The Medical Power of Attorney: What Do I Need to Know?

What is a Medical Power of Attorney?

A Medical Power of Attorney is a legal instrument that allows you to select the person that you want to make healthcare decisions for you if and when you become unable to make them for yourself. The person you pick is representative for purposes of healthcare decision-making.

What Healthcare Decisions are you Talking About?

Any kind of decision that is related to your health that you allow. You could limit your representative to certain types of decisions. (For example, the decision to put you on life support when there is no hope of you getting better.) On the other hand, you could allow your representative to make any healthcare decision that might come up. This includes decisions to give, withhold or withdraw informed consent to any type of health care, including but not limited to, medical and surgical treatments. Other decisions that may be included are psychiatric treatment, nursing care, hospitalization, treatment in a nursing home, home health care and organ donation.

How is this Different from a Living Will?

A Living Will is a statement of decisions you made yourself. It tells the doctor that you do not want to be kept alive by machines, if there is no hope of getting better. A Medical Power of Attorney gives someone else the authority to make medical decisions for you if you are unable to make them for yourself. It is meant to deal with situations that you cannot predict. Because you cannot predict these situations, you cannot decide in advance what choice you would make. The Medical Power of Attorney allows you to pick the person that you trust to make to these kinds of decisions when you cannot make them yourself.

Do I Still Need a Living Will If I Have a Medical Power of Attorney?

Yes. Any decisions that you make in your Living Will must be followed by the person you name as your Medical Power of Attorney.

When Would I Need a Medical Power of Attorney?

A Medical Power of Attorney is used when you become unable to make healthcare decisions for yourself. For example, if you are unconscious after a car accident and you need a blood transfusion; if you are under anesthesia and you need to have a more extensive procedure than you initially consented to; or if you become mentally incompetent as a result of Alzheimer’s Disease and you need medical treatment.

How will I know if I am able to Make Healthcare Decisions for Myself?

A doctor or psychologist or advance practice nurse working with a doctor will make this determination. Commonly, the doctor will say that you lack the capacity to make healthcare decisions. He or she may also say that you are incapacitated. If you are conscious, you will be told that you have been found to be incapacitated and that your Medical Power of Attorney Representative will be making decisions regarding your treatment.

How Does the Doctor Decide that I am Unable to Make Medical Decisions for Myself?

The doctor, psychologist or advance nurse practitioner will evaluate your ability to:

  1. Appreciate the nature and implications of a health care decision; (Are you able understand what your doctor is telling you and understand the consequences of any choices t hat you make ?)
  2. Make an informed choice regarding the alternatives presented; (Are you able to process the information the doctor gives you and make your decision based on this process?) and
  3. Communicate that choice in an unambiguous manner. (Are you able to let your doctor know what you have decided? You may state your choice, write it down, or in some case, just nod your head. The important thing here is that there must be no doubt about what your are trying to express.)

If the doctor determines that you are unable to do these things, they must write this in your medical records. The doctor’s statement must include the reason why you were found to lack capacity.

Can the doctor say that I do not have the capacity to make Healthcare Decisions just because I am old or have a mental illness?

No. Simply being old or having a mental illness is not enough to support a finding that you do not have the capacity to make medical decisions. The doctor must complete the three part evaluation discussed above before he or she determines that you do not have the capacity to make healthcare decisions.

Does the Person I Name as Medical Power of Attorney have any Control Over My Medical Care if I can Still Make My Own Decisions?

No. The person you name as your Medical Power of Attorney has no authority until you become unable to make your own decisions.

Can I Name an Alternative or a Back-up Representative in Addition to My First Choice?

Yes. You may name one or more “successor representatives” to fill this role if your first choice is unable, unwilling or disqualified to serve.

What Kinds of Things Can the Person I Name as Medical Power of Attorney Do?

The person that you name as your Medical Power of Attorney representative can make any decisions related to your health care that you allow. These decisions could include giving, withholding or withdrawing informed consent to any type of health care, including but not limited to, medical and surgical treatments. Other decisions that may be included are life-prolonging interventions, psychiatric treatment, nursing care, hospitalization, treatment in a nursing home, home health care and organ donation. Your representative can have or control access to your medical records and decide about measures for the relief of pain.

Your Medical Power of Attorney can be as broad or as narrow as you want it to be. You can specifically write that your Medical Power Attorney Representative shall not have the power to make one of these decisions. Or, you can specifically state exactly what decision you want your Medical Power of Attorney Representative to make. For example, you might say that your representative cannot give a certain person access to your medical records.

How Can I Make Sure that the Decisions My Medical Power of Attorney Representative
Makes are Ones that I Would Agree With?

There are several things that you can do to help your representative make decisions that you would agree with.

  1. Write it down. You can include specific instructions in your Medical Power of Attorney to cover particular circumstances. You can also include a statement of your personal values to help your representative make decisions.
  2. Talk about your wishes. Discuss your wishes with the person you appoint as your Medical Power of Attorney representative. Tell them about your religious beliefs and personal values. Make sure that they know the things that you definitely would want as well as the things that you absolutely do not want.

Who should I name as my Medical Power of Attorney Representative?

You should pick someone that knows you well and that you trust to make healthcare decisions for you based on your personal wishes and values. You may or may not want to name a family member as your Medical Power of Attorney Representative. Keep in mind, that some of the decisions your representative will have to make will be very difficult. It might be difficult for some family members to overcome their own emotions and make decisions that are based on your personal values. The most important consideration in naming a Medical Power of Attorney Representative is to choose someone you trust to be able to make decisions based on the values and directions you have set out.

Can I appoint my doctor as my Medical Power of Attorney?

No, the law says that you cannot appoint your doctor as your Medical Power of Attorney. Additionally, the following people cannot serve as your Medical Power of Attorney:

  1. Any doctor, dentist, nurse, physician’s assistant, paramedic, or psychologist who is treating you, cannot serve as your Medical Power of Attorney representative;
  2. Any other person who is providing you with medical, dental, nursing, psychological services or other health services of any kind, cannot serve as your Medical Power of Attorney representative;
  3. Any employee of any doctor, dentist, nurse, physician’s assistant, paramedic, or psychologist who is treating you cannot serve as your Medical Power of Attorney representative, UNLESS the employee is your relative;
  4. Any employee of any other person who is providing you with medical, dental, nursing, psychological services or other health services of any kind cannot serve as your Medical Power of Attorney representative, UNLESS the employee is your relative;
  5. An operator of the hospital, psychiatric hospital, medical center, ambulatory health care facility, physicians’ office and clinic, extended care facility operated in connection with a hospital, nursing home, a hospital extended care facility operated in connection with a rehabilitation center, hospice, home health care, and any other facility established to administer health care that is currently serving you cannot serve as your Medical Power of Attorney representative.
  6. Any employee of an operator of a hospital, psychiatric hospital, medical center, ambulatory health care facility, physicians’ office and clinic, extended care facility operated in connection with a hospital, nursing home, a hospital extended care facility operated in connection with a rehabilitation center, hospice, home health care, and any other facility established to administer health care cannot serve as your Medical Power of Attorney representative, UNLESS the employee is your relative.

Does My Medical Power of Attorney Representative Have to Pay My Medical Bills?

No. A Medical Power of Attorney only gives the person you appoint authority to make healthcare related decisions. This does not include authority to pay your bills. For that you need a Durable Financial Power of Attorney. It is entirely possible that the same person may hold both your Medical Power of Attorney and your Financial Power of Attorney. However, if this is not the case, your Medical Power of Attorney Representative has no financial authority.

What Happens If I Appoint a Medical Power of Attorney and Then Someone Petitions to Have A Guardian Appointed for Me?

If you appoint a medical power of attorney and then someone petitions to have a guardian appointed for you, the court will give the person you appointed as medical power of attorney special consideration. In other words, the court will appoint the person you name as a medical power of attorney to be your guardian unless it finds that there is a good reason not to.

Can I Change My Mind After I Sign a Medical Power of Attorney?

Yes. As long as you have the capacity to do so, you can revoke your Medical Power of Attorney at any time by any of these methods.

  1. You can destroy the Medical Power of Attorney. Tear it up or burn it.
  2. You can tell someone else to destroy your Medical Power of Attorney. They must destroy it in your presence.
  3. You can write out a statement that you are revoking your Medical Power of Attorney. This statement must be signed and dated by you. This revocation does not become effective until you give it to your doctor.
  4. If you are not able to write, you can tell someone to write out a statement that you are revoking your Medical Power of Attorney. This person must be over 18 years old. This statement must also be signed and dated. You can tell the other person to sign your name on your be half. This revocation does not become effective until your doctor gets it. You can have the other person give it to them if you are not able to.

Is my Medical Power of Attorney Affected if I Get a Divorce?

Yes, if you named your spouse as your Medical Power of Attorney Representative or successor representative. When a final divorce decree is granted, the appointment of your spouse is automatically revoked. You will need to sign a new power of attorney. If you still want your former spouse to serve as your representative, he or she may do so, provided that you reappoint the m in a new Medical Power of Attorney.

What is Required to Make a Valid Medical Power of Attorney?

There are seven requirements:

  1. You must be an adult or have been determined to be a mature minor*;
  2. The Medical Power of Attorney must be in writing;
  3. You must sign it;
  4. You must date it;
  5. You must sign it in the presence of at least two witnesses, age 18 or older;
  6. A Notary Public must acknowledge these signatures;
  7. It should contain the following language or substantially similar language:

This Medical Power of Attorney shall become effective only upon my incapacity to give, withdraw, or withhold informed consent to my own medical care.

*Persons under 18 are presumed to lack capacity. In order to defeat this presumption, persons under 18 must undergo an examination by a doctor, or psychologist, or an advance practice nurse who is collaborating with a doctor and found to have the capacity to make health care decisions. Once this determination is made, these individuals are referred to as “mature minors.”

Who can be a Witness for my Medical Power of Attorney?

The law only requires that a witness to your Medical Power of Attorney be over eighteen years old. Additionally, the law says that the following people cannot be a witness to your Medical Power of Attorney:

  1. The person who signed your Medical Power of Attorney on your behalf and at your direction can not be a witness to your medical power of attorney;
  2. Anyone who is related to you by blood or marriage cannot be a witness to your medical power of attorney;
  3. Anyone who will inherit from you cannot be a witness to your medical power of attorney; (This can be under your will or under the laws that provide for the distribution of your property if you do not have a will.)
  4. Anyone who is legally obligated to pay for your medical c are cannot be a witness to your medical power of attorney;
  5. Your doctor cannot be a witness to your medical power of attorney;
  6. The person you have named as your Medical Power of Attorney or the person you have named as successor Medical Power of Attorney cannot be a witness to your medical power of attorney.

As part of the Medical Power of Attorney your witnesses must sign a statement that they do not fit any of these categories.

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Perspectives on Death

Today we are talking about death, looking at philosophical approaches from Socrates, Epicurus, and Zhuangzi. We will consider whether it’s logical to fear your own death, or the deaths of your loved ones.

 

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Die like a dog

Pet dogs often have a peaceful death that forestalls protracted suffering and pain. Why can’t we do the same for humans?

Cris Cristofaro holds his dog Dino as his beloved pet is sedated during an in-home euthanasia on 9 May 2012 in New York City.

By Joseph Pierre

[I] killed my dog last year. Mika was a shelter mutt, so she was around 10 or 12 years old; I can’t be sure. Twelve dog years would have put her at around 80 human years, which is a pretty good run. But what’s strange about having a dog is how quickly they age relative to us – they start out younger than we are, catch up for a time, and then pass us by, declining into their twilight years, all in the space of a decade or so. As witnesses to that accelerated timeline, having a pet means that we often end up experiencing their eventual demise and learning something about death in the process.

Mika was a great dog. Obviously abused before ending up at the shelter, she had scars on her head when I rescued her and, whenever I took a broom or rake in my hand, she would cower in fear. She was easily overwhelmed when other dogs came up to sniff her, and would often growl defensively. But with time she grew to be less apprehensive and almost pathologically affectionate, if there is such a thing with animals, demanding to be petted by anyone who happened to be near. She was a great companion watching TV on the couch during my single years, and she helped me win the attention of the woman, a veterinarian, who would eventually become my wife. In fact, my wife has often joked – and maybe it isn’t a joke at all – that she would never have gone out with me in the first place if I hadn’t had a dog.

For whatever reason, the way I’d always pictured the proper death of one’s dog was like a scene taken from the 1957 Disney film Old Yeller (1956): after years of steadfast companionship, when man’s best friend no longer derives joy from chasing rabbits and can barely lift his head, his owner has to muster the resolve to get out the rifle to put him out of his misery. Although an oddly bucolic fantasy for someone living in Los Angeles, at least part of it was no doubt influenced by how I’d learned to think about death as a physician.

In human medicine, we’re used to implementing any and every life-saving intervention right up to the very end. As a medical intern 20 years ago, I remember thinking about the futility of that approach with patients in pain and suffering from multisystem organ failure, sustained only by machines and a regimen of some 30 or 40 medications, and unlikely to ever make it out of the hospital. What was the point? Whatever happened to quality of life? But those reservations be damned, we never gave up, and among the interns who transferred care to each other from shift to shift, the dictum of patients ‘not dying on my watch’ was something to which we all held fast.

As long as there were no ‘Do Not Resuscitate’ orders in the chart asking us to withhold ‘heroic efforts’, we rarely considered doing anything less to prolong life, and financial cost was never part of the equation either. As far as hastening death, that was never even mentioned. After all, the original Hippocratic oath states: ‘I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.’

[W]hen Mika, who’d had hip dysplasia from the start, developed increasing difficulties walking and was in obvious pain much of the time, my wife and I put her on medications and even tried acupuncture, which helped for a while. But one day, at the start of our morning walk, she ambled to the end of the driveway, sat down, and refused to go on despite me pulling the leash. It was the same the next day and the next, so I stopped trying. It was at that point that my wife first brought up the possibility of putting her down, but that seemed ridiculous to me because between Old Yeller and my experiences as a human doctor, I envisioned Mika struggling through the pain, fighting for her last breath to the very end. In other words, it didn’t seem right to think about letting her go because she hadn’t yet suffered enough.

As a veterinarian, my wife viewed things altogether differently. To her, putting our dog to sleep didn’t represent throwing in the towel as it seemed to me, but a compassionate way to preempt unnecessary but inevitable pain and suffering down the line. As she saw it, we owe this option to our pets as stewards of their care, especially given that animals can’t understand pain or decide for themselves just how much suffering they are willing to tolerate.

Indeed, the American Veterinary Medical Association Guidelines for the Euthanasia of Animals (2013) acknowledges that ‘there is no consensus on when it is appropriate to let [a] life go’, but notes that: ‘Euthanasia may be considered to be the right course to spare [an] animal from what is to come … if medical intervention would only prolong a terminal condition, or if current health conditions cannot be successfully mitigated.’

When we were dating in the years before we got married, my wife would often come home from a long day at work and say: ‘I killed my patient today.’ This, I came to understand, was a kind of self-reproachful statement of defeat as well as a starkly factual statement that reflected how she’d actually administered the medications that ended a dog or cat’s life that day, typically with tearful owners and their bawling children huddled around.

This strange admixture of guilt from failing to save a life, along with the resolve to be the agent that takes it, comes with the territory in a veterinary clinic where euthanasia is a daily occurrence. Although euthanasia literally means ‘good death’, it was totally foreign to me in my training as a physician. Human doctors might feel guilty losing a patient in the end, but that guilt is almost always tempered by the reassurance that while we might have lost the battle to cancer, nature, God or whatever, we did everything we could in the process. Being a physician means that doctors must sometimes admit defeat, but in doing so, we don’t go on to be the hand of death.

[A]s time went on, medications and acupuncture had less of an impact on Mika, and her hind legs would often give out so that she would walk only a limited distance before collapsing. She seemed to be slipping cognitively too, and one day even fell into the swimming pool while we were away at work, requiring rescue from a neighbour. In what seemed like a short amount of time, her muzzle turned fully grey, and she would often sigh heavily with a distant look in her eye. Finally, she began to lose control of her bowels, with increasingly frequent accidents around the house.

And so, discussions about euthanasia became more about ‘when’ than ‘whether’.

The difference in attitudes towards euthanasia for animals and human beings is understandable. After all, people have been killing animals without remorse for food, to avoid becoming food ourselves, and for sport long before we began domesticating animals or keeping them for companionship. Whereas traditional Judeo-Christian and Islamic teachings include strong proscriptions against murder and suicide for humans, religious doctrine questions the animal soul. And while euthanasia is used as an ethical means to preempt suffering in veterinary medicine, it’s not unusual for some owners to simply abandon their pets by the side of the road, put puppies in garbage bags, or refuse to pay for life-saving medical procedures based on both economics and expediency. No wonder the expression ‘die like a dog’ has historically referred to the most miserable of ends.

In 2009, US legislation that would have allowed physicians to be compensated by Medicare for providing voluntary counselling to patients about options for end-of-life care was defeated due to political uproar over ‘death panels’. And yet, as I discuss in the World Journal of Psychiatry in 2015, human euthanasia is being increasingly considered and sanctioned both in the US and abroad. As life-extending medical advances over the past 50 years have fuelled growing concerns about prolongation of suffering and loss of autonomy, the euthanasia movement of the 1930s has gained momentum, evolving into the modern ‘right to die’ and ‘death with dignity’ movements that challenge us to consider what constitutes a ‘good death’. Today, some form of voluntary active euthanasia – death by administration of a lethal dose of medication to avoid pain and suffering – is legal in several states in the US, as well as in Japan and parts of Europe including Belgium, Luxembourg, Switzerland and the Netherlands.

Still, if the historical divide between our attitudes towards euthanasia for humans and for animals is narrowing, the devil in the details of cultural sanctioning involves who can actually administer, or is willing to administer, the medications that end life. With existing legislation to date, the sanctioned individual – whether a physician, family member, some neutral third party, or the person seeking to end their own life themselves – varies by jurisdiction. Although ‘death with dignity’ is increasingly supported in many parts of the world, often neither doctors nor patients seeking death want to ‘push the plunger’ and take responsibility for being the hand of death. In this sense, euthanasia remains a hot-potato issue in human medicine.

Consequently, we now find ourselves debating a range of possible end-of-life care options, including passive euthanasia (withholding life-sustaining interventions including food or water), physician-assisted suicide (providing the means for a patient to end their own life), and active voluntary euthanasia (administering a lethal medication to a patient). Palliative sedation is an increasingly popular option within medicine, which involves administering medications that are intended to relieve suffering through sedation and pain control to the point of possible unconsciousness. Although death is a potential side effect, palliative sedation avoids the moral objections of suicide and euthanasia through the ethics of the so-called ‘double effect’, which argues that death is an acceptable outcome if unintended and in the primary service of relieving suffering among the terminally ill. Pushing the envelope of what it means to die a ‘good death’ for humans even further, my colleagues at the University of California, Los Angeles have been investigating the use of psychedelic drugs such as psilocybin to relieve anxiety and depressive symptoms and to find meaning at life’s end.

[A]fter hemming and hawing for weeks, my wife and I finally decided to pick a date to have Mika put down. We asked a veterinarian friend to perform the euthanasia in our home. On the agreed day, it was my wife who put off making the call until I couldn’t take it any longer, and had to prod her to do so. The vet came to our house, started an intravenous line, and filled a syringe with Euthasol as we sat on the floor by Mika’s bedside, petting her with long strokes and saying our tearful goodbyes.

When we were ready, I asked if I could push the plunger, and the vet allowed me to place my hand with hers as we did it together. I was worried that Mika might show signs of discomfort, but seconds after the medication went in, she simply took a single, long, deep breath, and then let it out slowly for the last time.

‘Good dog,’ I told her. ‘Good dog.’

It was a good death. We should be so lucky.

Complete Article ↪HERE↩!

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I Embalm Dead Bodies For A Living — Here’s What It’s Like


 
By Annie Georgia Greenberg

[T]he building that houses Milward Funeral Directors in Lexington, Kentucky has been around for 193 years. It’s a three-story maze that starts with a light-soaked, stone-floored entrance hallway. The hallway is home to an awfully regal cage of tiny, yellow-breasted finches, and they greet you as you walk in through the funeral home’s front doors. Even when they’re out of sight, you can hear their occasional, lively chirps, particularly if you’re in any of the nearby pastel-hued rooms on the first floor. Say, the powder blue chapel, the pink viewing room, the green family meeting room, or the front office where office associate Elaine Kincaid has found a way to answer the ever-ringing phone with a pressing sense of compassion.

By contrast, it’s nearly pin-drop-silent in the upstairs casket showroom, where, if you were preparing to bury a loved one, you would arrive to find a selection of 30-plus casket models in every variation of wood and steel. Should you be cremating your loved one, there’s an adjoining hall where you could select an urn, each one of them unique in presentation and name — “White Orchid” for the porcelain vase and “Solitude” for the simple, gold rectangle. You could also turn loved ones’ cremated remains into jewelry, a keychain, a bench or, in the words of Miranda Robinson, Milward’s youngest mortician, “pretty much anything you want.”

Like Milward funeral home, Miranda Robinson is polished and professional. Yet, at 30-years old, she both embodies and defies the stereotypes often associated with morticians. Yes, she has a fascination with death and dying. Yes, she loves the skeletal system, owns a black cat, and displays a ouija board on her apartment’s living room table — but she’s anything but morose. In fact, her bubbly Kentucky drawl is often interrupted by a burst of up-swinging giggles, even while discussing death. She used to be a cabaret performer and closely follows RuPaul’s Drag Race. Her most-used word is “lovely” and her retro-feminine personal aesthetic matches that same description.

At around 5 feet, 4 inches tall with an obvious flair for vintage, Miranda pays almost as much attention to her own presentation as she does to those on her embalming table. Robinson clips in hair extensions that she curls every morning. Her arms, which remain covered while at work, are decorated with tattoos. One of them is of a bottle of embalming fluid.

Still, at first blush you’d never guess that Robinson works with the dead on a daily basis. And, perhaps, you’d never guess how many women her age are actively entering the field, either. Frustrated by nursing school and looking for a change, Robinson shifted gears from aiding the living to preserving the dead, and enrolled in mortuary school in Cincinnati, Ohio. In doing so she joined the ranks of young women now outnumbering men in the mortuary education system. In fact, the National Funeral Directors Association reports that, “While funeral service has traditionally been a male-domination profession…today, 60% of mortuary science students in the United States are women.”

Once a male-dominated industry, after-life and funeral care is now becoming not only a budding, female-centric space but also one ripe for disruption. And no one knows this better than Miranda. “Even in mortuary school, I was taught that [funeral service] was still a different, difficult field for women.” She explains, “Women, so I’ve heard, were expected to wear skirts and heels still, so it seemed, before I got into the funeral home, that [the] funeral service [industry] hadn’t come a long way for women… but now that I’m here, I feel like I’ve made my mark and I’m really seeing women in funeral service emerge.” They’re emerging and they’re excelling, bringing with them calm, care, and attention to detail that may have long been lacking.

While embalming, Miranda says she feels like “both an artist and a scientist,” because her work combines aspects of both. Made prevalent during the Civil War, when bodies of fallen soldiers were shipped back home for viewings and funerals, embalming is a technique used to preserve the deceased by replacing a portion of their blood with chemicals (including formaldehyde). The body is also made up to look as it did in life — lipstick and all. But, while this method may long be favored in the United States, a new wave of green burial options seeks to challenge the traditional funeral industry. In fact, for the second year running, cremation is now more popular than burials, and the National Funeral Directors Association only expects this trend to continue.

That’s because green burials, alternative and eco-friendly practices are popularizing. Some of these green practices, like home funerals and vigils, pre-date the popularization of embalming, while others like bio-urn cremation (when the body’s cremated remains are buried and grow with the seeds of a plant) or aquamation (a proposed way of breaking down a body using water rather than fire) are brand new. Whether the increased options in funeral care signify an impending end of the traditional funeral industry that Miranda is a part of is a matter that may only be answered in time. For now, what it does mean is that this freshly energized attention to death care is bringing light to a space that, despite touching every single life on Earth, has largely been kept in the shadows.

Ultimately, it is not the method of end-of or after-life care that concerns women like Miranda, but rather the instinct to talk about death in a meaningful way, early and often. Miranda loves her job because what she does helps bring peace to grieving families. She explains, “The most beautiful thing about my job, is taking the loved one into my care from a removal, especially when family is gathered, just that intensity of how much they love that person. It’s an absolute honor to be in the worst possible moment in someone’s life. To be there and for them to look at me and just me to try to at least give them some answers, to try to give them some peace in that moment.”

And while it may seem strange to light up while talking about death, it’s a conversation everyone will someday need to have, regardless of personal preference or spiritual beliefs. Miranda has this conversation every day — at work, at home, with her 1,859 instagram followers — and in doing so helps to de-stigmatize a topic that’s long been off-limits.
As a mortician, Miranda believes that viewing the body is of the utmost importance. As she puts it, “I think it’s important to see the body because you face the reality of what’s actually happened.” But, it’s the trend toward personalization, transparency and increased discussion around death and dying that continues to be a universal priority for many women working in both alternative and traditional funerals.

For Miranda, part of this conversation means addressing the details of her own funeral. And, of course, she can’t imagine anything more fitting than a traditional embalming. Ever the enigma, while her choice to embalm may be traditional, her last look will be anything but. Robinson would like a “glitter casket” with a leopard interior. Dark brown extensions will be clipped and curled, her lips will be painted in the bright red pigment Ruby Woo by Mac. Years from now, when that day comes, Miranda may very well lay on the table that she works alongside every single day at Milward Funeral Directors, in the storied embalming room that she considers sacred. Perhaps somewhere beneath her in the entry hall, the finches will be singing.

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