Tag: Death Talk

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How to help your kids say goodbye to a beloved pet

Tips on how to guide little hearts through their grief to help them deal with their loss and recover from it

By Jennifer Walker

[S]aying goodbye to a pet is an inevitable experience many families will experience.

And telling the truth to children and allowing them to grieve is crucial in helping them deal with their loss, as well as recover from it.

“I think it is important to tell children the truth but depending on their age and developmental level, the information you communicate will differ,” said Kyle Newstadt, individual and family therapist and director of Integrate Health Services. “Regardless, they should know the truth and if you know the pet is sick or death is on the horizon, it is important to communicate that with children.”

According to Ms. Newstadt, books can be helpful to introduce the topic to a child with the family without any other distractions. She said parents could explain to their children that the animal has been to the doctor for medicine and that they’re waiting to see if it helps the situation.

“Don’t hide the truth and say the animal is sleeping or he ran away; it’s abstract and kids wont understand that,” said Ms. Newstadt. “Stick to the truth and avoid unknown language, explain death but leave it up to the child and what they’re asking — children can surprise us.”

A toddler is unlikely to understand death but those words should be used, she added.

“Parents could explain that medicine was given to dog and it will help him close his eyes and he will die peacefully,” said Ms. Newstadt. “Wait for them to ask “what does death mean?’ and, depending on religious beliefs, that would be a good time to talk about that.”

According to the local therapist, it is important to allow your child to express their feelings and deal with grief. A pet memorial would be a crucial part of the process for a child and the entire family, she said.

“Ask the child and give them choices in ways they would want to memorialize their pet and maybe each child can think of something they want to do; a burial outside, pictures in places around the house, creating a scrapbook, or a special ceremony to talk about the memories they had with their pet is important and helps them deal with grief,” she said. “This will open lines of communication which is so important when a child suffers from the death of a pet.”

According to Durham Region registered vet technician Sarah Macdonald, it is required of veterinarian clinics to dispose of a pet’s body once it passes away. A large majority of clinics also offer cremation, she said.

According to Ms. Macdonald and Ontario.ca, homeowners are permitted to bury their pets on their own property. For those living in an apartment, Ms. Macdonald recommends cremation.

The ashes can be kept in a special urn inside the pet owner’s home or be scattered in a special location for a ceremony or as part of a memorial, she said.

For those looking for more ways to memorialize their pets with keepsakes, funerals, cremation ceremonies, and more, Ms. Macdonald recommends Gateway Pet Memorial, specializing in pet aftercare throughout North America.

Parents should be focusing on positive coping strategies by modelling self-expression, letting the child know that it is OK and normal to have these feelings of sadness and that it is important to express, said Ms. Newstadt.

“Children experience grief in different ways from adults; there is no right or wrong way,” she added. “They may appear to be coping well and weeks later experience sadness. Meet the child where they’re at.”

According to Ms. Newstadt, parents shouldn’t approach the conversation until the child is expressing sadness.

“It’s OK if the child isn’t demonstrating that they’re sad, there is no right or wrong way to experience grief,” she said. “It is typical for a child to ask questions or to say they’re feeling sad and then engage in play, it’s a developmentally appropriate way of grieving.”

Complete Article HERE!

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Religious rituals surround death

Headstones at Catholic Cemetery No. 1 in Victoria.

By Jennifer Lee Preyss

[I]nside Memory Gardens, a well-groomed cemetery off Cuero Highway, marked graves and floral arrangements pay tribute to the lives of thousands of Victorians who have died.

Near the rear of the grounds, 50 plots have been reserved for members of the Victoria Islamic Center.

Even though many Islamic communities throughout the United States bury members in Islamic-only cemeteries, Victoria Islamic Center Imam Osama Hassan said the 50 plots in Memory Gardens fit the needs of the community.

“It has worked out perfect for us. It’s the right size for our needs for the future,” he said, mentioning the small size of its congregation.

Like many other religious sects in South Texas, including Christianity and Judaism, Islam has its own unique rituals for burying the dead.

Often, Islamic communities purchase their own cemeteries, especially if they are part of large communities of Muslims or live in larger cities. But death is an important part of life and how a Muslim is honored in death is especially important for believers.

“The Prophet Mohammed tells us to talk about death because it’s a part of life. But many people are afraid to. Some people feel if they talk about it, it’s like bad luck, like someone they know may die,” he said. mentioning the cultural aspect of international Muslims from various countries around the world who are reluctant to discuss or plan for death. “We should be talking more about it.”

Islamic members are not the only community in Victoria with special requirements for death.

In downtown Victoria, off Vine Street, a Jewish cemetery dating back to the mid-1800s indicates some of the city’s earliest residents were Jewish, including the first Jew to settle in Victoria, Abraham Levi, who established one of the city’s earliest grocery stores on Main Street.

Catholic and early Protestant cemeteries also remain pervasive throughout the region, established in the early 1800s as settlers moved in and established churches and parishes.

The Rev. Max Landman, of Sacred Heart Catholic Church in Hallettsville, said Catholic funerals are distinct, in part because of their reverence for the dead.

“The main thing, with respect to a Catholic funeral, is we’re there to pray for the soul of the dead person. A lot of times, it can be seen as a celebration of the person’s life – and there’s nothing wrong with celebrating the person’s life – but the point of the funeral from the Catholic’s perspective is to commend that soul to God,” Landman said. “We firmly believe that our prayers for that person, especially the Sacrifice of the Mass are helpful in obtaining mercy and speeding that person’s soul into paradise.”

As Halloween approaches, a time of year that gives a not-so-subtle nod to death, cemeteries and afterlife, the season offers a unique opportunity to examine the customs of area religions as they honor the members of their congregations in the religious context they acknowledge.

Here are a few of the many death traditions of Catholics, Muslim and Jewish believers around the world.

In most religions, tombstones and grave markers are permitted and visited by the living.

Islam
When a Muslim dies, the body should be buried as soon as possible. Three to four hours is preferable, up to one day, but no longer than 48 hours. The bodies are not embalmed, and careful consideration is given to treatment of the body because Muslims believe the person can still hear and feel pain.

Autopsies and cremations are not acceptable for this reason; however, organ donation may be permitted in some circumstances because it is seen as a charitable event.

Instead, Muslims are washed with soap and water and wrapped in a white cloth. Men prepare male deceased, while women prepare female deceased.

It is preferable that Muslims not be placed in a casket at all, allowing the dead to return immediately to the dirt.

Overseas, Muslims are buried directly in the ground. In the U.S., caskets are required, so Muslims typically place the coffin upside down to encapsulate the body once it is placed in the ground. Bodies must lie on their side and point toward Mecca in Saudi Arabia.

The typical mourning period is three days, and believers are encouraged to return to normal life. This varies depending on each person, with some wearing black for many years in remembrance of a loved one.

Catholics
Priests are called both right before and after death to pray the appropriate rites over the body.

Vigils are usually held on the evening before Mass, and there is often a praying of the rosary. This is typically the place where eulogies and tributes are delivered.

Caskets can be covered with white linens, or palls, and blessed with holy water as a reminder of baptism.

Bodies are allowed to be embalmed, however organ donation and cremation remain areas of disagreement among Catholics. It is preferred if cremation is being performed that the body not be cremated until after the funeral Mass, so the deceased can be present in the church for the service.

At burial, the Rite of Committal is given at the blessed burial site. The Lord’s Prayer is typically said upon closing.

Judaism
When a Jew dies, the “Dayan HaEmet” prayer is recited, which acknowledges God as the true judge.

Jewish tradition prefers the body be laid to rest as soon as possible, as soon as one day, so funeral planning often begins immediately.

It is also preferable the body not be unattended and is often given a “shomer” or guardian.

If funerals cannot be held right away, exceptions can be made. Sometimes, the body is refrigerated while waiting on the funeral.

Bodies are typically washed and dressed. Men wash men and women wash women. The washing is called the “taharah.” The submerging of the body in water for the ritual bath is the “mikvah.”

The body is fully dried and dressed in a simple white cloth called a “tachrichim.” Men are typically buried in a “kippah” or skull cap, and also a “tallit” or prayer shawl.

Jews tend to avoid holding funerals on holy days or Saturdays.

Organ donation is generally accepted and seen as a good deed. Autopsies and embalming are generally not accepted unless required by law.

Cremation may be accepted depending on the degree of orthodoxy of the Jewish family. Orthodox Jews do not permit cremation, while conservative and reformed Jews may allow it.

Jews are placed in a simple pine casket without any metal, and sometimes holes are drilled in the bottom of the box to accelerate decomposition. There is generally no wake or visitation in the Jewish faith. Funerals are held in the synagogue, at the grave or funeral home, and include a eulogy, reading of the psalms, and the memorial prayer, “El Maleh Rachamim.”

It is customary for the tombstone or grave marker to be put up one year after the death. A stone is usually placed on the grave within the first 30 days to indicate someone has visited.

Complete Article HERE!

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Cleaning the dead: the afterlife rituals of the Torajan people

For the Torajan people of Indonesia, death is part of a spiritual journey: families keep the mummified remains of their deceased relatives in their homes for years – and traditionally invite them to join for lunch on a daily basis – before they are eventually buried. Even then, they are regularly exhumed to be cleaned and cared for

By Claudio Sieber

[I]n contrast to Western norms, Torajans people, who live in the mountains of Sulawesi in Indonesia, treat their beloved relatives as if they are sick not dead. In this picture, a grandchild stands next to her deceased grandparents. Yohanis (right), was 77 years old and passed away two weeks ago; his wife Alfrida Tottong Tikupadang (left), was 65 years old and passed away five years ago. In Toraja, it is customary to feed the deceased every day and to keep the corpses cozily bedded in a separate room of the family house until the family can afford a proper funeral.

After the funeral rites of “Rambu Solo”, the deceased are finally buried in tombs. But still they are regularly visited, cleaned and given new clothes in a ritual known as Ma’nene (‘Care of Ancestors’). Datu died 35 years ago. In this picture relatives are removing the insects that covered her.

 

It’s customary for the Torajans to put gifts in the coffin, such as a bracelet or a watch. Others might even bury a diamond with their loved ones. Grave robbery often occurs and some Torajans keep their gifts a secret. Grandpa Ne Pua passed away when he was 85 years old. He has been buried in his favourite suit together with his favourite belongings.

 

Roughly 50 bodies are being moved from Balle’ graveyard to a new mausoleum. As soon as the traditional coffins are dragged out of the tomb, the relatives put on surgical masks and attend to their loved ones.

 

In this picture, a family presents Djim Sambara, who died two years ago when aged 90. Sambara was honourably buried in his military uniform before the family changed his outfit.

 

Andaris Palulun is given new clothes by his brother Ferri before returning to the family tomb. He died 20 years ago.

 

Todeng died in 2009. A young relative of his, Sam, lights him a cigarette and changes his glasses.

 

Yuanita takes a selfie with her relative Allo Pongsitammu who passed away roughly 20 years ago.

 

This picture shows Ne Duma Tata waiting to return his deceased wife to the mausoleum. Ludia Rante Bua (right) died in 2010. She stands alongside her sister.

 

With the bodies having been dutifully cleaned, they are carefully returned to the mausoleum.

Complete Article HERE!

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Learn to Cope With Death as a Future Physician

Prospective medical school students can use volunteer experiences to learn how to care compassionately for dying patients.

As a prospective medical student, remember to take the time to grieve.

By Kathleen Franco, M.D.,

[M]ost prospective medical school students set out to become physicians because they want to heal the sick, often forgetting that patients, young and old, sometimes die.

Death is a very real – and natural – part of medicine that you will not only face but also will need to learn how to handle. Before you start medical school, consider how you might care compassionately for a dying patient and how you will cope with the loss.

Some physicians – although very few in my experience – look at death as defeat and cope by emotionally running away from dying patients. For example, in the inpatient setting, they may visit the patient less often or avoid contact altogether.

In the outpatient setting, they might recommend a longer time between visits or, rather than suggest a follow-up appointment, wait for the patient to request one. This coping strategy makes patients feel abandoned.

Other physicians – again, very few – cope by behaving callously or indifferently. Subconsciously, they may be trying to avoid emotional involvement, but their behavior leaves their patients and families feeling hurt and disappointed.

Most physicians find healthy strategies to support their dying patients. These same strategies help physicians keep themselves emotionally healthy, too.

As a future medical student, it’s vital that you prepare yourself to compassionately face death and dying and the complex emotions that follow. One way to do this is by volunteering in a hospice facility or nursing home and honing these six skills.

1. Be authentic: As a volunteer, introduce yourself and express your hope that someday you wish to become a physician. Let patients know you are there to learn more about their experiences.

Ask patients about how they grew up or what they were thinking about at your age. Ask about their work or career – a generally safe place emotionally – and where they have lived or about their family.

Be sure to make eye contact and watch your body language. You’ll use these skills when you’re a physician to develop trust and open communication with patients.

2. Listen with purpose: Practice your active listening skills so that on future visits you can ask patients more about previous conversations.

By bringing up something from a past visit, you will show that you remembered what they told you and that they matter to you as a person. Active listening is another skill you will use throughout your medical career.

3. Allow patients to talk about death: Everyone faces death differently; some people want to talk about it, while others prefer to reflect on their life and accomplishments.

Whether now as a volunteer or later as a future physician, let patients talk about death as they need to. Don’t shut down the conversation by saying, “Everything will be all right.” Instead, ask them to tell you more. Listen to all they have to say, whether it’s about their health, fears or fond memories.

4. Visit or connect consistently: A good physician builds rapport over time, and you can develop this skill through your volunteer position. During extended time between visits, call or drop the patient a note.

This is a good habit to develop so that when you are a physician, your patients – particularly those who are dying – will feel supported. At the end of each visit, thank the patient. You won’t know at the time if it will be your last opportunity to visit, so treasure each interaction.

5. Seek support: Myriad scholarly articles and books are available to help physicians – and all people – accept that death is an inevitable part of life and that grieving is normal and encouraged. For instance, attending funerals help some people grieve, while others seek solace from support groups or counseling.

Social workers also deal with death and dying regularly and can give you advice about how they cope and prevent burnout. Make the social work team part of your professional network. Their support and advice will help you cope as a physician, especially when you lose a patient who had a particular influence on you.

6. Allow yourself to grieve: Over the course of your relationships with patients who are dying, you will learn a great deal about your capacity to care for others. It will likely hurt when patients die.

Remember that it’s important to grieve, and keep in mind that everyone grieves differently. Give yourself the room to process your emotions and to discover the coping mechanism that’s right for you.

Over time, you will gain some insight about your ability to cope. Physicians often cope by speaking confidentially with colleagues and expressing sadness and other emotions in a journal. After omitting a patient’s protected health information, some physicians publish their writings to help themselves and others who are grieving.

Many medical schools also teach students to reflect about their emotions and write them down. Writing and seeing the words help the healing process.

As a future medical student, embrace the opportunity to get to know someone who is dying. It will allow you to reflect on how you may feel when a future patient dies and learn to create a meaningful bond with the people you touch now and in the future.

Complete Article HERE!

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New study looks at end-of-life decision making for people with intellectual disabilities

by Bert Gambini

 
[A] new study by researchers at the University at Buffalo provides a groundbreaking look at how advance care planning medical orders inform emergency medical service (EMS) providers’ experiences involving people with intellectual disabilities.

Most states in the U.S. have programs that allow to document their end-of-life decisions. In New York, the Medical Orders for Life-Sustaining Treatment form (MOLST) allows individuals to document what measures , including EMS providers, should take near the end of a patient’s life.

Studies suggest that this approach to person-centered advance care planning can alleviate a dying patient’s pain and suffering, according Deborah Waldrop, a professor in the UB School of Social Work and an expert on end-of-life care. Yet little research on end-of-life decision-making has been done on the growing population of older Americans with intellectual disabilities, which the American Association on Intellectual and Developmental Disabilities defines as a disability characterized by significant limitations in learning, reasoning, problem solving, and a collection of conceptual, social and practical skills.

Waldrop and Brian Clemency an associate professor of emergency medicine in the Jacobs School of Medicine and Biomedical Sciences, authored one of the first scholarly examinations of how pre-hospital providers assess and manage emergency calls for patients who do not wish to be resuscitated or intubated. Jacqueline McGinley, a doctoral candidate in UB’s School of Social Work, joined their research team and served as first author for their most recent work.

Through a series of interviews with five different agencies in upstate New York, the researchers asked EMS providers specifically how forms like the MOLST shape what they do in the case of someone with an intellectual disability.

“The best available research before our study suggested that as of the late 1990s, fewer than 1 percent of people with intellectual disabilities had ever documented or discussed their end-of-life wishes,” says McGinley. “But with this study, we found that about 62 percent of the EMS providers we surveyed had treated someone with an intellectual or developmental disability who had these forms.”

That disparity points to the need to illuminate this understudied area of how people with intellectual disabilities are engaging in end-of-life discussions, according to McGinley.

She says the EMS providers’ charge is to follow protocol by honoring the documents, their directions and organizational procedures. The MOLST, as its name implies, is a medical order that providers are professionally bound to respect. Their procedures are identical for all emergency calls involving someone who is imminently dying regardless of a pre-existing disability, the study’s results suggested.

But questions remained.

“We heard from providers who wrestled with the unique issues that impact this population, including organizational barriers when working across systems of care and decision-making for individuals who may lack capacity” says McGinley.

There are approximately 650,000 adults age 60 and older in the U.S. with intellectual disabilities, according to Census Bureau figures from 2000. Demographers expect that figure to double by 2030, and triple within the foreseeable future.

Person-centered advance care planning specifically involves the individual in discussions about their health history, possible changes to their current health status and what future options might be available in order to best inform that person’s end-of-life decision-making.

The results, published in the Journal of Applied Research in Intellectual Disabilities, suggest that medical orders largely favor efforts to prolong life. This may be due to a reluctance to discuss advanced care planning in this population. Still, this sociocultural context must be strongly considered as future research explores how people with intellectual engage in end-of-life discussions.

Since January 2016, Medicare pays for patients to have conversations with medical providers. In fact, at least once a year, as part of a service plan through the state, people with have face-to-face discussions with their service providers, according to McGinley, who notes the importance of this built-in opportunity to have conversations about serious illness and the end of life.

“What’s most important in all of the work we do is knowing that people can die badly,” says Waldrop. “We know we can make changes that illuminate some of the uncertainties and improve care for people who are dying. Knowing how forms, like the MOLST, are applied in the field is an incredible step in the right direction.”

Complete Article HERE!

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Caitlin Doughty Talks Exploring the World to Find a Better Death in From Here to Eternity

By Bridey Heing

The question of what happens when we die—in a literal rather than philosophical sense—haunts many of us. But few have made it the focus of their life’s work like Caitlin Doughty. An advocate for shifting the conversation about the “right” way to care for deceased bodies, Doughty owns a Los Angeles funeral home and organizes events where people discuss death with a range of approaches. Her latest book, From Here to Eternity, explores death culture around the world, illuminating the many ways to hold a funerals.

Doughty describes herself as having always been interested in death, but it was after studying Medieval History that she wanted to learn in a more hands-on setting. “When I graduated from college,” she says in an interview with Paste, “I decided that I wanted to see what real dead bodies look like and how they were being taken care of and disposed of.” She found an opportunity when she got a job at a crematory, where she immediately felt a connection to the work. “It’s hard to describe to people, but really from the second that I started working at the crematory, it was like, ‘Oh, this is what I’m supposed to be doing.’”

Doughty immediately recognized that the knowledge gap between the funeral industry and the general public is significant; she says no one quite knows what happens with a body after death. So not only did she want to learn more about the American way of death, but she wanted to talk about it with others. Her first book, Smoke Gets in Your Eyes, chronicled her journey into the funeral industry. And if she needed any indication that people were willing to listen, the fact that the book was a bestseller suggests that there is a desire to learn more about what takes place behind the scenes.

Doughty received a similar response a few years earlier when she founded the Order of the Good Death, an organization dedicated to expanding our understanding of and comfort with death. The organization established a space where everyone from academics to creatives could discuss death. “I was trying to create a community around death, and over the years it has become a resource. It’s hopefully a place where the culture of silence around death can, even just for a moment, be broken.”

Breaking the culture of silence around death is the heart of From Here to Eternity. Each chapter focuses on one or two cultures that handle death in unique ways. In Indonesia, Doughty watched as mummies were taken out of special house-slash-tombs to be feted. In Japan, she visited hotels where families spent time with loved ones’ corpses before cremation. In Colorado, she witnessed an open-air pyre where the community came together to honor the dead. In Bolivia, she made offerings to skulls called natitas, which were dressed up and paraded in the streets during the annual festival in their honor.

Doughty’s mission with her new book is to start a conversation about death in other cultures in a way that says something about U.S. funeral culture, and she wants to communicate the significance of rituals other than our own to combat a lack of cultural relativism.

“I see over and over again people talk about American death tradition, like embalming and burial in a big vault underground, and not liking that at all,” Doughty says. “But at the same time, whenever they heard about something that goes on overseas, they’d go, ‘Ugh, that’s so disrespectful and morbid.”
From Here to Eternity humanizes rituals that might otherwise seem unfathomable. “Even the things that are so out there by our standards feels so normal when you’re there. I wanted to get across that just because it’s not what you do doesn’t mean it’s weird or morbid or should be disparaged.”

Doughty’s text about the way families interact with their deceased loved ones is incredibly moving. But she doesn’t lose sight of her own role as an outsider observing a deeply intimate ritual, and she even talks about the ways in which death tourism has become an issue in countries with well known ways of handling their dead.

“You go into it thinking, ‘I have the best intentions, I’ve spent my life researching these things.’ But the family doesn’t know that,” she says. Doughty relied on local contacts and close friends, who could make sure she didn’t overstep while families were grieving. “The places I chose to go were places I had some in, whether that was a local guide or a person I know who travels all the time to these places.”

While the book has an international focus, the message is clearly one of a domestic nature. The shadow of how the United States handles death is always present, and Doughty dips in and out of her travel narratives to contrast what she sees with what she experiences in her own work. She also questions the very foundations on which the United States has built its funeral industry, including supposed health concerns that have led to profit-driven models of post-death care that many funeral homes require.

Doughty ultimately wants to change the way we talk about and experience death for a simple reason: she regularly hears about how frustrated Americans have been with their own experiences grieving loved ones. “This is my country and my own industry that I work in and own a funeral home in, and it doesn’t seem to be working for a lot of people,” she says. “If I didn’t hear that again and again, I wouldn’t keep doing this work.”

Doughty doesn’t advocate anywhere in the book for one system over another, but she does reveal that the U.S. system as it exists is deeply flawed. Her goal is to explore better ways to handle death, and in this, From Here to Eternity succeeds.

Complete Article HERE!

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The G-Spot: A Good Death

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

-Dylan Thomas

By

[A]s organisms that fight for survival, just as other organisms on the plant, a fear of death is built into our psyche. We write about it, we sing about, and Woody Allen obsesses about it. Throughout the ages, civilizations have created various deities to try to explain our origin, our purpose, and our fates when our bodies fail us. As science has evolved, we have learned to worship technology as a new deity that may protect us from aging and our ultimate demise. Despite our growing medical technology, life still has a 100-percent mortality rate. Someday, you are going to die.

Our medical technology sometimes gives us false hope. We pray to the false gods of machines and newer and more expensive pharmaceuticals to stay our execution, often without the thinking about the financial and emotional costs. As a society, we need to be good stewards of resources, as these resources are not infinite. Money that is spent on futile health care could be better used for other things such as alleviating homelessness, treatment for substance use disorder, or perhaps ensuring that every American has a cell phone. What is often overlooked in this discussion is the burden of suffering.

When you are admitted to the hospital, you will often be asked your wishes as far as resuscitation. If you are a 46- year-old otherwise healthy person who is having a heart attack, the answer will almost always be to do everything possible to resuscitate you. If you are 102 years old with dementia and a massive stroke, the answer will probably be to allow natural death. In fact, if I’m the doctor for the latter, I would not ask the family their wishes; I would tell them that it would be medically futile to attempt resuscitation and would only prolong suffering.

In discussing the end of life, the trend over many decades has been toward less paternalism and more autonomy. We encourage living wills and we try to discuss these issues with patients ahead of time. When I was a medical student in an academic university, the discussion was never IF we were going to resuscitate, but what fluids, what size endotracheal tube, and how many medical students could practice procedures before we called the code. Now we are trying more to give the patients and families their opportunity to decide within the setting of their values.

One of the ethical dilemmas in medicine is the balance between autonomy and beneficence. In the United States, we greatly value autonomy in medical decision-making; your ability to make your own decisions about your life, including health care. Built into Western medicine is the idea of informed consent. I offer you medical options and you can choose to take a medication, undergo a procedure, or try your favorite essential oil. I inform you of the options, and make recommendations, but autonomy says that you get to decide if you prefer lavender or vanilla.

Beneficence is a stronger force in other cultures, but it is also ingrained in our medical culture. Beneficence is essentially when your clinician is deciding what is best for you. The opposite is maleficence, the act of committing harm, which every physician swears an oath not to do. If there was no beneficence in medicine, you could walk into your neighborhood pharmacy and get OxyContin, Adderall, Xanax, and a side of cocaine by request. I practice beneficence over autonomy regularly by telling patients that certain controlled substances are not in their best interest, or declining a patient’s request for an unnecessary CT scan because the risks of radiation outweigh potential benefits. It is also beneficence when I place a patient on a psychiatric hold because I feel that they are in imminent danger of harming themselves.

When discussing end of life care with patients, health-care professionals must balance these two ideas. Many providers are uncomfortable with these discussions, and often begin and end the discussion with, “Do you want everything done?”

Well, who doesn’t want everything done? The logical converse is putting someone in a corner to be ignored as they gasp for breath. In reality, there is plenty that can be done at the end of life. Medical school focuses on the diagnosis and treatment of disease, but often falls short in discussions of palliation of symptoms. I do not like the term “do not resuscitate (DNR)” as it implies that we are withholding care. In fact, what we are doing is changing to focus of care to allow natural death and palliation of pain and anxiety. We have many treatments available for symptoms at the end of life and I minimize the suffering of my dying patients.

What happens when the family and the provider are not on the same page? Just like most areas of human interaction, the key is communication. I was the chair of the bioethics committee at a community hospital for two years and the vast majority of ethics consultations were regarding end of life care. In almost all of these cases, the issue was resolved by compassionate, open communication. Physicians are often frustrated by patients and families who have unrealistic expectations. Unfortunately, we also put the burden on families in the name of autonomy. I have seen many families struggle with the decision of whether or not to attempt resuscitation for a loved one, and it is evident that they fear the guilt of making the wrong decision. I often then put that burden on myself and give them an opportunity to object by saying things such as, “resuscitation is unlikely to provide a meaningful recovery and likely to cause suffering so I recommend if she stops breathing or her heart stops that we allow a natural death.”

This often assuages the family’s guilt as I advise them what I think is best.

Since death is inevitable, the decision is really the balance between extending quality life and suffering. If I extend your life, but during that time you are unable to communicate and have to endure painful procedures, I have not really helped you. However, if those painful procedures will then return you to a life that you consider meaningful, I have done some good. Although I cannot see the future, I can predict the likelihood of a good outcome based on your prior health, function, and the nature of your current illness. All too often I see someone with severe dementia who is bed-bound with a feeding tube undergoing painful procedures that will inevitably only prolong suffering. Ethically, I think that is doing harm.

According to medical ethics, clinicians should not offer futile care. I see it happen in the name of autonomy or misguided fears of litigation. I do not offer feeding tubes to patients with dementia who stop eating because there is ample evidence that it does not prolong life and it does increase suffering. Those of us in healthcare need to remember that we are the experts and we should first do no harm. Those of you who are involved in these decisions need to ask your medical providers these difficult questions. Ask your physician, “If this were your mother, what would you do?”

Most of the deaths I see are predictable. As we age and deal with illness, we should not fear death, but plan for it. Death is a natural part of life, and will occur whether we are ready to accept it or not. Several studies have demonstrated that physicians are more likely to die at home and less likely to have aggressive surgical procedures at the end of life. Our patients should have the same consideration and be allowed a dignified death.

Speak with your family about your wishes and their wishes. If you have a family member with a serious chronic illness, don’t wait until you’re in the emergency department and frightened and someone is asking you if they should “do everything”.

We will all die some day and if we are prepared, we may be able to die well.

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