Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: FRIDAY, May 13, 1994 TAG: 9405180005
SECTION: EDITORIAL PAGE: A15 EDITION: METRO
SOURCE: CAROLINE W. CAGLE
DATELINE: LENGTH: Long
The challenges we face when death is near can be more difficult than we have ever imagined. In a recently published book, "How We Die," Dr. Sherwin B. Nuland has vividly depicted several widely varied episodes in the transition from life to death. A teacher of surgery and the history of medicine at Yale University, Nuland has produced a grippingly graphic medical drama. He offers hard lessons for the not-yet-dying to learn, and we read and contemplate his narratives with fascination and fear.
His ultimate hope is that the reader who acquires knowledge and understanding of the range of human experiences at the end of life's journey will be better prepared to accept the process of dying.
One of the most valuable lessons Nuland offers is the awareness that many of us will have choices to make as we approach the final days of our lives. Individual matters of resolve, religion, technology and tradition all influence the nature of the choices available to us. The strong and determined in our midst will continue to fight for life, even beyond all hope. The faithful among us will commit ourselves into the hands of a higher authority. For many, medicine and technology will determine the length and the course of our journey toward death.
All of us are closely bound by the influences of our culture, our legal system and our traditions. We are imbued, after all, with some vague notion of the American way of death. Either we ourselves, or others acting on our behalf, will be forced to face difficult decisions under difficult circumstances. We would be wise to begin making these choices now.
Certainly, we can anticipate that there will be medical, legal and even ethical issues to be resolved. The time to begin thinking about these eventualities is today. We each have a responsibility to consult with our families, our friends and our professional advisers, and to make our wishes known to them. In the course of our preparations, we owe it to ourselves to be good students of death.
Nuland pleads for the "resurrection of the family doctor." No medical specialist or technician can be expected to know the full history or personal philosophy of the patient. He writes, "I will choose my own way, or at least make the elements of my own way so clear that the choice, should I be unable, can be made by those who know me best." Nuland's feeling is that only a family physician of long standing can truly know who we are.
Few of us will be in a position to have old medical friends around to guide us through our dying. If we still have our wits about us, then we are likely to feel that we are fighting to find our own way and to maintain control in the midst of the professional strangers who gather at our bedsides. If we are able to make choices, then we can have a voice in this assembly. Or if choice is no longer possible for us, then our voices can be heard through informed decisions we made earlier in life.
Physicians are in the business of healing. If the patient is in the business of dying, then the physician finds himself or herself in conflict with the interests of the patient, as perceived by the patient. Thoughtful planning and paperwork in the form of the preparation of "advance directive" documents can help alleviate this conflict. These documents explain our requests for the kinds of medical treatment we want, or don't want, in the event we reach the stage in which we are unable to communicate our own wishes.
The most common advance directive is a "living will," which typically spells out the decision to forgo any life-sustaining treatment that would artificially prolong the dying process.
Another legal document is a durable power of attorney that grants to another person the authority to make decisions in our names. If the need arises when we are not able to let our choices be known, then our families will have been relieved of the burden of making decisions for us. But we need to let them know in writing.
At any age, the time may come when we are aware that our life is nearing the end. If we have decided not to receive life-sustaining medical treatment, then we can consider the benefits of a hospice program, which will provide care and support for us and our families in the last stages of life. Typical hospice teams consist of physicians, nurses, social workers, aides, counselors, ministers and volunteers who will help us with our physical, emotional, spiritual and social needs. Eligibility for hospice requires that we have an anticipated limited life expectancy, a physician who is willing to participate in the program and a primary care-giver who will assume responsibility for our needs.
"Quality of life" has acquired a great significance in the value system of our society. When important aspects of that quality can no longer be associated with our personal existence, then some of us, as we lay dying, will prefer not to prolong life. Some of us will ask of those around us that our death not be delayed. We owe it to our families, our physicians, our lawyers and our loved ones to get our homework done before the deadline arrives.
Caroline W. Cagle is a graduate student in Science and Technology Studies at Virginia Tech.
by CNB