The Dead Girl Who Continues to Live

Death Upside Down

Four years ago I wrote a post entitled “When Death Is Not Death: Stumbling Over the Parameters of “Brain Dead” about brain death and other medical-intellectual curiosities.  Turns out that one of the young women whose “brain dead” status I described is still. . . not dead, er… rather alive.  Alive for some people, seems to mean “brain dead” for others!  I read with interest Rachel Aviv’s Feb. 5, 2018 New Yorker article  about Jahi McMath, the teenager who suffered complications from a December 9, 2013 tonsillectomy at an Oakland, California hospital.  Some of the story is about our “health care system” and its values – about whose life matters, what condition of life passes for death.  The biggest challenge I see for all of us and this predicament we find ourselves in with health care in this country – is the dogma of the medical-industrial complex and its insistence on getting everyone “in line” about what passes for death and training us to simply not question the information we are given by the professionals reading the diagnostic screens.

Acting “As If” Death Had a Clear Legal and Medical Definition

To the extent we privilege the measurement of brain activity as a measure of our consciousness, as an indicator of the proof of our existence, we deny the underlying philosophical problem of defining or delimiting life and death (and consciousness).  Our present obsession with the measurable quantification of our biological activities is a major component of our current health care system.  We love the pictures of our insides and their operations in “real time.”  As long as we continue to collectively pretend that one’s existence can be verified by a particular type of brain scan, we will remain in denial.

But that denial is often a safe place, based on the “safety in numbers” type of thinking and as a result of the unquestioned power that doctors have and wield over us with their technocratic medical delivery system.

The Audacity to Think – or Rather Believe – That Our Technology Alone Can Be Used as a Means of Extending Someone’s Life by Prolonging Rudimentary Bodily Functions.

I talk to many people who confuse life support with extending one’s life and also with prolonging the dying process.

How do we tell the difference?  Why, ask the doctors!

Can I be kept alive indefinitely against my will? I haven’t heard that question yet, but I suspect there are versions of it being asked.  I am not comfortable handing over my authority to a health care provider who refuses to consider (let alone struggle with) the bigger questions about life – and death.

At a fundamental level, Jahi McMath’s story is about her family members who simply refused to believe what they were being told by the doctors.

One of the neurologists who examined Jahi McMath was the recently retired chief of neurology at Olive View – UCLA Medical Center.  Dr. D. Alan Shewmon was no stranger to cases where patients – many of them children or youths, survived for months or years after being declared brain dead by the medical establishment.  You can read his 1997 article “Recovering from Brain Death: A Neurologist’s Apologia”   here.

No answers in this post, only questions.  How far does the death taboo extend to our thinking or believing (which are often indistinguishable) about what passes for life?  In our brain-obsessed culture that is fascinated with measurements and arriving at the quantifiable, where does the subjective and mysterious show up – or is it simply banished and its existence denied?

© 2018 Barbara Cashman  www.DenverElderLaw.org

Vulnerable Elders and the Slayer Statute

Italian Stone Face

Italian Stone Face

A couple weeks back, I posted an update on the proposed End of Life Options Act, a bill in the Colorado legislature which has since died (presumably of natural causes).  There is concern that some version of the bill will make it onto a ballot to become law by other means.    For this reason, today’s post will go into a bit more detail about the concerns I raised about the implications of having no reporting requirements for such a law and concerns I have with regard to the safety of some vulnerable elders.

Vulnerable Elders

Colorado’s mandatory elder abuse reporting statute defines an at-risk adult as “any person who is seventy years of age or older or any person who is eighteen years of age or older and is a person with a disability.”  Colo. Rev. Stat. §18-6.5.102(2).  The only reputable (US Census based) internet fact I ran across about this population was for persons 65 and up, who in July 2014, were estimated to be 12.7% of the population of Colorado.

From a civil rights perspective, aspects of elder abuse prevention statutes can often seem paternalistic.   Much of the research that could be done on the subject is problematic because of ethical and methodological problems.  Collecting information about elder abuse may publicly expose cognitive, physical, mental and social vulnerabilities and the collection of such information could have negative implications in the form of legal, financial or social consequences for both the elders and caregivers and others who might participate as part of a study.  I mention this because the vast majority of elder adults are competent and retain capacity, at least in the eyes of the law.  The implication of these observations is that we really don’t have solid numbers about how many perpetrators and victims we are talking about.  As an elder law attorney, I can say that it is extremely difficult for an elder parent to call me (or adult protective services) to report abuse or exploitation being perpetrated by an adult child or family member of the elder.  Suffice it to say we don’t really know, and may never have a very firm handle on how many elders are affected as victims of exploitation and abuse.

When you couple this with the lack of any reporting requirement for a physician assisted death law, it would not be possible to track the numbers of vulnerable elders who might fall prey to an abuser’s or exploiter’s plan to hasten someone’s demise so that they might inherit something from the elder.  Enter the slayer statute.  Here’s an article about “disincentivizing” elder abuse.  Keep in mind that elder abuse statutes have criminal penalties.  There are of course distinguished from civil remedies, which can provide other types of relief.

The Slayer Statute – A Modern Law with Ancient Origins

If you’ve never heard of a slayer statute, you’re not alone! It’s both obscure and ancient.  Before there were any state “slayer statutes” there was the common law slayer rule.  Its origin hearkens back to the first known remedial law code in human history: the Code of Hammurabi.  The Code of the Babylonian king was inscribed on a stone pillar (called a stele) and installed in a public place.  It was a combination of legal principles and history.  Most of us are familiar with the axiom “an eye for an eye and a tooth for a tooth” as some precept of retributive law in the form of revenge as recompense for personal harm, but it is much more likely the expression has been badly misinterpreted and taken out of context.  It is probably much more closely aligned with other commentary in the code which describes the value of certain personal injuries in terms of repayment.  In short, it was a code of remedial law – akin to modern day worker’s compensation and tort law.

The principle from Hammurabi’s code is that “a killer cannot profit from his wrong.”  The common law rule, nullus commondum capere potest de injuria sua propria (no one can take advantage of his wrongdoing) forms the basis of the historical slayer rules and subsequent statutes, preventing slayers from inheriting from their victims.

Probably the most well-known case (from law school) to articulate a slayer rule is Riggs v. Palmer, 22 N.E. 188 (N.Y. 1889). In that case a grandfather had executed a will leaving small portions of his property to his children and the remainder to his grandson. The grandfather subsequently married and stated that he intended to change his will to include his wife. The unhappy grandson caused his grandfather’s death in an attempt to secure his portion of the estate.  The court held that grandson was disqualified from inheriting because of his action and relied on the grounds of moral equity to articulate a slayer rule in American jurisprudence.

Forty-seven states have slayer statutes. Colorado is a Uniform Probate Code state, among many other states which have adopted that version of the slayer statutes.  Colorado’s is codified at C.R.S §15-11-803 and contains both a criminal and civil provision for determining that a felonious killing has occurred such that a slayer/felonious killer is prevented from inheriting from the person whom they slew.

This post will be continued next week. . .

© 2016 Barbara Cashman  www.DenverElderLaw.org

Conscious Living and Dying: Death and Depth – part 2

Japanese Garden at DBG

The first part of this post was about death and depth, depth as in “deep end” of something (yes, I likened it to the familiar swimming pool, with those rope float dividers) that is distant from us, unfamiliar, unknown and just plain scary.  So now I will continue the analogy with a different topography, but along the same theme of that invisible mystery which spooks many of us. . . 

For those of us who have experienced earthquakes, we have a different sense of the relationship between what is the visible ground that appears to be solid and the deeper ground where stirrings can cause a shearing away of that surface, revealing new ground, new possibilities, even amidst massive destruction.

Of course there is a choice about how to react when the ground breaks open.  We can be careful to try and repair it, admiring the petrified crust and not wanting to upset any apparent order or appearances.  Or we can break through the crust, willing to fall hard and break through the known into the unknown.

Into the depth of a center.  Symbolically and mythologically speaking, there can be many places which can serve as a deep center, a mountain or a tree, which one could ascend or which can be reached only after a descent, the undoing of the apparent, exterior, the superficial.  Where is the center?  Well, that depends of course.  Often we simply fail to slow down and consider the obvious question because we are so accustomed to looking past it, well beyond where we are at the moment.  What is it that we know or we think that we know?  I’m thinking of a quote from the poet and essayist Wendell Berry here (this from his collection of essay Standing By Words at 50) about the shortcomings of language – “It is not knowledge that enforces this realization [that you cannot act in your own best interest unless you espouse or serve a higher interest] but the humbling awareness of the insufficiency of knowledge, of mystery.”

Perhaps that mystery is the center for which we long and the voyage to which we dread.  Again there is a choice – to do our won spiritual excavation to uncover truth, the meaning in our won life . . . .  or we can admire the relics of another’s questioning or their excavation, from the comfort of an armchair.  What does it take to move into uncertainty and “go with it?”  Sometimes we don’t have a choice.  This is the dying process.  I’ll include another quote, this one by Vladimir Maximov:

All is mere ashes and dust-

All except the Temple within us.

It is ours and with us forever.

(From Henry Corbin’s 1986 book Temple and Contemplation.)

So if that movement, that moving away from and toward something, is in terms of a center, it is a place where we may realize that we are no longer separate from it but rather identify it as part of a larger whole of existence.  In this way conscious living, along with conscious death, can be our final act of creation in this life.  If death is a transcendence, of words or being, the question follows “to where?”  I had the pleasure of reading “Creation and Recreation” by the late University of Toronto professor Northrop Frye, who observed: “Every unit is a whole to which various parts are subordinate, and every unit is in turn part of a larger whole.” [Creation and Recreation at 73.]

If death is a return, a remembering, a completion, then many of us may feel stranded by a sense of things undone, words left unspoken during a now-deceased dear one’s lifetime.  Guilt, resentment, helplessness, remorse are common feelings here.  These may arise from a denial of death, that we will indeed have time to finish our life to our own satisfaction.   I have seen this approach in more than a few people.  Many of us have never lived liked this before, so how can we be expected to change all this in preparation for a death that is most certainly not desired?  It is difficult to determine when the time of sickness transitions to the time of dying, but an inability to accept one’s life seems to ensure that it will be much more difficult to accept impending death.  Death is a final act, unknown and mysterious, yet it happens every day, all over the world.  It is a final act, an ending, that realization that someone is “over and done with,” but our experience of course tells us otherwise.  In one of the chapters of “Who Dies?” Stephen and Ondrea Levine look at how to finish business with someone who is no longer around?  They note that the answer is always the same – one need not see that person in order to send them love, in order to finish business the other person doesn’t even need to acknowledge your presence, much less the process you are sharing.  Like other types of forgiveness, this type of work is done for its own sake and is not dependent on any “results.”

To conclude this, I will loop back around to that idea of the deep center – which we can travel a path to in our lifetime if we choose, as part of our conscious living, or which we can travel to as part of the final destination in our physical body.  The Levines attribute the following quote from Albert Einstein:

A human being is a part of a whole, called by us “universe,” a part limited in time and space.  He experiences himself, his thoughts and feelings, as something separate from the rest – a kind of optical delusion of consciousness.  This delusion is a kind of prison for us, restricting us to our personal desires and affection for a few persons nearest to us.  Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty.

Levine at 183.  Just a gentle reminder that Einstein spent his life searching for a unified field. . .

Depending on how we look at it, we have been practicing dying all of our lives.  When we get stuck on or attached to particular outcomes based on our expectations or who we think we are  – we suffer.  Perhaps we can practice this living and dying mindfully, so we can look beyond those prison walls and lessen our suffering in this life.  At the very least, practicing it will make our dying and most likely the acceptance of our loved ones’ dying, much easier for us.

©Barbara Cashman 2013     www.DenverElderLaw.org

Longevity, Conflict and Meaning

 

I must be on a roll here thinking about conflict at the end of life.  In light of the recent 911 call from the independent living apartments in Bakersfield and other recent things I’ve read – this issue can use much more discussion.  I even posted a link to my Facebook page    about it.     I liked reading Charles Ornstein’s recent article in the Washington Post entitled “I thought I understood health care.  Then my Mom went into the ICU.”  Read it here.    Ornstein’s poignant and personal account of the difficult decision faced by his family after his mother was in a coma and certain decisions had to made is very instructive.  I hear  frequently from clients and family members who are health professionals  that their training makes these difficult decisions much easier.  I am not always so sure.  Some oncologists, for example, are much more focused on a patient’s quality of life at the end of the course of a long and devastating disease, while others prefer to operate in more of a “superhero” mode, vowing to never give up on a patient’s chances for recovery.  There is no right or wrong here – all of these decisions are difficult, even when we have a pretty good idea about the choice and preferences our loved one has previously expressed.  I think of my own experience with my parents’ deaths.  My father died in March 2010 after a long bout with a combination of an undiagnosed neurodegenerative disease coupled with what was later discovered to be metastatic prostate cancer.  I accompanied him to the doctor on many occasions and was his health care agent for the last nine months of his life.  My mother, his wife of 59 1/2 years, worked for many years as a Registered Nurse  – but this set of considerations and +decisions was a whole different ball game.

It is usually extremely difficult to talk with others about death, and this difficulty is lessened somewhat when the conversation is initiated by an older loved one who wants to make his or her wishes known.  This doesn’t often happen.  There are ways to start the conversation though!  It only becomes more difficult in the face of a life-altering illness.    I have worked with many people with terminal illnesses.  It is not any easier to consider end-of-life issues even if they are more “real” in light of a life-threatening disease.  Because I know how difficult it can be for a doctor to raise the issue of hospice care and associated palliative care or quality of life issues with a patient – the patient may believe that their doctor is “giving up” on them – I will often take the opportunity to discuss these issues when appropriate.  I think the questions are much less threatening when you are discussing them with your lawyer as opposed to your doctor.  These involve, after all, legal questions.  Elder law is such a fascinating mix of and intersection of legal, medical, financial psychological and cultural questions.

I also enjoyed reading “Managing Our Miracles: Dealing with the Realities of Aging” in the latest issue of Bifocal, the publication of the ABA Commission on Law and Aging    In this article, Monsignor Charles Fahey refers to “the third age” – the one that is part of human aging that is beyond human reproduction and physical strength – which has become profoundly extended in recent years.  I have blogged previously about Erik Erikson’s developmental stages   and his wife Joan’s extension of  “The Life Cycle Completed” which included her own chapter entitled “The Ninth Stage.”   I think old age and elderhood need to be examined and re-examined in our culture so that we have a more inclusive definition of what is our human “useful shelf life.”  Many of the clients I see, along with assistance from their family members – do an excellent job of meeting the challenges of increased longevity.  As I remind people, this new age of elderhood is something that affects us in a variety of new and sometimes surprising ways.  This longevity can provide opportunities to live parts of a life that had previously been unlived, or not – depending on each of our own unique circumstances and how we find meaning in our lives.   As Hermann Hesse observed:

There’s no reality except the one contained within us. That’s why so many people live an unreal life. They take images outside them for reality and never allow the world within them to assert itself.

Longevity challenges that, and we generally have no frame of reference for today’s longevity.  We can create this new stage of life within ourselves and share it with our loved ones.    Dementia can be a side effect of longevity for many of us or our family members or loved ones.  We make meaning in our lives and others in our ability to “do” often as some kind of proof of our existence.  Dementia can challenge all those beliefs and ideas about who we are, what it means to “be” simply and no longer able to “do” as we did for ourselves and for others before.  This is part of the new reality of aging and longevity.  More on this topic later. . . .

©Barbara Cashman     www.DenverElderLaw.org

Human Rights and the Elderly

 

December is universal human rights month! Why December?  The Universal Declaration of Human Rights (UDHR) was adopted by the UN General Assembly on December 10, 1948.  After the end of the Second World War, the international community came together and vowed that such atrocities would not be allowed to happen again.  That’s right, there is such a thing as universal human rights under international law.  That’s the reason I went to law school – to study the international protection of human rights.  The UDHR formed the basis of important political and legal developments internationally and in many regions and individual countries, and spawning two International Covenants – on Civil and Political Rights and Economic, Social and Cultural Rights.

Now that I’ve been practicing elder law for many years, referring to the National Academy of Elder Law Attorneys’ Aspirational Standards (coincidentally, many internationally recognized human rights are “aspirational” in nature – meaning they are emerging or not fully recognized as rights as such in the legal system), I am seeing more of the broader connections between elder law and human rights.  So, based on that theme, I started looking around a bit more after I saw a reference in the latest query on the rights of elder people in international law.  Thomas Hammarberg, former Council of Europe human rights commissioner recently spoke in Gothenberg, Sweden   about the pressing situation faced by many elders in the European Community.  The number of elders worldwide is burgeoning and coupled with the Great Recession, many are faced with dire circumstances that are a breeding ground for exploitation and degradation.  The “rights of the elderly” is a concept that is both broad and particular at the same time, as it reflects the fact that the challenges and needs facing elders are quite diverse, reflecting a broad range of legal, social, financial, medical, emotional and social implications.

The UDHR, at article 25, para. 1 states

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

The rights of the elderly often tend to be a right “to” something (such as security, health care, participation, dignity and nondiscrimination) as opposed to the United States’ historically preferred position to support freedoms “from” on the basis of governmental intrustions.  Of course, elders have well-recognized civil rights in this country to be free from exploitation, abuse, neglect and inhuman treatment.  How will the rights of elders evolve and develop?

Here’s a link to an interesting law review article entitled “International Human Rights and the Elderly,” published in the Marquette’s Elder Advisor and available here.     I also found an interesting abstract of a paper by a member of the law faculty at Montreal’s McGill University titled “The Human Rights of the Elderly: An Emerging Challenge.”     The most interesting aspect of this abstract is the connection made between “ageist” attitudes and discrimination in youth-glorifying and death-denying societies.  I find this connection especially apparent in our culture, which is obsessed with the “doing” aspects of life, and when we are no longer able to “do” as we previously did, we are diminished, worn down, used up and not entitled to the same level of respect as we previously enjoyed.  I think this attitude is not uncommon.  As long as our notions of dignity and respect are linked exclusively to “doing,” the ethics of how we treat people as rights bearing “beings” will be difficult to make coherent.   Included in this conundrum are the rights of the disabled along with those of many elders, whose capacities may be diminishing and are part of a large group of vulnerable persons in need of protection.  I found helpful an overview by the Human Rights Education Association about “The Rights of the Aged,” available here

I couldn’t write this post about the implications of youth-glorification and death-denial in our culture and legal systems without mentioning how our separation from our older, sicker and frailer selves also serves to distance us from the last part of our existence, our life journey  – dying.  Can the dying person and their dear ones reclaim grace and dignity in the process of dying?  Why yes, and thanks to The Soul of Bioethics newsletter I receive from The Healthcare Chaplaincy,    I learned about The Sacred Dying Foundation.    This follows on some familiar themes I have previously blogged about – how our treatment of death and dying informs our values about life. That’s all for now.

Should Anyone “Practice” Grieving?

 

 

 

 

Well, what kind of a question is that?  I was thinking about a friend who I knew was “grieving” the outcome of the election.  Then I saw GriefLink’s post today about grief and the election results.  You can read it here.   So why do we tend to associate the grieving process exclusively with death?  I don’t know, but part of the challenge with grieving, recognizing it, making space for it and honoring the process as we individually experience it and as others experience it – is to sufficiently recognize what it is.  I have written about Kuebler-Ross’s five stages of grief before, but here’s a review:

1. Denial.  We may dig in our heels and simply refuse to accept that things have changed.

2. Anger.  We might rant and rave at people, institutions, God, or life in general for delivering us a package that we didn’t want.

3. Bargaining.  We make try to “cut a deal” with life, the universe, the “powers that be,” in the hope of getting what we really want.

4. Depression.  We might get the idea that nothing really matters, that everything is futile, when we deeply feel our helplessness.

5. Acceptance.  We might arrive at this stage only after each of the above stages has been fully experienced, when we are finally ready or able to see.

The five stages of grief apply not only to death of a loved one, but to death of a pet, but changes in relationships like marriage, a job or career, a change in health status or well-being, or some cause or effort that was held dear that did not come to fruition.   We practice this death and dying things every day, whether or not we are aware of it.  The quote from the Greek philosopher Heraclitus comes to mind: “You can never step into the same river twice, for new waters are always flowing on to you.”  And why would I mention just one quote from Heraclitus when I could also say “there is nothing permanent except change.”  We practice grieving every day, and sometimes it helps to recognize that for ourselves, but more importantly – to see it in others, when they are grieving.  Sometimes simply witnessing can be enough for another person to help get through this often difficult process that follows the heart’s timeline and not a chronology that an intellect can measure or otherwise quantify.

So what is important about being with someone who is grieving?  Presence.  Presence is a form of compassion.  Another suggestion – this one from Henry James (I’m a huge fan of his brother William James) who wrote “three things in human life are important:

The first is to be kind,

the second is to be kind, and

the third is to be kind.

So in the meantime, I think it’s a good idea to follow the advice of Kahlil Gibran: “be like the flower – turn your face to the sun.”  If you’re not sure which direction the sun is, let your smile find it.  Smiling a little bit more will lengthen your days and make you a happier person.  Yep, there’s a Ted video to prove it!  Watch Ron Gutman’s presentation here.

I’m grateful for the little things, which reminds me of another awesome Ted video!  Neil Pasricha will jump start your thinking about change and gratitude!  Nope, nothing “legal” in this post, except that I help people work through many of these changes, which often involve grief – every work day.

©Barbara Cashman     www.DenverElderLaw.org

 

National Healthcare Decision Day – Are You Ready?

Does It Matter How We Face a Health Crisis or the End of Our Life?  If you answered yes, like most Americans, then you may want to have that difficult conversation now – while you can, and put a plan in place to ensure that your preferences are known and that the pressure is taken off family members to decide in a vacuum.

Monday, April 16th marked the 5th Annual National Healthcare Decisions Day.  What is National Healthcare Decisions Day?      It is designed to educate the public and providers about the importance of advance care planning.  It promotes the idea that having these conversations and making plans to support having the preferences and choices carried out is taking care of each other.

Please don’t mistake this for a national “fill out a form” day.  This is not the message!  It is about appreciating the significance of talking to loved ones about health care scenarios and making preferences known.  The end result of this process is the documentation.

You can begin the process by asking yourself: “what kind of health care do I want if I have suffered a life-threatening traumatic injury, accident or face an illness that may be terminal or is likely to impair my ability to decide for myself?  These are not “unthinkable” scenarios, they happen every day whether we are aware of them or not.  While we cannot control many of the circumstances leading up to the illness or injury (when it is often too late to have the conversation), we can choose to make deliberate and informed choices about health care, and this will make it much easier for our loved ones to take care of us, instead of worrying about “what we would have wanted.”  A great form that is readily available to assist in thinking about these questions, scenarios, preferences and values is available from the University of New Mexico in pdf form.     This form is long but it is thorough and likely to cover situations that we otherwise wouldn’t consider.  Many of us use our personal experience as a reference point (“don’t let me end up like great-Grandma Jones who was kept alive for seven months . . . !”), but that should just be the starting point for the conversation.

How do I get started?

  1. Educate yourself – take a look at the Colorado Bar Association’s pamphlet about Advance Medical Directives.
  2. Think about what is important to you by using a tool like the Values History form or the American Bar Association’s Toolkit for Health Care Advance Planning
  3. If you have special concerns relating to your decisions, or need help getting family or loved ones involved in the process – get assistance!
  4. Pick a person (an agent or proxy) on whom you can rely to be your health care agent and make sure that any questions you have about how this arrangement works are addressed by legal and/or medical professionals.  Some basic questions about the difference between a financial and a health care power of attorney are answered in the Colorado Bar Association’s Senior Law Handbook   where you can also find good information about hospice and palliative care.
  5. When you have identified what you want, communicated with others and discussed your preferences, you will want to ensure that these will be carried out – so don’t forget the last step of making the documents!  Each state has its own unique laws, so while you may think that  a “one-size-fits-all” form you find is great, you may want to be sure that it will work in the way you want it to – so check with an attorney who focuses on elder law and these types of issues.

Difficult Conversations About End of Life – DNR vs. Health Care Power of Attorney

What many people don’t want to consider – is the prospect of when a person’s DNR/DNI (do not resuscitate/do not intubate) directions may come into conflict with what an agent under a health care power of attorney decides. When a surrogate overrides the patient’s stated wishes (for example, where the children’s interests in “saying goodbye” override a mother’s DNR wishes) Check out this very powerful video of two daughters recounting the difficult decisions they made regarding their mother’s health care.

This video highlights the slippery slope of medical intervention and not knowing when the intervention will end and a daughter’s grief about going against her mother’s wishes.  She poignantly describes her mother’s searching eyes which seemed to ask “why are you doing this to me?”  This is an excellent reminder for all of us, especially those who work with older people who are facing health challenges: have the conversation with your kids or other surrogate decision makers and make your wishes explicit!  It is also useful to note the ongoing need for what the medical document known as a DNR means –it doesn’t mean “no medical care” – it means do not resuscitate.

Between the short periods of time a doctor may spend (if any time is spent at all) explaining to an older person or one who has a medical condition or disease which would make a DNR, and the reluctance that most people have to talk to their loved ones about these difficult situation, these conversations are hard, but worth the effort according to all the people I’ve spoken to about it.  I always encourage my clients, and sometimes also participate in family meetings around this issue of facilitating a specific conversation about identifying a older adult’s wishes, talking about particular scenarios and using specifics where appropriate to illustrate how wishes might be carried out.

Daughter who decided, when asked by the doctor whether she would give permission to put her mother on ventilator decided that she would have done things differently and would have declined intubation.  Daughters could see the pain their mother went through and finally asked mother to respond by blinking to their question “do you want to be taken off the ventilator?”  Very powerful video I strongly recommend.  This is why I think it is important to take time with clients, who are willing and interested in getting real about the difficult end-of-life choice, to discuss with them and often with their adult children the difficult but inevitable prospect of “letting go.”

Along similar lines is an article by Sally Mauk in The Missoulian entitled “Doctor Says Advances Prolong Life, Make Dying Harder,”   The article pinpoints several of the difficult facts that we baby boomers must face in light of the experience of many of our parents’ deaths as well as medical and economic realities that have dramatically changed in recent years.  Mauk’s article is primarily about Dr. Ira Byock, a past president of the American Academy of Hospice and Palliative Medicine.  Byock’s website is www.dyingwell.org and his book Dying Well, published by Riverhead in 1997, is on my office bookshelf, and his newest book “The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life,”  is a book I’ll be reading soon.  It is best to take the time to start thinking about these issues so that a conversation with loved ones will be more likely and probably less stressful – start with your doctor and don’t forget to consider how the medical and legal documents can work together to support your goals.