A study published recently in JAMA Network highlights the need for improved pediatric advanced care for adolescents with terminal cancer. The research reveals a gap in understanding between parents and children when initiating and discussing critical conversations about end-of-life decisions.
“Advance care planning interventions are needed to improve families’ awareness and understanding of their teens’ end-of-life choices,” says principal investigator Maureen E. Lyon, Ph.D., a Children’s National Hospital clinical psychologist.
“Teens need to have a voice in their care and families are eager to know what their teens want, but those conversations can be difficult,” says Dr. Lyon. “Advance care planning interventions for parents and adolescents create a space where they can ask questions and be honest with each other.”
While families with adolescents with cancer are often spinning with the daily struggle of life, the authors say that clinicians presume that families understand adolescents’ treatment preferences for end-of-life care – and this can cause miscommunications. As has been seen not only in the pediatric setting, a lack of advance care planning is associated with increased hospitalization, poor quality of life, and legal actions.
The study involved a survey of 80 adolescent-family dyads (160 participants) from four tertiary care U.S. pediatric hospitals. From July 16, 2016, to April 30, 2019, the families were exposed to Family-Centered Pediatric Advance Care Planning for Teens With Cancer intervention sessions.
The results showed that family members’ understanding of their adolescent’s beliefs about the best time talk about end-of-life decisions was poor, with 86% of adolescents desiring an early conversation on the topic (before getting sick, while healthy, when first diagnosed, when first sick from a life-threatening illness, or all of the above), but with only 39% of families understanding this. This was particularly when it came to the topics of dying a natural death and being off life-support machines. Nevertheless, families’ did seem to have an excellent understanding of what was important to their adolescents in regards to wanting honest answers from their physician and understanding treatment choices.
The findings from the study can be found here in the article “Congruence Gaps Between Adolescents With Cancer and Their Families Regarding Values, Goals, and Beliefs About End-of-Life Care.”
Visitors are typically restricted, which means that family members of some coronavirus patients are prohibited from being with them in their last days, unable to touch or hold their loved ones. This scenario is only expected to get worse. According to the Institute for Health Metrics at the University of Washington, as many as 82,000 people in the United States could die from the contagion, while other models show up to 125,000 people. Many health facilities—from traditional hospitals to makeshift alternative care sites—will have to decide how best to provide dignified end-of-life care to COVID-19 patients and their loved ones.
The two of us have collectively worked in healthcare architecture and research for more than 30 years and have worked nationally and internationally on palliative care solutions in a variety of healthcare settings. We also both recently lost loved ones. We know firsthand how important compassionate end-of-life care is. Yet existing guidelines from Centers for Disease Control on alternative care sites—the very places many acute COVID-19 patients are dying—do little to address it. Here’s how traditional and nontraditional care spaces alike can create safe, comfortable end-of-life experiences, even when resources are stretched thin.
A comfortable environment
Support privacy
Having a degree of privacy is crucial so that each patient can say goodbye to loved ones or have religious rites. This can be done in-person or, more likely these days, virtually. (Some facilities do allow a visitor for end-of-life cases, with the provision that visitors wear personal protective equipment.) Normally, patients get a private room, but many hospitals are overrun and simply don’t have the space. Instead, hospitals and makeshift medical facilities could provide a simple curtain or a divider between beds.
Family visits
Establishing protocols for visits is important, so patients and family alike know what to expect. Facilities should clearly communicate whether visitors are allowed in person or virtually, what visiting hours are, how many visitors are allowed, and what sort of screening they need to pass. There should also be clear direction around mementos or spiritual items that family may want to pass to their loved one: Are they allowed or not? How should they be handled?
Support two-way communication
If family members are not allowed to visit physically, care centers can support other ways loved ones can say last goodbyes, such as two-way video communication, or visual contact through a protective barrier, like a window.
Positive distraction
Personalized acoustics or comforting nature sounds can go a long way toward making a patient feel comfortable. Many of the makeshift hospitals that have been built to support COVID-19 patients are bare bones and don’t support elaborate sound systems. But headphones or bed speakers can work just as well. When patients are conscious, access to sunlight, nature, or images of nature can also be soothing.
Hospice caregivers
Dedicated hospice workers can manage the caring aspect of end-of-life care when resources across the system are under siege. Staff qualified to tend to very sick patients should remain in those designated areas.
How to create a safe environment
Building dignity into end-of-life care is only part of the solution. Care facilities also have an imperative to prevent spreading the virus further. Here are some key considerations.
Medication access
Narcotic drugs should be securely stored but located so caregivers can reach them easily. The medication may be placed in a locked cabinet at a designated staff workstation near patient care areas, for instance.
Dedicated entry
For facilities that allow family members to say their final goodbyes in person, providing a dedicated entry to the space can reduce the chance of transmission. Mobile handwashing stations can also be provided throughout the facility. Donning and doffing zones should be established for any staff and family members entering or exiting the facility.
Staff accommodations
Dedicated toilet rooms and respite areas can be provided for healthcare workers. The death of a patient can be difficult for even the most experienced caregivers and they, too, need space to process their pain.
Back-of-house access
When patients die, they should be removed discreetly from the facility, through a separate exit. This is not only to preserve their dignity and avoid frightening visitors and other patients. It’s the safest approach to prevent spreading the coronavirus.
None of these are new ideas in healthcare design, but as hospitals rush to treat legions of new COVID 19 patients, they have to embrace the reality that many patients will succumb to the virus and their families will suffer. There are ways to help ease that suffering in a compassionate way.
Notwithstanding some poignant and passionate speeches by particular individuals (notably New York Governor Andrew Cuomo), much of the discourse has focused on the economic, political and policy division, rather than grief for the victims.
This broadly sanguine response might be due to perceptions that it is mostly older people dying from coronavirus, although experts warn younger people can die too. Witness the relief at new reports that children under 10 have not accounted for a single transmission of the virus. The deaths of older people have been comparatively discounted, not the least because many were socially isolated even before the pandemic.
The Greeks of antiquity reflected on the death of the young and the old in some very creative mythical narratives. Greek myth reflects on and reminds us of some of the less attractive characteristics of human life and society, such as sickness, old age, death and war. In the ancient Greek world this made it harder to put old age and death into a corner and forget about it, which we tend to do.
Choosing when
Achilles, the hero of Homer’s Iliad, actually has a choice in the timing of his life and death.
He can have a long life without heroic glory, back on the farm, or he can have a short life with undying fame and renown from his fighting at Troy. The fact that he chooses the latter makes him different from ordinary people like us.
Achilles’ heroism is fundamentally linked to his own personal choice of an early death. But it also means his desperate mother, the goddess Thetis, will have to mourn him eternally after seeing him for such a short time in life. Such is the pain for the loss of a child in war.
A play by the master Athenian dramatist Euripides is even more focused on young and old death. The play Alcestis was produced in Athens in 438 BC, making it the earliest surviving Euripidean play (about ten years before the plague at Athens).
In the play, the king of Thessaly – an appallingly self-interested person called Admetus – has previously done the god Apollo a favour, and so Apollo does Admetus a favour in return. He arranges for him to extend his life and avoid death in the short term, if he can find someone to take his place and die in his stead.
Admetus immediately asks his father or mother to die for him, based on the assumption that they are old and will presumably die soon anyway. But the father, Pheres, and his wife turn down Admetus, and so he has to prevail on his own wife, Alcestis, to die for him, which she agrees to do.
The story of the play is based around the day of her death and descent to the Underworld, with some rather comic twists and turns along the way. Death (Greek Thanatos) is a character in the play, and he is delighted to have a young victim, in Alcestis, rather than an old one. “They who die young yield me a greater prize,” he says.
The light of day
There is a particularly spiteful encounter between Admetus and his father on the subject of young and old death:
Admetus:
Yet it would have been a beautiful deed for you to die for your son, and short indeed was the time left for you to live. My wife and I would have lived out our lives, and I should not now be here alone lamenting my misery.
Father:
I indeed begot you, and bred you up to be lord of this land, but I am not bound to die for you. It is not a law of our ancestors or of Hellas that fathers should die for their children! … You love to look upon the light of day – do you think your father hates it? I tell myself that we are a long time underground and that life is short, but sweet.
The Alcestis of Euripides, and other Greek myths, remind us, should we ever forget, that love of looking upon the light of day is a characteristic of human existence, both for the young and the very old.
Cheryl Goldman of Valley Stream, N.Y., has emphysema and relies on supplemental oxygen. She told her son that if she contracted Covid-19 and needed a ventilator that she would refuse treatment.
Sobering statistics for older patients sharpen the need to draw up advanced directives for treatment and share them with their families.
Earlier this month, Cheryl Goldman, a retired high school teacher living on Long Island, called her son, Edo Banach, in Maryland. It seemed a routine chat until Ms. Goldman announced that if she became ill with Covid-19, she would decline a ventilator.
“I’m her health care proxy,” said Mr. Banach, who happens to be the president of the National Hospice and Palliative Care Organization. “Her perspective was, what’s the point? In all likelihood it’s not going to help, and she’d be taking a vent away from someone else.”
At 69, Ms. Goldman has emphysema and already relies on supplemental oxygen. She told me that she’d been following the news, including the grim statistics for older adults with chronic illnesses who require ventilators during extended stays in intensive care.
In such cases, “the number who leave the hospital is low, and it’s lower for someone with health problems like me,” she said. She also feared being separated from her family during a hospitalization and wanted, instead, to remain at home with hospice care. “It’s a pragmatic decision.”
Mr. Banach, leading the response of about a thousand hospices nationwide that are facing heightened demand and bracing for worse, appreciated her forthrightness. “It’s the kind of conversation everyone should be having with their loved ones,” he said.
In the best of times, it can be tough to get Americans to discuss and document their end-of-life wishes. Depending on the study, a third to two-thirds of adults haven’t drafted advance directives, the documents that outline which medical treatments they would accept or refuse and designate a decision maker to act on their behalf if they’re incapacitated.
“People think, I’ll deal with it in the future,” Mr. Banach said. But for thousands of older adults, the future may have arrived.
To date, there’s no clear evidence that older people are more apt to contract the new coronavirus, said Dr. Douglas White, a critical care specialist and the director of the Program on Ethics and Decision Making at the University of Pittsburgh School of Medicine.
“What we do know is that older individuals are more likely to experience very severe disease if they do become infected,” he said. “The data are sobering.”
That’s partly because most older adults have chronic conditions — heart or lung disease, diabetes, high blood pressure — known to intensify the virus’s effects. And they have less physiologic reserve — “less ability to rebound from an overwhelming illness,” Dr. White explained.
When seniors and their families engage in what’s called advance-care planning, they often focus on the D.N.R. question — whether patients would want to be resuscitated after cardiac arrest.
But because Covid-19 is a respiratory disease, the more pressing question will likely be whether a hospitalized patient who’s seriously ill will accept intubation and ventilation.
That initially involves a tube inserted down the throat, connected to a ventilator that pushes air into the lungs. When a patient has spent two weeks on a vent, doctors commonly perform a tracheostomy, creating a surgical opening in the windpipe that replaces the swallowed tube.
Long before the virus erupted, among people over 66 who spent 14 days in an I.C.U. on a ventilator, 40 percent died within a year of discharge. Now, “those numbers are too rosy for Covid,” Dr. White said, citing findings from Italy and Britain, where more than half of older patients on prolonged ventilation died.
A just-published JAMA article looked at coronavirus patients admitted to Northwell Health hospitals in and around New York City. Excluding those still hospitalized after the monthlong study, the mortality rate among patients over age 65 exceeded 26 percent, and almost all patients over 65 who needed mechanical ventilation during that period died.
That data can prompt frank exchanges. “If a patient is elderly and has significant medical issues, I’ll explain that a large proportion of people who become ill with Covid-19 and need a ventilator unfortunately will not survive,” said Dr. Kosha Thakore, the director of palliative care at Newton-Wellesley Hospital in Massachusetts.
Moreover, longevity is not the only priority, and sometimes not the primary one, for older people considering medical options. What will life look like if they do survive?
“After elderly people have been on a ventilator, they’ve often already developed physical debilitation, difficulty swallowing, bedsores,” Dr. Thakore explained. They frequently cycle in and out of hospitals with complications. Their deficits can be physical or cognitive or both, and are often permanent.
Even pre-Covid, after 14 days on a ventilator in an I.C.U., only about one in five older discharged patients went home. “The others end up in nursing homes,” Mr. Banach said. “Some may later go home, and some will die in the nursing home.”
Though older adults with Covid-19 may not require hospitalization or ventilation, the decisions they face if they do highlight the importance of reviewing advance directives.
A new study in JAMA Internal Medicine questioned 180 patients over age 60 with serious illnesses; most said they would trade a year of life if that meant they could avoid dying in an I.C.U. on life support.
But that kind of aggressive care is exactly what they might receive. “If you don’t let the system know your wishes, the system takes over,” Mr. Banach pointed out. Family members can feel lingering trauma if they’re forced to make life-or-death decisions for loved ones who never discussed what they wanted.
“Many older patients we’ve encountered with Covid-19 have opted not to undergo ventilation and an I.C.U.,” Dr. White said. “No one should impose that on a patient, though if there’s true scarcity, that may arise. But patients might choose it for themselves.”
If older people have paperwork stashed in a drawer or safe, now is the time to unearth it and see if their instructions still reflect their values. If so, scan the document and send it to family members and doctors, Mr. Banach advised.
But for those who never got around to drawing up advance directives, appointing a decision maker — and telling that person what’s acceptable and what’s not — is ultimately more crucial. In emergencies, doctors probably won’t flip through documents to learn patients’ wishes; they’ll ask family or friends.
Mr. Banach’s counsel: “Take out your phone and do a video selfie: ‘This is who I am. This is the date. This is what I want.’ Send it to your friends and relatives. That’s enough.”
Many hospitals and health systems have developed workarounds when documents require signatures or witnesses; some are also doing palliative-care visits via telemedicine.
Dr. Gregg VandeKieft, a palliative care specialist with Providence Health on the West Coast, recently spent half an hour on Zoom talking with a patient’s sons about her end-of-life care. Dr. VandeKieft and a nurse were in Olympia, Wash.; one son was in Alaska and two elsewhere in Washington. “It felt not all that different than if we’d been in the same room,” Dr. VandeKieft said.
The coronavirus pandemic may spur more such conversations. In Los Angeles recently, Brie Loskota and her husband contacted close family friends, a couple in their 70s, asking about their well-being, offering to FaceTime, and then inquired: “If you got sick, is there anything we should know?”
The older couple, one of whom has a neurodegenerative disease and has already experienced mechanical ventilation, responded that they both wanted to avoid hospitalization and to die at home.
“It was a relief to be told,” said Ms. Loskota. “It’s not less heartbreaking, but it lets us make a decision with them in mind. It led my husband and me to talk about it for ourselves.” They’re in their 40s and have not yet drafted advance directives.
About a month before the coronavirus pandemic engulfed us, my mother understood that she was dying. She had cancer. She had struggled to swallow food and maintain her weight. She was so light that I could lift her like a 12-year-old. On her firm instructions, the ambulance we children had arranged to take her to the oncologist was rerouted to a hospice. There, she received tender and expert end-of-life care. After four days, she died: peacefully, without pain, and with her family around her.
Today, this memory feels weirdly distant. In Italy and Spain — and soon in other countries — patients are dying in opposite conditions to the ones my mother experienced. They go to hospitals hoping for treatment. But, for lack of ventilators, some of them die gradually, alone. Visits from loved ones are often prohibited.
The flood of commentary on the pandemic focuses, correctly, on how to reduce fatalities. But we should also consider how to ease the loneliness and pain of those deaths that are inevitable. No one wants to die slowly in a medical hangar, cut off from family and friends. Rather, most want something as close as possible to what my mother had. They want to choose their own balance between prolonged life and prolonged pain. They hope to have the right to reconsider their choices.
Of course, in the current crisis, the hospices cannot serve everybody, and infectious disease presents risks to caregivers that cancer does not. The imperative is, therefore, to give people the tools to manage death at home, as humanely and safely as possible. Yet this component of our response to the pandemic is missing. We have not grappled with the need to distribute morphine to those who are suffering, even if this is a risky course, as the opioid crisis makes obvious; once we have finally supplied our medical professionals with the masks and other protective gear they need, we need to do the same for family caregivers. But we do not discuss these things, because we are determined to resist death, not dwell on the question of how we might go about dying.
My mother’s last lesson to her children was that this obstinacy is mistaken. While I was vainly learning all I could about her treatment options, she was coming to terms with the reality she could feel around her liver. “No more abracadabra,” she told me fiercely, when I protested that it was too early to give up. She knew she would soon die, and she wanted a good death.
A good death requires lucidity, not magical thinking. Today, this means confronting the reality of overloaded hospitals, and being honest about their inability to help all those who are stricken. In Italy, doctors have had to perform a kind of triage normally seen in wartime: They allocate life-saving ventilators based on age and health status. The same has happened in Madrid, where hundreds queue to be admitted to emergency rooms. Countries such as the United States and Britain will be lucky to escape this fate. New York’s governor, Andrew M. Cuomo, has repeatedly sounded the alarm about the shortage of ventilators. “You’re going to be thousands short. Thousands,” he said on March 15.
Hospitals don’t like to talk about the terms of the triage. Like the rest of us, they prefer to focus on preventing death; they recoil from being explicit about when death might have to be accepted. As a recent article in the New England Journal of Medicine noted, the absence of clear guidelines burdens front-line clinicians, who are forced to make heart-rending choices — doctors in Italy have wept under the pressure. But the absence of clear guidelines also leaves citizens adrift. If you or I fall seriously ill, will we have access to a ventilator?
Last week, two medically connected relatives called me. Being well informed and 70, they both know they fall on the wrong side of any triage. They have therefore resolved that, if their lungs begin to fail, they will avoid going to the hospital. At 70 — even in their 80s — patients still have a good chance of surviving covid-19 at home. But if they do not, my relatives’ definition of a good death is to be together at the end, even at the risk that one will infect the other. All that they ask is access to the palliative drugs that will control the suffering.
Society should think about the millions of people who are not medical insiders, and who should be helped to understand the choices that may potentially confront them. No doubt if governments and hospitals made public their criteria for triage, people would be horrified. But at least they could decide whether to seek help at a hospital or remain in their own beds. And the medical authorities, having leveled with the citizens, could be more forthcoming about the help available at home. To anyone who has witnessed death, it would be a huge relief to know that at least the pain can be managed. Death will be inevitable for each of us, one day. Terrible suffering should not be.
My father, Mel Lipman, died one year ago today on his own terms. He signed himself into hospice, stopped artificial nutrition, and died peacefully with the aid of pain-killing medication.
As a humanist, I appreciate straightforward language regarding death. I don’t consider my father to have “passed away,” and I certainly don’t think he’s in a better place. Although I suppose MedCure, an organization that supports medical science and the place my dad’s body was sent, could be considered a better place than fighting pain in the hospital. That said, I appreciated everyone’s well-wishes.
The sympathy cards showed a wonderful understanding of me, my family, and my father. Everyone who sent them had chosen exactly what applied to us—no talk of heaven or other theistic concepts. Instead, the focus was on the legacy and memories that my father left for us all. Notes recalled wonderful memories of specific times with Dad and appreciation of all he had done for the community. I’m grateful for those notes, as well as the wonderful longer letter I received from Dad’s colleague in the Humanist Foundation, which I read to him during his final days.
If you had asked me (before it happened) what I would need most when my parents died, I would have said the companionship of my friends. But what I really needed was time alone with my parents’ “stuff” (including paperwork), time off from work to handle necessary paperwork, and time with my immediate family (my spouse, my brother, and my brother’s family).
If you want to help a friend whose loved one has died, it’s fine to say, “Let me know what I can do.” However, suggesting specific things you might be able to do is even more helpful. Taking into consideration restrictions imposed by the current coronavirus pandemic, you can offer advice or assistance with:
Burial/cremation/funeral arrangements
Childcare
Rides to appointments
Laundry pick-up and other errands
Meals at your home/their home/take-out from restaurants
Grocery shopping
Add to the list whatever you think your friend might need that you can do. If you’re wrong, no harm is done in offering assistance.
As I mentioned, I received many wonderful emails, calls, cards, and letters of condolence. Below is an example of the kinds of emails that I found to be helpful when my father died.
Date: March 2019 Email Subject: So Sorry to Hear of Mel’s Death
Dear Lori,
I was so sorry to hear that your dad died. He gave so much to us in his activism, his warmth, his humor and his friendship. Please DO NOT FEEL THE NEED TO REPLY TO THIS EMAIL; I know you have a lot on your plate right now with all the details that need to be handled following a death.
If I can help you in any way, please let me know. Here are some things I think I could do well that might help:
I can notify everyone at the local interfaith group.
If Mel left his tax documents and you trust me with such, I can help with his tax filings.
I can help go through Mel’s belongings and can bring anything you want donated to his favorite charity.
I can listen if you want to call/skype/visit/meet for coffee to share memories of Mel, how you are coping, or anything else you want to talk about.
These are just a few things I can think of that I could do, but if you think of anything else you need me for, just let me know.
With deepest friendship…
Emails like this made my life less stressful during a trying time. It left me free to read and then move on. Although I did not mind responding to condolence notes, I mainly wanted to focus my time on going through my father’s documents before I had to return to the East Coast.
I did take advantage of some offers of assistance. Bullet number one in the above email was quite helpful. It would have been burdensome to wonder whether I had left out any individual who needed or wanted the information, but even more burdensome to try to contact them all. Another item on the list that I took advantage of was that I had someone else help me with Dad’s taxes.
I greatly appreciated an offer to take Mel’s many mementos and writing and place them in an appropriate setting. I was about to ship to my small condo a large trophy that had been awarded to my father by the Humanist Foundation (of which he was a trustee and treasurer). At my condo, it would hardly ever be seen by anyone other than me and my spouse. Then I received a sensitively worded query from the American Humanist Association about whether I would be keeping it. I was asked if I would consider making it available to the AHA headquarters in Washington, DC, where it could be displayed. I thought that was a perfect place for the award. I also received an offer to send my father’s humanist papers to the Meadville Lombard Humanist Library in Chicago. The papers are now there.
However your friends handle the death of their beloveds, please remember that whether they reach out to you or not, it is simply important that you’re available to them. Your job as a friend is to be kind and compassionate in allowing them to do what they need to do.
A note on Mel’s last days:
The folks at hospice assured me that even after he seemed to be less aware and more asleep as the medication took its course, he could still hear me. I wasn’t certain if this was an accurate medical fact or something they said to make me feel better when I visited. But on one of his last days, Dad was furrowing his brow in discomfort. I sang to him, and I could see his whole face relax. I mention this, because it can be helpful to both you and your loved one to spend some time together even if one of you is less communicative than the other. (These days that time might have to be via computer or smart phone, but contact is still key.)
Finally, anyone who knew Mel, knew that he loved to play the dice game craps. He used to say: “A good death after a good life is like a long roll on the craps table. It has to end sometime.”
The future is unpredictable. The unexpected happens often and can have a major impact. Nevertheless, some thought of how the future might look is important in preparing for it. Scenarios are one way of doing this and were developed after the wholly unforeseen oil shock of 1974. Scenarios are not predictions of the future, but rather sketches of plausible futures with the limits of plausibility set wide. They are not what people would like to happen, but rather what might happen. They have been used to think about the future of South Africa after Apartheid, the NHS, and scientific publishing. They are in many ways devices for thinking about the present, recognising things that will be important whatever the future brings.
Elaborate methods can be used to produce scenarios, but there is value in simply shared imaginings. I have imagined here four scenarios of the future of death and dying. Famously, the future is already here, but not evenly distributed, and that is true of these four scenarios.
“Immortality” and inequality
Medicine is successful with extending life but at great cost, increasing global inequality
Medical research uses genetics, big data, nanotechnology, artificial intelligence, and other methods to find ways to increase the length of life considerably. At the same private companies develop ways of “downloading brains” to allow some people to achieve “immortality.” These methods are extremely expensive, making them available to only a few. The very rich can access them and live much longer, while the poor, as now, have much shorter lives.
Climate response
The world and end of life care become much more equal
The climate crisis causes people to recognise our global interdependence and the rich to accept reducing their carbon consumption and access to expensive health care. Resources—financial and health care workers—shift from rich to poorer countries. The world becomes more equal, and the minimum package of palliative care described by the Lancet Commission on Palliative Care and Pain Relief becomes available to all while end of life care in rich countries becomes less technical and more human.
Rebalancing
Families and communities become more important and health care simply supportive in managing dying and death
A growing number of people become unhappy with the increasing medicalisation of end of life care and the lack of meaning around death and dying. They take back control from the health establishment, change laws, set the agenda, and run end of life programmes. These developments are an extension of programmes—like that in Kerala and Compassionate Neighbours, Communities, and Cities—that have developed to increase the capacity of families, communities, and volunteers to manage death and dying. Health care remains important but plays a supportive role.
Assisted dying spreads
Assisted dying becomes a component of universal health care
Assisted dying spreads to all almost all high income countries and many low and middle income countries. It is available not only to those judged to be near the end of life but all those with unbearable suffering and those developing dementia. It is tightly regulated but provided by many health care professionals, including those working in palliative care. In most countries some 10% of people die this way, but the range is from 1% to 25%.
