The New Hampshire legislature is considering a bill to join our Maine and Vermont neighbors to allow New Hampshire residents with a terminal illness, in consultation with two medical providers, the option of ending their suffering and having a peaceful death. As a Licensed Independent Clinical Social Worker who has spent over four decades working to prevent suicide at the local, state, national and international level, I think it is time to look closely at the differences between the two, and stop referring to medical aid in dying as suicide.
Legally, in the 10 states and Washington D.C. where medical aid in dying is allowed, the death is not counted as a suicide death. Medical Examiners and Coroners list the underlying terminal illness, which the person was diagnosed with, as the cause of death on the death certificate of patients who utilize medical aid in dying.
People who die by suicide, for whatever reason, no longer wish to live and feel that they have no other option than death. The person who chooses medical aid in dying wants to live yet has been diagnosed with a terminal illness that will end their life, and may cause intense suffering before they die. They are fully informed of other options including palliative care, hospice, and comfort measures. This is not a decision they are allowed to take lightly or at the spur of the moment. It requires thoughtful controls and two medical opinions in support of specific terminal illness.
A high correlation exists between suicide and mental illness. The person who dies by suicide may or may not be rational, or even competent in that moment. Research shows that many suicide deaths are impulsive. Although the person may have contemplated suicide for some time, it may only be a matter of minutes between making the decision to die and then taking their life. By contrast, in medical aid in dying, people go through a formal process with two medical professionals that includes: an assessment of their mental capability, a determination about their terminal illness, an informed consent process including a review of available options, and a mandatory waiting period
People who die by suicide die alone, and often die by violent means. In New Hampshire, over 75% of suicides involve firearms or hanging. Nationally, over 75% of suicide deaths occur in a home or primary residence. These violent deaths result in trauma for their loved ones who return home to find their loved one dead. The scene, shock, and aftermath are so distressing that many people are no longer able to continue to live in their homes. Suicide deaths can also be traumatizing and contribute to PTSD in first responders who are called to the scene.
Family, friends, and loved ones of a person who dies by suicide can experience intense emotions including shock, guilt, anger, shame, regret, and despair as they try to come to terms with the suddenness of the death, and make sense of the often-unanswerable question: “why?” People who are bereaved by suicide may experience suicidal thoughts and are statistically at higher risk themselves for suicide. Suicide deaths are often devasting and life altering for family and friends resulting in a long and complicated grief process that may last years. It is said the person who dies by suicide dies a single death, but their family/friends are left to die a thousand deaths.
By contrast, the person who goes through the medical aid in dying process, frequently includes loved ones in their decision. Most die in their home, surrounded by their family and friends. The death is planned, and peaceful. Family and friends are left at peace knowing that this was their choice and their suffering is over. To be clear, this does not stop those close people from grieving the death, but it eliminates the “whys” and “what ifs” as well as the trauma from a sudden suicide.
Despite our best efforts, there is still considerable shame and stigma associated with, and experienced by family and friends after a suicide. We should be careful not to contribute to that stigma by extending it to medical aid in dying. Whether you support or are opposed to medical aid in dying, we should acknowledge there are significant differences between the two, and we should stop labeling medical aid in dying as suicide.
– A palliative care specialist’s practical guide to life’s end
Even people who are comfortable discussing death – including the inevitable prospect of their own – might understand little about how it actually tends to unfold unless they’ve experienced it firsthand alongside a loved one. In this brief animation, author Kathryn Mannix, who worked as a palliative care physician for 20 years, offers viewers a sensitive, honest and practical guide to how death tends to progress under normal, or perhaps ideal, circumstances. Pairing her narration with gentle, flowing animations, the UK filmmaker Emily Downe’s short makes a powerful case that there’s deep value in discussing and understanding death well before it touches us.
— How living funerals are changing the way we deal with death
I watched my own dad die when I was 25, and it made me realise how awkward people get around the subject. I wanted to see if living funerals – both those for the terminally ill and those who are not – are opening up how we talk about death.
I am lying in a coffin, the lid gently placed on top. A warm light filters through the woven fibres, as a meditation chant reverberates around the room.
“Welcome to your funeral,” death doula Emily Cross said, moments earlier.
A photograph of me and my husband sits between two flickering candles, with confetti from our wedding scattered in front of the frame. I wriggle, trying to relax but coffins, it turns out, aren’t designed for comfort.
Meditating on my own death isn’t how I spend most Tuesday evenings. But like many who seek out Emily’s services, I am intrigued by the idea of confronting my own mortality.
“Everyone comes with a different reason,” Emily, 35, says when I ask her about the kind of people who usually attend. Sometimes they are dying, sometimes they are just curious about the service.
I watched my own dad die when I was 25, and it made me realise how awkward people get around the subject. I wanted to see if living funerals – both those for the terminally ill and those who are not – are opening up how we talk about death.
Dad’s funeral was beautiful and cathartic – 500 people packed out a church to celebrate him. I remember wishing he had been there to see how deeply loved he was.
Emily’s living funeral is a more solitary affair, and you don’t need to be dying to do it. To start, she plays haunting music and asks participants to look at a photo of themselves, imagining they are dead. Then they are asked to visualise their bodies shutting down before being “brought back to life” in a coffin.
I only go through part of the ceremony but it’s enough to bring up a raft of emotions. Lying inside the cosy coffin, I remember how shocked I felt seeing Dad in his – that such a larger-than-life figure could fit into such a small space. It’s a relief when the lid is lifted, the room comes back into view and Emily helps me stand.
Death doula Emily Cross
Earlier this year, Kris Hallenga – one of the founders of breast cancer charity CoppaFeel who shares her own cancer journey with her 145,000 Instagram followers – threw herself, what she called, a FUNeral.
Kris sent out invitations shaped like coffins. Inside each was a test tube of tequila and a letter explaining her intention.
Guests were invited to sign a cardboard replica of her coffin and childhood footage was projected around Truro Cathedral in Cornwall. Dawn French did the eulogy in character as the Vicar of Dibley, while Kris gave a speech and sparkled in a glittery jumpsuit.
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For Robert Hale, he decided to hold his own living funeral when he found out he had just months to live. When the 33-year-old aerospace engineer was told by doctors that his leukaemia was terminal, he decided to organise a “happy send-off commemorating my life”.
“The doctors were honest,” he said, his dogs curled up on the sofa next to him. “They said straight from the start, I didn’t have a good prognosis.”
With the support of his parents, he arranged to hold his living funeral at a farm park near his home in Gloucestershire.
“I used to go there as a child for the parties and thought it would be a good place,” he said.
Rob Hale
He was surprised when hundreds of friends and family turned up on the day. At one point, he snuck off to take on what he calls the “death slide” – despite being fitted with a catheter – only to be greeted by 50 people cheering him on at the bottom of the steep drop.
“It was overwhelming,” he said. “I had friends that I hadn’t seen for years. I’d always told myself that I would catch up with them next year, because I thought I had plenty of time.”
Now, he says he can “go without leaving anything unsaid”.
Rob didn’t flinch when he talked about his own death and shared candid accounts of his final year on Instagram. He said he wanted to be honest about what was ahead of him.
“The closer I get to the end, the more important those things become because other people are facing it,” he said.
Rob died three weeks after we spoke – but his parents, Caron and Nigel, told me they wanted his story to be told.
Caron and Nigel Hale
End-of-life ceremonies are nothing new – in some cultures, they have been around for hundreds, or even thousands, of years. But their exact roots are difficult to track.
Before a member’s death, the Native American tribe the Lakota Sioux of South Dakota repair relationships, make amends, and distribute family heirlooms. A similar tradition became popular in Japan in the 1990s as the older generation sought to remove the financial burden of funerals from their children.
In 2019, the Hyowon Healing Centre in South Korea began offering free-living funerals to the public as a way of tackling high suicide rates in the country, which in 2016, was almost double the global average.
Participants, who were usually completely healthy, would undergo a meditation, often while in a coffin or under a shroud, and come face to face with their own mortality and the realities of death.
Death doula Emily says she was inspired by these Eastern practices. Situated in a Dorset village, her Steady Waves Centre is something of an anomaly on this quiet, rural high street. Originally from the US, she says she suspects residents sometimes wonder “what that weird American girl is up to”.
“There’s a [fishing] shop next door, and people just walk in here by accident thinking it’s a tackle shop,” she says, laughing. “I’ll say something like, this isn’t a tackle shop, but do you want to come lay in a coffin?”
So far, no one has taken her up on that offer, she says.
Rachel Bass, a Pagan celebrant, has planned plenty of funerals – including her own.
“I was born with a serious heart condition, so I’ve always been aware of my own mortality,” the 47-year-old says.
Rachel has had several major surgeries for her condition, tetralogy of Fallot, and doctors have always been very clear with her that she is unlikely to “make it to old age”. During the COVID lockdown, her health declined dramatically and she made contact with a hospice to begin planning her end of life – but emergency heart surgery bought her some more time.
But it made her realise if she organised – and attended – her own living funeral, there would be less of a burden on her family.
Rachel Bass
“In the last few years, other problems have arisen,” she says, referring to scarring she has suffered on her liver. “It’s made me more conscious of [death] because I’m only going to go one way.”
Rachel also lost her mum at the age of 24. “For me, it is about accepting that I will not make old bones,” she says.
While we talk, Rachel lightens the mood with laughter, but she does admit that the idea of leaving her 21-year-old son behind makes her emotional. “All I care about is my son, who still relies on me,” she says.
While she doesn’t feel the need to set a date for her living funeral, she has started to plan it. It will be held in the town where she grew up and will feature karaoke and a 1970s-style buffet.
“I’d like to give away my jewellery and certain books at that point too, so I know everything has gone to the right people,” she says.
Jane Murray, who manages bereavement support at the Marie Curie hospice in the West Midlands, tells me living funerals are “definitely becoming more popular”.
She says patients often become frustrated planning traditional funerals: “People think – it’s going to be such a good time and I’m not going to be there. That leads to have you ever thought about having it beforehand?”
Kris Hallenga was supported with her FUNeral by Legacy of Lives, a social enterprise that helps with funeral planning.
“We hope it will encourage more people to be open about death and what they want after they die,” says the charity’s chief executive, Rebecca Peach.
Rebecca Peach from Legacy of Lives said how we talk about death is changing
Data from Legacy of Lives found that less than 1% of people surveyed knew the funeral wishes of their loved ones, which Rebecca says can cause trauma, especially in the case of sudden death.
“I hate when I go see families and they don’t know what that person wanted. That’s tough on them at a traumatic time,” says Rachel, explaining why she has been so explicit in her funeral planning.
A party to plan your own death isn’t everyone’s idea of a good time, but after James Barrett’s dad died of lung cancer during COVID, he realised how important it was to know a person’s wishes.
ames hosted a ‘death party’ with his mum and her sisters. Pic: My Goodbyes
He developed the My Goodbyes app to help people plan, and host, their own death parties.
His mother was initially reluctant but agreed to participate. The party they hosted with her sisters ended up lasting two hours.
“They were arguing over which song they wanted, saying, you can’t have that, that’s my song,” James says, laughing.
Pic: My Goodbyes
I empathised with James – losing dad was the most difficult experience of my life, and he only opened up about his own funeral in the weeks before. There was a constant fear of doing something he didn’t want before I ultimately realised there were no wrong choices when it came to planning his funeral.
While stepping into a coffin sounds like an odd form of therapy, I found it cathartic. My mind wandered from the profound: would I be as open as Rob and Rachel about my own death if I knew it was coming? To the mundane: would my husband remember to de-flea the cats when I was gone?
I’ve spent weeks immersed in discussions of death but I have never felt more alive. Because it was Rob, and his courage and strength, that left me with the most to think about.
Rob Hale<
"Death shouldn't be something you hide from," he told me.
"Everyone goes through it. We are all going to die at some point. I think we need to be more open about it and embrace life rather than focusing on death."
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In 2020, in the midst of a worldwide pandemic, my 85-year-old father suffered a heart attack in Pittsburgh and was rushed to the hospital.
The stent, a minorly invasive procedure, was the easy part.
But the two days he spent in UMPC’s state-of-the-art ICU were a nightmare. The anesthesia made him groggy and aggressive. The sleep meds made him perversely restless and short of breath. The IV he constantly fiddled with, once even ripping it out, much to our horror.
Instead of restraining him, which I imagine to be a cruel and unusual punishment for an Alzheimer’s patient, the ICU staff let me stay with him overnight (a massive kindness made greater by the strict Covid protocols of that time). This way, I could keep him from wandering, from pulling out the IV, from being confused about where and why and what. Every two minutes—I timed it, and it was comically on the clock—I explained and comforted and explained again. By midnight, I thought I would go mad with worry and exhaustion. By 3 a.m., I was seeing stars, my father and I afloat in an endless hallucinatory universe of the now. By 6 a.m., we were both catatonic.
After he came home, my father was in a bad state. Physically he was fine, if a bit unsteady, but emotionally, he was depressed, anxious, raging, unresponsive. His appetite was out of control and he raided the fridge at all hours. He barely slept, wandering the house like a ghost of himself. It took almost three months for him to return to his ‘normal’—another immense gift from the universe, as medical crises often spell inexorable decline for the elderly.
A year later, the doctors discovered a giant (painless) aneurysm in his stomach, which could rupture and kill him “at any moment”.
Operating would mean a five-inch incision, at least five days in the ICU and up to a year to recover fully (if at all). For someone with dementia, major surgery also seemed a cruel and unusual punishment. From New York to Philadelphia to Pittsburgh, my siblings, my mother and I met over video chat to discuss at length. We made the difficult decision to let the aneurysm be, to keep my father comfortable and at home.
Initially, my mother felt tortured. Were we giving up on my father? Was she abdicating her responsibility?
These are questions that modern medicine is not always fully equipped to answer.
Doctors (especially surgeons) are often focused on finding and fixing the physical problem. But Alzheimer’s is a uniquely mental condition and it forced us to consider my father’s health and well-being on more than just the physical front. We wanted to prioritise his dignity, his comfort, his pain-free state: namely, his overall quality of life.
Days later, the doctors told us that the aneurysm was actually inoperable because of its position in his body. Moreover, there were two rogue blood clots that, if disturbed, could travel to the brain and kill him instantly. Our decision had been the right one, not just mentally but also medically.
Our family made another big decision at this time: we would not take my father to the hospital anymore—instead we would start palliative care.
I have been recommending Atul Gawande’s brilliant book Being Mortal to everyone since I read it five years ago. It lays out the case for palliative medicine (a.k.a. hospice care) in compelling detail. Instead of trying to prolong life, palliative care prioritises a patient’s physical and mental well-being and focuses on pain management. Not only does this kind of care drastically reduce the chances of family members developing major depressive disorder, but the patient outcomes are astonishing:
Those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives—and they lived 25% longer. If end-of-life discussions were an experimental drug, the FDA would approve it.
Atul Gawande, in his book ‘Being Mortal’
In February 2023, my parents moved to Dhaka after 54 years abroad (in Libya, Nigeria and the States), abandoning the isolating, exorbitant, often neglectful care networks of America for the familial support and affordable at-home caregiving of Bangladesh. We were privileged to have this option, to have extended family so loving and helpful, to have enough money to pay rent and hire multiple caregivers.
For my mother, who had been my father’s full-time caregiver for over a decade, it was a new lease on life, letting her visit childhood friends, walk in Ramna Park every morning, get a full night’s sleep. We were additionally lucky that over 10 months, we did not have to see a doctor because my father’s occasional tummy upsets and falls did not result in serious illness or injury.
In December 2023, my mother left for the US for five weeks to visit my sister and her three children and to hold her newest month-old grandchild (my brother’s first child) in her arms. It would be the first time in more than a decade that she would leave my father for more than a few days, and she agreed to this vacation only because I had taken an extended break from my life in New York to be in Dhaka while she was away.
Three days after she landed in Pennsylvania, my father suffered his first medical crisis in over a year: a distended belly and extreme stomach pain.
I immediately called my cousins who live down the street. Two of them brought over their mother’s doctor, a young generalist who worked in the ICU of the hospital around the corner from us in Bonosri. Seeing my father’s taut and grossly swollen stomach, the doctor advised urgent hospitalisation. Thus started a gruelling, repetitive, exhausting conversation about palliative care, all while my father cried out in pain from the bedroom.
Despite several palliative and hospice centres in Dhaka, the concept seems unknown to many Bangladeshis, perhaps even heartless.
Neither of my cousins could sleep that night after hearing my father’s cries. I explained why we had decided against hospitalisation, against X-rays, ultrasounds and blood tests, against antibiotics and IV-administered fluids. I predicted that the hospital would likely have to restrain or sedate him or both. I said that even if we eased his physical state, mentally he would be traumatised.
This resistance to palliative care is not uniquely Bangladeshi. Families across the world are torn apart because family members have different ideas on how to best take care of a loved one. Too often, no one has asked the patient their preferences about resuscitation, intubation, mechanical ventilation, antibiotics and intravenous feeding. Too often, it’s too late to ask by the time these medical interventions come into play.
The doctor finally offered pain and gastric medicine via intravenous injections. One bruised wrist later, my father was more comfortable. Over the next 24 hours, he had two more injections, but by the third one, the pain meds were no longer working.
At 2 a.m. on a cool Dhaka winter night, we levelled up, the doctor generously taking time off his night shift to come to our house with a nurse and administer an opioid that eased the pain for another day and half.
By Christmas, or Boro Din as they call it in Bangladesh, I had defended palliative care more than half a dozen times to my relatives, each one aghast at how my father could suffer so, without my helping, i.e., hospitalising him.
This then was my struggle: to remember I was not there to fix anything, but to ensure that he remain in familiar surroundings, in his sunny airy bedroom. That he not be in pain.
This too was my struggle: to get my extended family on board with palliative care.
The cousin who came to live with us in America when he was in high school and who idolised my parents. The cousin who asked me to bring my father’s nice shirts and blazers from Pittsburgh so he could wear them. Their sweet wives, my bhabis, and their lively loving children who visited my father almost every day. To hold back my kneejerk reactions:
Are they questioning my family’s judgement? Is this the patriarchy at work? Do they understand that it is no easier for me to see my father in pain?
My challenge was to set my defensiveness aside and try to infuse their love and concern with knowledge and perspective, so they could help me help my father spend his remaining days in comparative ease, rather than more aggressive medical treatment.
My last struggle was the hardest of all: The one that questioned the kind of life my father had been living these last few years.
Nine years after his Alzheimer’s diagnosis, he could not do a single thing that used to bring him pleasure: dressing nicely each morning, making himself breakfast while exclaiming over the newspaper headlines, reading history books and novels, writing fiction in Bangla, teaching geology in English, wandering the EkushayFebruary book fair, visiting his ancestral home in Barahipur, playing cards and watching action films, making his grandchildren collapse into giggles, walking on the deck at sunset with Amma, holding court with the Bangladeshi community in Pittsburgh, speaking to his two beloved remaining siblings, my Mujib-chacha and Hasina-fupu, delighting my mother with his quick-witted jokes.
If he could make no new memories and the only joys he had were fleeting—the chocolate chip cookies from Shumi’s Hotcakes, my mother’s smiling face, his caregivers’ tender ministrations—were these enough?
Was there some Zen-level lesson here on living in the moment?
And when these brief moments were interleaved with longer troubling periods of confusion, distress, rage and sadness… What then?
What about the endless hours spent restless and awake, his eyes lost and searching?
My father and I had had a fraught relationship my whole life.
Patriarchal and emotionally distant, he threw me out on several occasions, literally and figuratively. I didn’t speak to him for years at a time, and even reconciled, our exchanges were limited to politics, education and writing. He seemed uninterested in anyone’s emotional life, unable to engage in conflict without judgement and anger. His gifts of intellectual brilliance, iron-clad willpower and moon-shot ambitions did not make him an easy father—or easy husband, for that matter.
But now, none of that mattered. The only thing that did was my attempt to attend to him with kindness.
Linking his dementia-fueled rage to his life-long habitual rage would make the already difficult task of caregiving impossible. I had read enough studies that showed that caregivers died earlier because of their stress. It wasn’t hard to see the toll it had taken on my mother over the years. She had been hospitalised for rapid heartbeat issues twice last year and, despite a lifetime of healthy living, had developed high blood pressure to boot.
In his sleep-deprived, pain-addled state, my father didn’t always respond or recognise those around him. But one night, in a moment of lucidity, he reached for my hand and asked urgently, “Are you doing ok?”
“Yes Abbu,” I assured him, “I’m doing fine.”
And then he said—faint, incomplete, clear—“Take… your Amma.”
I said, “Of course I will.”
He was telling me what I’d always known, that despite everything, he had always looked out for my health and self-sufficiency, and more importantly, that looking after my mother was our shared act of service.
If this winter of struggle and sorrow gave my mother more time in the world, then I was ready for it. Would that the path were palliative for us all.
— The country is divided over a law that would allow patients suffering from mental health illnesses to apply for assisted death.
Jason French has undergone years of treatment for his depression without any improvement. He says he wants access to assisted death so he can die on his own terms.
Canada already has one of the most liberal assisted death laws in the world, offering the practice to terminally and chronically ill Canadians.
But under a law scheduled to take effect in March assisted dying would also become accessible to people whose only medical condition is mental illness, making Canada one of about half a dozen countries to permit the procedure for that category of people.
That move has divided Canadians, some of whom view it as a sign that the country’s public health care system is not offering adequate psychiatric care, which is notoriously underfunded and in high demand.
The government of Prime Minister Justin Trudeau, which has been criticized for its rollout of the policy, has defended its actions by pointing to a 2019 court decision in Quebec that officials say mandates the expansion.
Members of the Conservative Party have accused the government of promoting a “culture of death.” There has also been opposition from politicians on the left who would like the government to focus its health policy on expanding mental health care.
Jason French is among those building a case for why a doctor should help him die.
With copies of a document describing his troubled mental health history tucked in his backpack, he attended an event in Toronto to lobby for making assisted dying available to people like him.
He has severe depression and has tried twice to end his own life, he said.
“My goal from the start was to get better,” said Mr. French, of Toronto, who agreed to share his name, but not his age because so many in his life don’t know about his illness. “Unfortunately, I’m resistant to all these treatments and the bottom line is, I can’t keep suffering. I can’t keep living my life like this.”
But Dr. John Maher, a psychiatrist in Barrie, Ontario, who specializes in treating complex cases that often take years to improve said he was concerned that hopeless patients will opt for assisted death instead.
“I’m trying to keep my patients alive,” he said. “What does it mean for the role of the physician, as healer, as bringer of hope, to be offering death? And what does it mean in practice?”
Canada’s existing assisted death law applies only to people who are terminally ill or living with physical disabilities or chronic, incurable conditions. The country’s Supreme Court decriminalized assisted death in 2015 and ruled that forcing Canadians to cope with intolerable suffering infringes on fundamental rights to liberty and security.
About 13,200 Canadians had an assisted death last year, a 31 percent increase over 2021 according to a report by the federal health ministry. Of those, 463 people, or 3.5 percent, were not terminally ill, but had other medical conditions. Patients who are approved have the option to end their lives using lethal drugs administered by a physician or nurse, or by taking drugs prescribed to them.
There is still uncertainty and debate over whether assisted death will become available to the mentally ill early next year as scheduled. Amid concerns over how to implement it, Parliament has delayed putting it into place for the past three years and could delay it again.
Clinical guidelines were released to address those concerns last March, but some people involved in providing mental health care say they are insufficient.
Lisa Marr, a paramedic diagnosed with post-traumatic stress disorder, said the wait for the assisted dying law to take effect has been grueling.
But supporters say denying mentally ill people access to the same humane option to end their suffering amounts to discrimination.
“I have a very deep empathy for patients who suffer deeply,” said Dr. Alexandra McPherson, a psychiatry professor at the University of Alberta and assisted death provider. She said she treats a small number of patients “with severe disabling mental health disorders who suffer equally to the patients that I see in cancer care.”
Lisa Marr, a former paramedic diagnosed with post-traumatic stress disorder who lives in Nova Scotia, said she was desperate to take advantage of the new law. She has bipolar disorder, depression and excoriation disorder, or skin picking, from anxiety and has made, she estimates, 15 attempts on her life but “always managed to pull myself out.”
Ms. Marr at home with her support cat, Fig. “All the medications I take just barely keep me together,” she said.
Canada amended its criminal code to legalize assisted death for the terminally ill in 2016, and in 2021, responding to the court ruling in Quebec, the country loosened the law to add other severely ill people experiencing “grievous and irremediable” conditions.
Eligible patients must wait 90 days before receiving an assisted death and be approved based on the assessments of two independent physicians. One of the assessors must be a specialist in the patient’s illness or have consulted with a specialist.
A panel of experts and a special parliamentary committee have worked to address concerns from the public and medical community, by laying out practice standards and advising clinicians and regulators.
The government has also funded the development of a training program for physicians and nurses who assess patients for assisted death.
“The work has been done,” Dr. Mona Gupta, the chair of a government-appointed expert panel — who is a psychiatrist and bioethics researcher at the University of Montreal — told a special parliamentary committee in November. “We are ready.”
Anyone in Canada seeking assisted death must be deemed by the physicians or nurse practitioners who assess them as not impulsive and not suicidal, and those who are mentally ill would need to be evaluated to show that their condition is “irremediable.”
But even some psychiatrists worry that they may not always be able to determine if someone seeking an assisted death could actually get better or not.
“The research that we have shows psychiatrists are no better at identifying who’s not going to get better,” said Dr. Maher, the psychiatrist in Ontario. “The challenge for us is it’s not a short term process. When people have been sick for years, healing takes years.”
The Centre for Addiction and Mental Health, Canada’s largest teaching hospital for psychiatric care and research, has said that clinicians need more guidance to assist them in assessing who is acutely suicidal or capable of making a rational choice to end their lives.
“We’ve been clear that we have concerns about expansion at this time,” said Dr. Sanjeev Sockalingam, chief medical officer at the center, which has convened several professional groups to assist physicians in preparing for March.
Dr. Sanjeev Sockalingam is the chief medical officer at the Centre for Addiction and Mental Health, Canada’s largest teaching hospital for psychiatric care and research.
Ms. Marr, the paramedic, said the wait for the law to take effect has been grueling. She takes eight psychiatric drugs every day. “All the medications I take just barely keep me together,” said Ms. Marr, who is on disability leave and spends most days in her room, leaving home only for therapy.
Her father had an assisted death after being diagnosed with prostate cancer, and her mother died shortly after, all while she was juggling her job as a paramedic.
“Then, my mental health started to rear its ugly head,” she said.
The uncertainty over whether the mentally ill would be allowed assisted death motivated Mr. French to leave his home after work, something his depression rarely allows him, to attend a screening of a documentary financed by Dying With Dignity, a charity promoting assisted death.
He went with several copies of a five-page document he created explaining his case, hoping to give it to medical experts at the screening.
Death doesn’t scare him.
“My biggest fear is surviving,” he said.
He said he’s not suicidal. But, he added, “I don’t want to have to die terrified and alone, and have someone find me somewhere. I want to do it with a doctor. I want to die within a few minutes, peacefully.”
“My biggest fear is surviving,” Mr. French said.
Both Canada and the United States have a three-digit suicide and crisis hotline: 988. If you are having thoughts of suicide, call or text 988 and visit 988.ca (Canada) or 988lifeline.org (United States) for a list of additional resources. This service offers bilingual crisis support in each country, 24 hours a day, seven days a week.
We’re all going to die, and before that, we will probably navigate the deaths of several people we love along the way.
Too dark? Discomfort with the idea of death may be the reason that people rarely talk about it, plan for it, or teach each other how to cope with it.
“Many people in our society are death phobic and do not want to talk about it,” said Marady Duran, a social worker, doula, and educator with the International End-of-Life Doula Association. “Being an end-of-life doula has been so much more than just my bedside experiences. I am able to talk with friends, family, and strangers about death and what scares them or what plans they have. Being a doula is also about educating our communities that there are many options for how end-of-life decisions can be made.”
When you or a loved one inevitably faces death, there can be an overwhelming feeling of What do I do now? What do I do with these feelings… and all this paperwork? End-of-life doulas (also called death doulas or death coaches) are compassionate and knowledgeable guides who can walk with you through death and grief.
The experience of supporting a childhood friend through her death at the age of 27 motivated Ashley Johnson, president of the National End-of-life Doula Alliance, to commit herself to this role.
“Walking alongside her during her journey, I recognized the tremendous need for education, service, and companionship for individuals and their families facing end-of-life challenges,” Johnson said. “The passing of my dear friend only solidified my commitment to this path. I saw it as my calling to extend the same level of care and support to others who were navigating the complexities of end-of-life experiences. I firmly believe that every individual deserves the dignity of a well-supported end-of-life journey, and that starts with demystifying the process, reducing fear, and helping families achieve the proper closure they need to heal.”
What to expect from a death doula
The services provided by an end-of-life doula are actually pretty varied and flexible. Much like birth doulas, they do not provide any medical care. These are some of the services Johnson said she provides in her work:
Advance health care planning. This might include a living will, setting up durable power of attorney for health care, and advance directive decisions. “We help individuals and their families navigate the complex process of advance healthcare planning, ensuring their wishes and choices are respected and documented,” Johnson said.
Practical training for family caregivers. End-of-life doulas can teach caretakers and family members how to physically care for their loved ones as they near death.
Companionship to patients. “We provide emotional support and companionship to patients, helping to ease their feelings of isolation and anxiety,” Johnson said.
Relief for family caregivers. Caring for a dying family member can be relentless, but caregivers need time to step away and care for themselves too.
Creating a plan for support at the patient’s time of death. A person nearing the end of their life may be comforted by many things in their environment, from the lighting, music, aromatherapy, and who’s present. A doula can help coordinate all the details.
Grief support. “Our role extends into the grieving process, offering support to both the dying person’s loved ones and the patient during the end-of-life journey and beyond,” Johnson said.
Vigil presence for actively dying patients. “We ensure that no one faces the end of life alone by being a comforting and compassionate presence during the active dying process,”Johnson said.
Help with planning funeral and memorial services. Planning services is a complicated task to tackle while you are likely exhausted with grief. Doulas have been through this process many times and can be a steady hand while you make decisions.
“Our aim as death doulas is to enhance the quality of life and death for all involved,” Johnson said. “We provide a range of non-medical support, fostering an environment where individuals and their loved ones can find comfort, guidance, and a sense of peace during this profound and delicate phase of life.”
When is it time to bring in a doula?
Death doulas can provide comfort and support to both the dying person and their loved ones at any stage of the process. They can step in to help before, during, or after a death.
At any time, before you even receive a terminal diagnosis, doulas can help you prepare emotionally and practically with planning for end-of-life wishes, advance care planning, and creating a supportive environment.
During the end-of-life phase, doulas are more present to offer emotional, spiritual and practical support. They may be available weekly or daily, as needed.
After death, doula services continue for the family of the deceased.
“There really is no timeline for grief,” Duran said. “Some will want to meet one or two times after the death, and some do not want to do grief work at all. It is a personal journey, and some people may take years to do the work.”
Support for an unexpected death
Not all deaths come with an advanced warning or time to prepare and plan. Even in the case of an unexpected death, an end-of-life doula can help you handle practical details and process grief. They can:
Provide emotional support
Help you understand the grief process
Teach you coping strategies
Help with arrangements, legal, and financial matters
Help you create meaningful memorial rituals to honor the deceased
Provide connection and community
Listen and validate your feelings
Provide long-term support
“My mentor Ocean Phillips, who is also a doula, always reminds me that ‘grief is another form of love,’” Duran said. “Grief gets a bad rap, and many people do not want to feel grief, but it can be transformative for many who experience it. People who go through an unexpected death of a loved one may feel guilt—‘If only I…I could have…’ The doula can hold space for them and allow them to share that. We can never fix or change, but we can stand with them and provide loving kindness along the way.”
Other professionals to help you navigate a death
Death doulas work in conjunction with many other professionals, including healthcare workers and hospice staff, to help families go through the process of death and all that follows.
“The whole team has a piece in being able to connect with those navigating grief and death. I always recognize that I am just one small part of the larger community that will help support those facing death and loss,” Duran said.
These are a few other professionals you might want to reach out to when facing the death of a loved one:
Death is a taboo subject in American culture. So much so that, by the time someone close to you passes, you may not have any idea how they want their affairs handled.
But according to death doula Alua Arthur, getting an “end-of-life plan” in place can make death easier to think and talk about at any age. And this plan goes far deeper than the financial and logistical items covered in a will.
Here’s how Arthur recommends making your end-of-life plan and the benefits it can bring for a well-lived life.
What is an end-of-life plan?
Arthur thinks everybody should have an-end-of-life plan. While the exact contents will be unique to each person, here are some items she recommends including:
Your end-of-life care: When you’re nearing the end, what kind of environment do you want to be in? Where would you like to be? What type of food do you want to eat? How do you want to feel? This will help your loved ones make the best decisions for you if you’re physically unable to.
Your body & funeral service: What do you want done with your remains? Do you want a funeral? What does it look like? Any places you’d prefer not to have it? If you don’t know your options, consider looking into it. There are so many innovative and beautiful ways to handle remains you probably haven’t heard of yet.
Your possessions & financial affairs: This tends to be covered in a will, but can be included in your end-of-life plan as well.
Your pets & non-relative dependents: Are there any living beings you take care of that you want to pass on information about but may not be included in your will? If so, add a plan for them in this document. Consider pets here if you have any.
Now, it’s important to remember that these end-of-life plans are meant to change and evolve with you.
If you learn about a new burial service that interests you, add it to the document. If you went to a funeral and saw something you wouldn’t want for yourself, put it in your document. This way, when you do eventually pass, your loved ones will know it’s up-to-date with your honest wishes.
Why are end-of-life plans important?
For those who prefer to shy away from discussions about death, don’t worry—you’re not alone. But here are a few reasons that making an end-of-life plan and talking more openly about death can actually help us live healthier lives:
1. Too often, we see death as “a failure”
Shoshana Ungerleider, M.D. has a unique perspective on death as an internal medicine physician and the founder of End Well–a nonprofit on a mission to change how the world thinks about the end of life.
Ungerleider says some of the strong distaste toward the topic stems from how Western medicine views death in a hospital setting. “It’s partly because we as doctors see death very, very often as a failure. And we try to do everything we can to avoid failure in medicine,” she explains.
But in the end, she notes, “Death keeps us awake to our lives.” By pushing thoughts of death away, we can actually increase the power they have over us. Making an end-of-life plan is a way to accept death for what it is and take away some of the stigma that surrounds it.
2. Speaking about it can help with death-related anxiety
On an individual level, death can be scary and anxiety-inducing to think about. The unfortunate truth is that we don’t control how we pass or when. But, what you can control (at least a little bit) is how your death is handled, hence the freeing effect of the end-of-life plan.
Knowing this part of the equation is sorted can actually bring an element of known to the unknown, potentially easing death-related anxiety.
3. A plan can help support your loved ones when the time comes
Having these big questions answered ahead of your death is a service to your loved ones who will care for you in your final days. By taking some of the work off your loved ones’s plate through pre-planning, you’ll help them grieve your passing with just a bit less stress related to logistics. Think of it as paying it forward to those who will care for you during this time.
Though it may not be accessible for everyone, working with a death doula could also prove helpful for you and your loved ones (and you can even request that in your end-of-life plan).
4. Acknowledging death can make you more present
Your considerations around death don’t need to stop once you wrap up your end-of-year plan. Instead, Arthur strongly recommends that everyone start talking about death more often. This doesn’t need to involve serious sit-down conversations. In fact, sometimes easing into it with casual topics can take away the initial shock and overwhelm.
Having more casual conversations around death can improve your quality of life and presence. Ungerleider notes that her colleague Lucy Kalanithi, M.D., often says that living and dying aren’t separate things. We’re doing both at the same time. This perspective can make death a bit less scary and unfamiliar since it reminds us that while we are living every day, we are dying every day, too.
Death keeps us awake to our lives
Making an end-of-life plan probably won’t make you completely fearless when it comes to death. But there’s a chance that it can ease your anxiety around it a bit, as well as provide support to your loved ones.
5. Don’t be afraid to ask for help
If you feel strong anxiety or fear when you think or speak about death, consider reaching out to a therapist for help. They can guide you through difficult emotions that come up and process any potential trauma that could be impacting your fear of death.
The takeaway
Death doula Alua Arthur recommends making an end-of-life plan that includes preferences related to remains, funeral services, how you’ll be cared for in your final days, and other important considerations that may not be covered in a will. If you find the topic of death uncomfortable to talk about, you’re not alone. However, getting familiar with your wishes and desires may benefit your mental health and presence, and help those around you in the long run.
