Category: Philosophy of Living

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The Growing Acceptance of Medical Aid in Dying

More and more voters support options to allow the terminally ill to peacefully end their suffering. Politicians have little to fear from the issue.

By Kim Callinan  

While expanding and protecting health care was the number-one issue for voters on Nov. 6, what has gone unreported is that elected officials can now safely run on the issue of expanding and protecting end-of-life care options. For decades, lawmakers feared that sponsoring medical aid-in-dying bills that would allow terminally ill adults to have the option to peacefully end their suffering would harm their chances of getting re-elected. This year’s elections proved those concerns false.

Nearly all of the lead sponsors of bills in 28 states to authorize medical aid in dying in 2017 and 2018 who ran for re-election won (13 out of 14 state senators and 49 out of 53 state representatives). Voters also elected or re-elected at least five governors who publicly supported medical aid in dying: David Ige in Hawaii, Gavin Newsom in California, J.B. Pritzker in Illinois, Gretchen Whitmer in Michigan and Michelle Lujan Grisham in New Mexico. (Grisham’s opponent, Steve Peace, vehemently opposed medical aid in dying.)

In addition, Congressman Keith Rothfus of Pennsylvania, a sponsor of a failed resolution to overturn Washington, D.C.’s Death with Dignity Act and another House resolution condemning medical aid-in-dying laws nationwide that garnered only 13 co-sponsors, was defeated for re-election.

None of this should be particularly surprising. A majority of voters embraced this issue long before many elected officials and political candidates did — since 1996, according to Gallup’s annual polling; its 2017 poll shows that 73 percent of Americans support medical aid in dying, including 81 percent of Democrats and Democratic-leaning independents and 67 percent of Republicans and Republican-leading independents. In short, medical aid in dying is a rare bipartisan/nonpartisan issue. Five GOP legislators are among sponsors or co-sponsors of bills allowing medical aid in dying.

This unusually strong, wide-ranging support explains why 29-year-old Brittany Maynard, who moved from California to Oregon in 2014 to access its medical aid-in-dying law, was able to capture the attention of the American public. Three weeks after her YouTube video went viral, generating international news coverage, a YouGov poll showed that 38 percent of American adults — 93 million people — had heard her story.

Inspired, in part, by Maynard’s advocacy, since 2015 California, Colorado, the District of Columbia and Hawaii have enacted medical aid-in-dying laws. Today, D.C. and seven states accounting for nearly one out of five Americans have the option of medical aid in dying.

This movement is picking up major momentum, particularly among the millions of baby boomers who have watched their parents die in needless suffering because they did not have the option of medical aid in dying.

In addition, we know that these laws improve care by prompting conversations between doctors and patients about all end-of-life options, including hospice and palliative care. Oregon’s 1994 Death with Dignity Act has helped spur the state to lead the nation in hospice enrollment.

This helps explain why a 2016 Medscape survey of physicians showed doctors supporting medical aid in dying by nearly a 2-to-1 margin, 57 percent to 29 percent, up from 46 percent support in 2010. Just last month, the American Academy of Family Physicians dropped its opposition to medical aid in dying and adopted a position of “engaged neutrality,” noting that “family physicians are well-positioned to … engage in creating change in the best interest of [their] patients.” Medical societies in D.C. and nine states have adopted similar positions, and the New York State Academy of Family Physicians has endorsed allowing medical aid in dying.

Perhaps the most important benefit of medical aid in dying is that it is transforming end-of-life care in the same way childbirth care was transformed decades ago. As more states implement medical aid-in-dying laws, more and more patients have a voice in how they live the final chapter of their lives and how they die. Just as obstetricians and gynecologists now ask women for their input about who they want in the birthing room and whether they want to receive medication, doctors in states where medical aid in dying is authorized now are engaging in similar conversations with terminally ill patients.

In time, we will live in a world where health care providers fully inform their terminally ill patients about the benefits and burdens of all available forms of treatment and where deciding to end suffering and allow for a peaceful death will be a widely accepted medical option. The sooner we get there, the better.

Complete Article ↪HERE↩!

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At a Death Cafe, Tea and Couscous Make Mortality Easier to Swallow

Let’s talk about death, baby.

Attendees gather around a table to talk death at Tagine.

by Abbey Perreault

On a brisk November night, Tagine, a Moroccan restaurant tucked away on a quiet side street near Times Square, is alive with conversation. Nearly 20 people pack in around two tables cluttered with heaping, communal plates of steaming couscous, chickpeas, and yellow lentils. People exchange stories, laughs, and soft wedges of bread dipped in bright green chermoula. Multi-colored disco lights dance across the walls, and the swell of conversation rises and falls against a soft pulse of music and noise from the bar. A young, blonde woman walks through the door and surveys the crowd.

“Is this the singles’ event?” she asks, pointing to the tables. I shake my head.

“Nope,” I tell her. “This is the Death Cafe.” She thanks me, brow furrowed, and heads to the back of the restaurant.

While it may seem strange for conversations about death to be conflated with courting, our group could easily be mistaken for speed daters. Relatively young, open, and inquisitive, my dining companions exude a curious energy, solid appetite, and hunger for good conversation. But, unlike the majority of small talk with strangers, dialogue here is all about death—from philosophical musings about post-death life to the physiological components of dying.

“When the body is dying there are lots of … secretions,” says Tanya, a nurse who works in the intensive care unit at a local hospital. “We sometimes give patients medicine to try to dry them out and stop them from gurgling.”

“Is that what they call the death rattle?” someone asks from across the table.

Those noises, we learn, arise once the dying person can no longer swallow or clear fluid from the throat, and often indicates that they’re within a day of passing. But as disturbing as it may sound, the death rattle typically doesn’t cause the individual pain or discomfort. We talk about the sounds of death, and how to attempt to interpret them, sipping mint tea from delicate, warm glasses. “Having to take care of somebody who’s dying, and their family … it can be a lot. I want to talk about it with my husband, but I don’t want to fatigue him with it,” says Tanya. “But I think about it all the time.” It can be months, even years, she says, before she stops thinking about a patient who has passed away under her watch.

But not all Death Cafe diners come from professions that deal with death. According to Nancy Gershman, the facilitator of our cafe, attendees come from all walks of life, from college students with a philosophical curiosity about death to those who have witnessed something supernatural. Some people want to understand death better in order to prepare for their own. “I had this one 80-year-old who kept asking these roundabout questions,” recounts Gershman. “It turned out she wanted to know what dying was like.”

Hot tea helps the conversation flow.

Gershman, who has been facilitating this Death Cafe for the past three years, says there’s no agenda. Meetings often meander thematically, driven by the questions and stories people bring to the table. But she’s quick to remind me that, while the Death Cafe is a safe space to talk about loss, it’s not a support group. “When you lose someone, there’s a particular period right after it happens where you keep repeating, like a groove on a record,” she says. “We’re not here to stay stuck in that groove.”

Instead, Gershman says, it’s a place to speak openly and inquisitively about the end of life. Formally established in 2011, the original Death Cafe arose as the brainchild of the late founder, Jon Underwood, in his East London home. Inspired by Swiss sociologist Bernard Crettaz’s café mortel, he set out to create an intentional space dedicated to talking death in order help people “make the most of their (finite) lives.”

Strangers began gathering in Underwood’s London basement to sip tea, munch on cake, and casually discuss death and dying. Before dying unexpectedly from undiagnosed leukemia in 2017, Underwood and his mother created accessible guidelines and protocols so anyone could create Death Cafes within their own communities. Since then, more than 7,300 cafes have cropped up in over 60 countries—an indication that they address a deep-seated desire to understand death, one that’s been ignored, if not avoided.

After remaining relatively tight-lipped on the topic for centuries, those in the U.S. are more willingly peeking into the abyss—a cultural moment that’s been dubbed the “positive death movement.” From the growing demand for end of life doulas to the creation of apps that send daily reminders that you’re going to die, it’s apparent that more people are interested in confronting death.

“There’s a growing recognition that the way we’ve outsourced death to the medical profession and to funeral directors hasn’t done us any favors,” Underwood told the New York Times in 2013. By avoiding the topic until it happens, we’re left with all sorts of strange feelings about this universal life event. And yet, many of us prefer to keep it at a distance.
Part of this aversion, Gershman suggests, is that talking about it reminds us that it’s real. It shakes the comfortable illusions many of us cling to—that our bodies and brains are ours to control and keep. Sitting around the table, talking about how to financially plan for our funerals (to keep our partners and families from going into debt) can feel alien, even morbid, at first. But, through sips of mint tea, mouthfuls of warm lentils, and a few laughs, I’m reminded that it’s as necessary as making a financial plan before any big life event, such as going to college or getting married.

The strangeness of talking about death, Gershman says, goes beyond the mere fact that it’s been a longtime taboo topic in some cultures. There’s a lot of subject matter that’s taboo, she says, but death is different—largely because it’s inevitable. She compares it to the sex-positive movement in the U.S., where much of the silence surrounding sexuality has been stripped away to increase transparency and dismantle stigma. “People still have a choice when they’re talking about sex. You can either have sex zero times … or many times. But with death, you don’t have a choice. It’s going to happen, and it’s not going to be in your control.”

Nancy Gershman and a cafe attendee.

While making death less taboo will help us understand it and plan for it, it can’t help us prevent it. So planning for it is both frightening and necessary. But by ensuring tea and food are present, hosts of the cafes are able to make discussions of dying a little less scary. “There’s a superstition that if you talk about death, you invite it closer,” said Mr. Underwood. “But the consumption of food is a life-sustaining process. Cake normalizes things.”

My tablemates seem to agree that eating makes engaging with death easier. Tanya mentions that the pediatric unit has a giant bowl filled with candy, and it’s intended for the staff, not the patients. Digesting and processing death might be easier when accompanied by something sweet, something that nourishes us, something we understand to be routine. Like death, eating is something all living bodies simply have to do.

As the night progresses, one attendee whose husband passed away a few years ago tells me that, when she lost him, she lost her appetite, too. But in the past few years, her love for food, particularly dark chocolate, has returned forcefully. “Now, I eat it and I can’t stop,” she chuckles. She reaches into her purse, shuffling around a bit before pulling out three wrapped Hershey’s Dark Chocolate with Almonds nuggets, and hands one to each of us, smiling.

Laughter is common at the Death Cafe.

Even after years of facilitating Death Cafes, Gershman finds herself surprised by the feverish interest the cafes continue to garner. Month after month, newbies and returners come to talk death with strangers. A big part of the appeal, she ventures, is that death is great fodder for in-person conversation. “This is a subject that people can stay on, as opposed to babysitters and real estate,” says Gershman. “Death is such a rich topic that you could approach it in a million different ways and never be bored.”

Back at Tagine, conversation shifts from the life and death lessons learned from watching Golden Girls to the weirdness of grieving on social media. In a group of complete strangers, no one looks awkward or distracted, and no one is fiddling with a phone. “I really think that people are starved for interesting conversation at dinner,” laughs Gershman.

As I gulp down my piece of chocolate, another swell of laughter erupts from the table to my left. In comparison, the singles’ event in the back seems relatively lifeless. Gershman tells me that what I’ve seen and felt tonight is no anomaly.

“One of the waiters told me, ‘Whenever your group comes in, there’s always such great energy.’” she says. When she told him that this was a Death Cafe, a group focused on death and dying, he thought he had misheard her. “I think it’s because there’s a tremendous sense of relief. When you have relief, there’s more laughter.”

Complete Article ↪HERE↩!

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‘I was widowed at 23, young people need to talk about death’

Amy Molloy and husband, Eoghan

By Amy Molloy

‘They say you’ve got three months to live.” These were the words I spoke to my then-fiancé when I was 23 years old after learning that his cancer – malignant melanoma that spread to his liver, lungs, pancreas and brain – was likely to be fatal.

At the time, my only experience of “the end” was watching my parents disappear into a room where my grandparents were lying, and of seeing an empty rabbit hut at the end of our garden after the loss of a pet.

When I was 17 years old my father was paralysed from Hodgkins Lymphoma but, after a stem cell transplant, he defeated the odds and made a miraculous recovery. So, I had faith in the power of modern medicine over mortality.

However, not this time.

I was practically still a child when a doctor ushered me into a private room, whilst my soon-to-be husband, Eoghan, was in a chemotherapy session, and revealed his prognosis. I asked if I could be the one to tell him, and they readily agreed.

Perhaps, even doctors will do anything to avoid saying the T-word. Terminal.

In the next three months, I had a crash course in end-of-life conversation: the jargon, the euphemisms and the social awkwardness.

I froze with fear when I walked into the chemo ward and heard another patient ask my partner, “Have you ever thought about euthanasia?” But, in a way, that was better than the wall of silence.

After my husband died three weeks after our wedding day, even my closest friends evaporated or became stiff in my company. In the next few months, as I rebelled against my grief – drinking too much and becoming promiscuous – nobody dared challenge me or raise the topics I ached to discuss.

What on earth are you doing?

Do you really think this is helping you?

How does it feel to marry a man who is dying?

…Do you want to die too?

Do you know what to say when a friend’s loved one dies? Have you thought about the day your own parent, partner or best friend may no longer be visible? How would you discuss it, in a way that would be supportive, constructive, and even light-hearted?

If you don’t know the answer, you’re not alone.

A new study from the Royal College of Physicians in the UK has urged medical professionals to improve their bedside manner when it comes to discussing death, after identifying that “timely, honest conversations” about patients’ futures are not happening. However it’s not only doctors who need to become more comfortable with these conversations.

It’s been suggested that millennials are the generation most fearful of death, unlike our grandparents, raised through world wars, who learnt that life can be short. As medicine advances and life expectancy increases, we prefer to think of death as our “future self’s problem”.

But is postponing the inevitable increasing our terror of it?

As psychologists report a rise in young people presenting with anxiety linked to death, it’s time for honest, open, educational conversations about loss of life, and how it can look. Its not enough to be aware of Facebook’s ‘death policy’, warn experts.

“Death is still a certainty even if people are living longer,” says clinical psychologist Renee Mill from Sydney’s Anxiety Solutions CBT.

“When treating anxiety, exposure is what works and avoidance increases the problem. Talking about death or visiting a dying person will decrease your fear of death and make it easier to accept that it is a part of life. Every funeral we attend, no matter how hard, actually helps to reduce anxiety in this way too.”

And, it’s never too early to think about the end. “Planning in life is important,” says Mill. “We plan our careers, we save, we want to buy property – end-of-life is another part we need to plan. It means we get our wishes fulfilled and gives guidance to our loved ones who otherwise have to pick up the pieces.”

In a good way, change is happening. Since 2017, the multimedia project We’re All Going to Die has encouraged people to embrace their immortality and use it to empower their lives, through educational films and festivals.

The award-winning podcast, GriefCast, hosted by comedian Cariad Lloyd whose father died when she was a teenager, sees entertainers speak with startling honesty – and surprising humour – about death, from the logistics of palliative care and funeral plans to the long-term effects of bereavement.

When we can talk openly about death, we may also increase our chances of reducing suicides. To help people to help each other, Lifeline offer an online course in QPR – the equivalent of CPR for people experiencing a suicidal crisis.

As part of the training – which only takes an hour and costs $10 – people are urged not to tiptoe around the conversations. Instead, be direct: “Do you feel like you want to die?”

In our social circles, we need to discuss worst-case-scenarios. Do you have a will? Do you have death insurance? Are you an organ donor? As an Australian immigrant living 16,000 kilometres from my parents, I always have enough money in my bank account for an emergency flight home. Because, nobody lives forever.

It’s confronting but it’s necessary

During my book tour, I cried on stage for the first time whilst discussing my journey from a 23-year-old widow to a 34-year-old wife and mother of two. Because, for the first time in a decade, I have reached a place where I can talk about my experience of death – and really be heard.

I shared the reason I light a candle in my bedroom every evening and say a prayer: help me to act from a place of love, not fear.

“If my dad’s cancer comes back, on that day I will light that candle,” I said, “If my husband, who is here with my newborn, dies and I am widowed again then I will light that candle to remind myself to act from a place of love.”

We need to talk about death to be active participants in the full spectrum of life: so we can decide who to be when a doctor pulls us into a private room, when we answer the phone to bad news, when we say goodbye for the last time.

We are so scared of death, we don’t discuss what an honour it is to watch someone die; to be present – really present – when someone takes their last breath, to lean in and breathe them in, to put your head on their chest as their heart stops beating and kiss their skin as it transforms.

I hope you all have that experience one day.

We are not meant to say that, but we should.

Complete Article ↪HERE↩!

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Death doulas can fill care gaps at the end of life

Palliative care nurses, social workers and people from the funeral industry are among those who work as death doulas.

by , , and

With continual advances in modern medicine, we’re enjoying longer lives. As the population ages, and particularly as many people are living longer with cancers and chronic diseases, end-of-life care is adapting and changing.

People who are approaching the end of their lives will usually spend some or most of their time at home, requiring care and support to do so. Family members might not always be available to provide this care. When they are, the process can be rewarding, but it can also be challenging and complex, often leading to a severe emotional burden for the carer.

Gaps in our health and social care systems are starting to be filled by death doulas. But beyond providing practical support, families are increasingly seeking the services of death doulas to help navigate the experience of dying. Those nearing the end of their lives, too, may bring in a death doula to ensure they can die the way they want to.

We urgently need a conversation about death doulas and new models of care at the end of life. We are continuing to build an evidence base through research with the death doula community and via consultation with the health services that interface with death doulas.

Defining the death doula

We’ve seen a similar concept in midwifery, where birth doulas have long been providing social, emotional and practical support to help women through the process of childbirth. This has been shown to have positive outcomes for mothers and their babies.

Like birth doulas, death doulas’ roles and functions are non-medical; these can include advocating, supporting (spiritually and sometimes physically), guiding, and providing emotional support to the person and their family, mainly in the home.

We undertook a systematic review of the literature to find available evidence about the death doula role. We found little formal academic literature describing the role, their training, or contribution to individuals, families and the health system.

But what we do know is that each death doula enacts the role differently. They might spend time with the dying person, offering emotional and spiritual support, and sometimes providing physical care. They might support the family carers in the work they are doing. Some death doulas are only present in the last days of life, offering “vigiling” – sitting with the dying person so they are not alone.

Some doulas offer after-death rituals such as helping families prepare the body or keeping the deceased at home.

A death doula can provide additional support to family members acting as caregivers at the end of life.

Some death doulas are paid by families who engage their services. Families have often found their chosen doula online or through word-of-mouth. Other death doulas work voluntarily, in a similar way to a hospice volunteer. But, because there are no formal structures or registers, we don’t know how many death doulas there are.

In Australia and elsewhere, palliative care nurses, social workers and those from the funeral industry work as death doulas. This seems to be a natural progression, but it’s a grey area: doulas are providing care, but are not registered or supervised.

There is little formal assessment to guide patient and family choice or to inform end-of-life care provided by professionals.

How can doula care be formalised?

Providing care in homes can be informal. It may be provided by families, friends, or community groups. Care can also be formally negotiated and provided by health services, aged care providers or private agencies.

It’s necessary to understand the implications of the death doula role. For example, they could become part of formal care arrangements such as home care packages or via private health insurance funding.

We also need to look at how these new roles are authorised to represent the dying person, as they are neither a family member nor a qualified health professional. It’s also important that they are appropriately trained and insured (if providing paid services).

There are personal, social and cost advantages in enabling care in the home for a dying person. For families, being able to support the person in a familiar environment can be a powerful motivator to engage a death doula to fill the gaps in care provision.

For the health system, care in the home is seen as positive. It can avoid unnecessary hospital use and help spread the costs of caring.

For the dying person who may prefer to die at home, it is a way of achieving this. Importantly, death doulas can improve the dying person’s ability to control their own care.

The death doula role may well incorporate some of the direct care provided by families and help them to navigate the complex needs and planning required at the end of life. If so, death doulas could represent an important opportunity to improve dying outcomes.

We need to ensure our community is informed, health service provision crosses both hospitals and homes, and that those providing care – regardless of setting – have skills and knowledge appropriate to their role.

Complete Article ↪HERE↩!

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Cradle to the grave: ‘death midwife’ faces court battle to keep her title

B.C. College of Midwives and Pashta MaryMoon, 65, to litigate ‘death midwife’ title this week

Death midwife Pashta MaryMoon (far right) uses a live model to demonstrate how to properly wash and care for a dead body at home. MaryMoon will be in B.C. Supreme Court this week after the B.C. College of Midwives filed an injunction to demand she stop using the title.

By Liam Britten

In a sworn affidavit, Pashta MaryMoon says her passion for alternative holistic death care began when she was a seven-year-old girl watching a 1950s western movie.

She described watching a scene with a pioneer’s wife whose husband had died. The fictional woman, all alone, had no choice but to care for his body herself, prepare it for burial, inter it and then comfort their grieving children.

“Young as I was, and with the benefit of hindsight, this ‘hands-on’ approach struck me as making more sense than conventional funeral practices,” MaryMoon, now 65, wrote.

“I am a Death Midwife; Death Midwifery is my vocation and it is what I do.”

The problem with MaryMoon’s vocation, in the eyes of the B.C. College of Midwives, is its name.

The college, which is the legal body regulating and overseeing the practice of midwifery in B.C., has sent several cease and desist letters to MaryMoon since 2016 demanding she stop using the term “midwife” to describe her services.

Now, it is turning to B.C. Supreme Court to compel her to drop it in a two-day hearing this week.

Cites history back to ancient Egypt

MaryMoon evokes the Egyptian goddess Isis’ dual roles as a god of life and death to explain what she says is the traditional dual role of the midwife.

According to the college of midwives, its birth-focused registrants provide a “continuity of care and support throughout the childbearing experience.”

Before birth, they provide physical exams and diagnostic tests; during birth they can conduct normal vaginal deliveries; and they also provide postpartum care after birth.

MaryMoon says death midwifery honours the philosophy and tradition of traditional midwives as someone who “attends to birth or death.”

In a document submitted to the court, her friend Mia Shinbrot outlined the services MaryMoon provides.

Before death, she helps the dying plan at-home funerals and work through their grief; during the death itself, she organizes death vigils; and after the person has died, she takes care of paperwork, helps with the funeral and provides grief support.

MaryMoon, in her affidavit, said the dual role of a midwife stretches back into ancient times and claims its roots go as far back as recorded history, as evidenced by ancient Egyptian gods like Isis or the Bird-Headed Snake Goddess, which she claims have aspects of both life and death in their natures.

College wants to avoid confusion

In an affidavit of her own, college of midwives registrar Louise Aerts argued it is important to keep the term midwife legally reserved for college-certified midwives to avoid confusing or misleading members of the public.

Aerts declined to comment further for this story, saying the matter is before the courts, but in her submission, she noted that other holistic death practitioners call themselves “death doulas” or end-of-life doulas.”

Douglas College even has an End-of-Life Doula certificate program.

 

But MaryMoon, in response to that, said the term “death midwife” is the only title that accurately encapsulates her services and approach. She believes there is no chance of confusing her work with that of a college-certified midwife.

“When people hear ‘death midwife’ or ‘death midwifery,’ they automatically assume a philosophy about it, in part, because they’re familiar with birth midwives,” MaryMoon said.

“There’s no other term in our culture right now that that the public recognizes.”

Pashta MaryMoon says about a half dozen other people called themselves “death midwives” until the B.C. College of Midwives ordered them to stop. MaryMoon believes she is the last one remaining in B.C.

She believes that without the title, people facing death will not know that they can take a different approach to dying.

She will ask the B.C. Supreme Court for an exemption to restrictions on the midwife title on Nov. 29 and 30.

Complete Article ↪HERE↩!

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At Death’s Door, Shedding Light On How To Live

By Judith Graham

Nothing so alters a person as learning you have a terminal illness.

Ronni Bennett, who writes a popular blog about aging, discovered that recently when she heard that cancer had metastasized to her lungs and her peritoneum (a membrane that lines the cavity of the abdomen).

There is no cure for your condition, Bennett was told by doctors, who estimated she might have six to eight months of good health before symptoms began to appear.

Right then and there, this 77-year-old resolved to start doing things differently — something many people might be inclined to do in a similar situation.

No more extended exercise routines every morning, a try-to-stay-healthy activity that Bennett had forced herself to adopt but disliked intensely.

No more watching her diet, which had allowed her to shed 40 pounds several years ago and keep the weight off, with considerable effort.

No more worrying about whether memory lapses were normal or an early sign of dementia — an irrelevant issue now.

No more pretending that the cliche “we’re all terminal” (since death awaits all of us) is especially insightful. This abstraction has nothing to do with the reality of knowing, in your gut, that your own death is imminent, Bennett realized.

“It colors everything,” she told me in a long and wide-ranging conversation recently. “I’ve always lived tentatively, but I’m not anymore because the worst has happened — I’ve been told I’m going to die.”

No more listening to medical advice from friends and acquaintances, however well-intentioned. Bennett has complete trust in her medical team at Oregon Health & Science University, which has treated her since diagnosing pancreatic cancer last year. She’s done with responding politely to people who think they know better, she said.

And no more worrying, even for a minute, what anyone thinks of her. As Bennett wrote in a recent blog post, “All kinds of things . . . fall away at just about the exact moment the doctor says, ‘There is no treatment.’ ”

Four or five times a day, a wave of crushing fear washes through her, Bennett told me. She breathes deeply and lets it pass. And no, psychotherapy isn’t something she wants to consider.

Instead, she’ll feel whatever it is she needs to feel — and learn from it. This is how she wants to approach death, Bennett said: alert, aware, lucid. “Dying is the last great adventure we have — the last bit of life — and I want to experience it as it happens,” she said.

Writing is, for Bennett, a necessity, the thing she wants to do more than anything during this last stage of her life. For decades, it’s been her way of understanding the world — and herself.

In a notebook, Bennett has been jotting down thoughts and feelings as they come to her. Some she already has shared in a series of blog posts about her illness. Some she’s saving for the future.

There are questions she hasn’t figured out how to answer yet.

“Can I still watch trashy TV shows?”

“How do I choose what books to read, given that my time is finite?

“What do I think about rationale suicide?” (Physician-assisted death is an option in Oregon, where Bennett lives.)

Along with her “I’m done with that” list, Bennett has a list of what she wants to embrace:

Ice cream and cheese, her favorite foods. Walks in the park near her home. Get-togethers with her public affairs discussion group. A romp with kittens or puppies licking her and making her laugh. A sense of normalcy, for as long as possible. “What I want is my life, very close to what it is,” she explained. And deep conversations with friends. “What has been most helpful and touched me most are the friends who are willing to let me talk about this,” she said.

On her blog, she has invited readers to “ask any questions at all” and made it clear she welcomes frank communication.

“I’m new to this — this dying thing — and there’s no instruction book. I’m kind of fascinated by what you do with yourself during this period, and questions help me figure out what I think,” she told me.

Recently, a reader asked Bennett if she was angry about her cancer. No, Bennett answered. “Early on, I read about some cancer patients who get hung up on ‘why me?’ My response was ‘why not me?’ Most of my family died of cancer and, 40 percent of all Americans will have some form of cancer during their lives.”

Dozens of readers have responded with shock, sadness and gratitude for Bennett’s honesty about subjects that usually aren’t discussed in public.

“Because she’s writing about her own experiences in detail and telling people how she feels, people are opening up and relaying their experiences — things that maybe they’ve never said to anyone before,” Millie Garfield, 93, a devoted reader and friend of Bennett’s, told me in a phone conversation.

Garfield’s parents never talked about illness and death the way Bennett is doing. “I didn’t have this close communication with them, and they never opened up to me about all the things Ronni is talking about,” she said.

For the last year, Bennett and her former husband, Alex Bennett, have broadcast video conversations every few weeks over YouTube. (He lives across the country in New York City.) “What you’ve written will be valuable as a document of somebody’s life and how to leave it,” he told her recently as they talked about her condition with poignancy and laughter.

Other people may have very different perspectives as they take stock of their lives upon learning they have a terminal illness. Some may not want to share their innermost thoughts and feelings; others may do so willingly or if they feel other people really want to listen.

During the past 15 years, Bennett chose to live her life out loud through her blog. For the moment, she’s as committed as ever to doing that.

“There’s very little about dying from the point of view of someone who’s living that experience,” she said. “This is one of the very big deals of aging and, absolutely, I’ll keep writing about this as long as I want to or can.”

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Choosing your own exit.

For some who are terminally ill, hastening their own death may be the answer.

By Samuel P. Harrington

Four months before he died, my father, a widower of six years and a hospice patient, asked me to discuss techniques for hastening his death, although he did not use that term: “I have lived too long. What can I do?”

He was living in Wisconsin where medical aid-in-dying, which allows terminally ill patients to obtain a lethal dose of medicine from a physician, was not legal. At first, I was afraid that he was asking me, a physician, to go around the law and supply him with a lethal dose of sedatives. Fortunately, he was not. He was dying of lymphoma and geriatric “failure to thrive” (old age), but it was a slow and unpleasant process. What could he do, he wanted to know, to move things along? He was ready

It was Christmas Day and I was cooking a few of my mother’s traditional dishes. Gradually, and recognizing the irony of simultaneously baking his favorite pie, I eased into a conversation about refusing to eat and drink. We had had this conversation in the past and it always ended the same way. Unlike most of my terminally ill patients, my father had not lost his appetite and would not give up the pleasure that food brought him.

The next day, he had come to decision: He would no longer take any medications designed to prolong his life, he announced to his family, caregivers and hospice nurses. These included heart pills, blood pressure pills and electrolyte supplements. He would, however, continue palliative medications, including tranquilizers and pain pills. My father died painlessly exactly four months later from the effects of multiple ministrokes.

According to the Center for Disease Control and Prevention, 90 percent of people over age 65 die of six chronic illnesses (heart failure, cancer, lung disease, stroke, dementia and diabetes). If I am fortunate enough to live to a ripe old age, I expect that I will suffer from one of these illnesses. If treatments are ineffective and a prolonged dying process is intolerable, perhaps I, like my father, will want to hasten my death.

As a doctor, I have found that having a sense of some control at the end can be reassuring to people. Yet it’s not easy — nor should it be — for someone to say, “I’m ready to be done with this,” and then have it be so.

In general, three ways are available where a terminally ill patient can speed up the process of dying without the assistance of someone else. One is by declining (or discontinuing) medical treatments that prolong life without improving the quality of life. Stopping his non-palliative medications was my father’s variation on this theme.

Another approach is to refuse to eat or drink. Known as voluntarily stopping eating and drinking, VSED (pronounced “V-said”) is an effective technique that takes advantage of the natural tendency for the terminally ill to lose their appetite to the disease process. This means that there are minimal hunger pains. Patients die of dehydration, which sounds bad but dehydration, by itself, is a pain-free condition. Most people have easily managed symptoms of thirst that stop as things progress. About 10 percent have significant, hard-to-manage symptoms of thirst. Most people slip into a coma in two to four days and pass away in 10 to 14 days.

The third approach is to take a lethal dose of medication. Medical aid-in-dying is legal in seven states and the District. The vast majority of terminally ill patients who choose to exit life this way slip into a coma in minutes and die painlessly within hours.

Having tended many terminally ill patients, I’ve often wondered what I would do if faced with a prolonged death from a chronic illness. If told I had less than six months to live, I would certainly enter hospice care, where the focus of doctors and other health-care professionals is on preserving quality — not quantity — of life. But then what?

Discontinuing or declining medical treatment includes everything from refusing life support or turning it off after a catastrophic stroke, infection or heart attack to discontinuing a pacemaker, a feeding tube or kidney dialysis.

It can also mean no antibiotics for a pneumonia or bladder infection in a bedbound hospice patient. Comforted by palliative treatments — narcotics and sedatives that induce comfort and sedation — any of these decisions will result in a comparatively comfortable death.

My quandary with this method for hastening death is that it relies on the random development of a disease or complication (stroke, infection or heart attack, for example). It is not a proactive strategy offering a better sense of control.

Medical aid-in-dying is proactive and it is effective. It is an option that I believe people should have available to them. Yet it comes with an unanticipated scheduling complication that gives me pause.

The laws allowing medical aid-in-dying are written to protect chronically ill patients from impulsive decision-making, coercion and premature deaths. Most require that patients themselves initiate the process; be certified by two physicians as terminally ill (defined as a life expectancy of less than six months) and mentally competent (without serious depression); undergo a two-week waiting period between the time of certification and acquisition of the medications; and remain mentally competent and physically capable of self-administration at the time of ingestion.

One woman I interviewed lives in Oregon, where medical aid-in-dying has been available for more that 20 years. Her story epitomized the scheduling conundrum.

When her husband was dying of rapidly progressive cancer, they scheduled a family gathering at which time he planned to take his lethal potion. One week before the event, progressive disease threatened his ability to self-administer the medication and they had to hurriedly reschedule with their children and the end-of-life volunteers who mix the medications and witness the process. One son could not reschedule. The wife felt rushed and disappointed that her son could not make it in time.

That scheduling artifice bothers me and supports the nagging sense of prematurity that I associate with many aid-in-dying deaths.

Yet if I lived in a state where it was available, I would consider it, particularly under two conditions: If I were suffering from poorly controlled pain or if I could not be kept clean because of uncontrollable incontinence. (I have seen this in men and women who have suffered complications from pelvic radiation, surgery or cancer itself.)

For me, under most circumstances, that leaves VSED. It cannot really be premature or impulsive. It accelerates the body’s natural decline. And it takes 48 to 96 hours of self-controlled commitment before the patient slips into a self-propagating coma. It would offer me control and demonstrate to my family that my death is appropriate and appropriately timed.

How I will face the final phase of my life is of course unknowable. But I am sure that a sense of control is the most important attribute of a good death and that advance care planning helps more patients achieve their end-of-life wishes.

I know that I do not want to be a burden on my family. I want my values and my legacy to be affirmed and appreciated. I want to be clean and comfortable. I want to optimize my relationships and bring closure to as many problems as possible. And I want my death to be appropriate in time and place.

To achieve all this requires discussions with doctors, family and friends. It also requires understanding one’s disease and likely prognosis and then deciding when to say “no” to aggressive treatment and when to say “yes” to hospice care.

These are not easy conversations or decisions. Yet to reach the peaceful end that most of us wish for, one might require a plan to hasten the process.

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