At the Bedside of Life and Death
In the old days, before people became foolishly arrogant because of life-saving technology, they were wiser about the human life cycle and about the inevitability of death. When Grandpa took to his bed, they brought food to him, but when he stopped eating, they wisely realized that his time had come and gracefully accepted it.
I don't believe it happened this way.
In our own era, we are preoccupied with "stages" that we are supposed to go through at certain ages. In this tale, the concept of a "stage" is inappropriately transposed upon the imaginary death scene of the past. It is true that, in the past, nursing the ill at home was the rule, and families were no strangers to death. But before modern times — with our good nutrition, vaccinations, sanitation, and antibiotics — dying was by no means confined to the aged!
Far from having today's idea that death is just another "stage" of life — like preadolescence, adolescence, middle age, and all of the other "stages" we read about and dutifully try to fit ourselves into — they knew the reality that death could steal you away at any age.
The lady of the house — an old-fashioned expression, but that's the way it was — nursed the same people over and over again, both the young and the old, and she saw them recover many times before she finally saw them die.
She may not have been familiar with all of the diagnostic categories in today's medical world, but she knew all too well about the vicious cycle of exhaustion and dehydration that carried many people away in those days. They became feverish and too exhausted to drink. She knew that if she couldn't get her relative to drink, he would perish. She had seen it many times.
I don't believe she sat by his bed calmly thinking about how death was inevitable. She knew from the past that when an ill person lay weakly in his bed, things could go either way. He might look like he was going to die, but then recover and get strong again.
Grandpa was no exception. She couldn't kid herself that his death was inevitable. She knew it was possible that she could make a difference, by bringing him appealing drinks at the right time, by encouraging him, by cooling him, warming him, praying for him, whatever.
She understood that it was a life-or-death matter. When he stopped eating or drinking, she was probably heartbroken, and may have pushed herself to exhaustion — she may even have succumbed herself, to illness, or even death — trying over and over again to give him different foods, different drinks, different words of encouragement. Having no technology to help her, she understood intimately that human beings need constant sustenance and that they die without it, at any age.
Right-to-die advocates portray themselves as the intellectual heirs of this old-fashioned caretaker. Nothing could be further from the truth.
Mortality Is Not Predictable
Although modern families, sheltered from contact with death, often believe that their loved one in hospice is caught up in some sort of unstoppable, universally applicable "death process," the old-fashioned caretaker would not think this way.
She knew the process of death intimately. She knew that, in most cases, it did not consist of just a gradual fading. An ill person would have a crisis and either pass through it or not. If he was weakened at the time of the crisis, he was more likely to die, but nothing was definite.
The old-fashioned caretaker was tuned to clinical reality, which, of course, hasn't changed. In a 1999 research report published in the Journal of the American Medical Association, Ellen Fox and her colleagues took the hospice-recommended criteria for predicting six month mortality and tried to apply them to a group of patients with congestive heart failure, chronic obstructive pulmonary disease, and end-stage liver disease. The criteria failed to predict mortality.
In an editorial in the same issue, Finucane wrote, "Even in this carefully studied group, death was an unpredictable event. On average, 3 days before death patients who died of congestive heart failure were predicted to have an almost 80% chance of living 6 more months. At 2 days before death, patients with chronic obstructive pulmonary disease were predicted to have a 6-month survival of 50%. On the day before death, patients with congestive heart failure were predicted to have a mean chance of 62% to survive 2 months."
Finucane quotes the authors saying that many of the patients "never experience a time during which they are clearly dying of their disease."
Fox and her coauthors explain that for "patients with advanced lung, heart, or liver disease...the proximate cause of death is often a relatively sudden and unpredictable event such as a pulmonary infection, a cardiac arrhythmia, or a massive gastrointestinal tract hemorrhage...."
If we don't believe that the removal of life-saving interventions would restore the allegedly peaceful and predictable deaths of yesteryear, how can we explain the fact that many families come away from hospice feeling that their loved ones faded gently away in a very natural process?
The Interpretive Framework
The apparent smoothness of the hospice fading-away process is due to a combination of factors.
First of all, hospice has talented counselors who constantly interpret everything that is happening and keep the family resolute and calm. Remember when Terri Schiavo was dying? Her husband Michael Schiavo and his attorney George Felos, in spite of Terri's smiles, had always referred to her as a suffering victim. But once the dehydration process started, Felos referred to her as beautiful and peaceful. Clearly, the beliefs of the observer have a big impact on how the patient looks to him. Hospice counselors keep talking to the families, offering them interpretations that make them feel that whatever is happening is supposed to be happening. In spite of all the right-to-die rhetoric circulating in our culture, families have trouble withholding treatment from their relatives, and the hospice counselors have to repeat to them over and over again the hospice justifications that they are not really doing anything and that the disease process is what the patient is dying of.
Counseling the patient and his family is important because the cooperation of the family is critical for the smooth appearance of the death process. If the family insists on feeding and hydrating the patient and giving him almost all of the medications and treatments that he had in a curative setting, he may remain vital enough, as his symptoms get worse, to complain loudly about them — as sick people are wont to do — and violate the family's idea of what a peaceful death should look like.
For the death process to seem peaceful, it is therefore important for the hospice staff to coax the patient and the family to forgo many of his previous supportive treatments that may have been keeping his blood pressure under control, his airways open, and his hemoglobin and electrolytes at appropriate levels and to adjust his attitude from a fighting attitude to a waiting-for-death attitude. This combination of adjustments, along with a comfort-food diet and hospice doses of sedatives and pain killers, may cause him to fade considerably. This fading can then be the grounds for announcing that he is in the "death process" so that the family can be induced to start withholding food and fluids. Once this has occurred, the physician can be induced to prescribe higher doses of morphine or similar medications.
The appearance of a peaceful death is not a natural occurrence.
The hospice staff has to work on two fronts to gain the cooperation of both the patient and his family, on the one hand, and the physician, on the other.
The terminal events that take a patient's life still have to occur for him to die. It is just that no one takes any official notice of them.
The patient is weakened from dehydration and sedation, and his functioning is not being monitored. So who would know that he was having a heart attack or whatever?
Why does the modern family, observing this semblance of a peaceful death, need the aid of professional counselors, unlike the families of the past? Certainly, the emotional ties of the families of the past with the deceased were not any weaker. On the contrary, they may have been stronger. Back then, Grandpa didn't live in a distant city. He lived with the family. Back then, when the culture wasn't changing as rapidly, the ideals that Grandpa had lived by were the same ideals that the rest of the family lived by. He didn't seem out of date. On the contrary, he may have been looked up to as a leader.
According to hospice proponents, the reasons modern families need so much counseling is that they have a lot of psychological issues and also that we have become so arrogant about preventing death that they need counseling to accept it.
I don't believe this.
The real reason is quite different. The old-fashioned family tried their utmost to keep their loved one alive. They did not hesitate to do everything for him that they knew how to do and that they were able to do.
Their actions were completely consistent with their ethical beliefs, and therefore, although sad, they were spiritually at ease. In contrast, the modern family has been coached in a new ideology that has only partially taken root. They have been told by innumerable newspaper and magazine articles and television programs that they will have to make "tough decisions" about withholding care. However, this new attitude conflicts with the religion they learned from their grandparents, and when the time comes when they are expected to withhold care from their loved one, they hesitate. The counseling is necessary to help them over the hump.
Without the counseling, many families would balk at the idea of withholding care.
And if the family does agree to withhold care, they continue to experience uncertainty and pain, to the extent that they might change their minds. The hospice counselors reinterpret this pain. They tell the family that they are distressed because of the death of their loved one. They talk with them about their pain and discuss all sorts of family matters, and a few days go by, and before you know it, the dehydration is over with.
The reason the modern families need counseling, in contrast to their ancestors, is not because they have difficulty accepting death itself or the loss of their loved one. It is because they have difficulty accepting that their loved one's death is brought about by passive euthanasia. The expertise of hospice in creating the appearance of a smooth death includes palliating not only the symptoms of the patient but also the conscience of the family.
The right-to-die fairy tale is one of the tools that health care counselors can use. A family member who might tend to lean on traditional values and reject the right-to-die rhetoric as new-fangled can be told that he has it all backwards, that giving up on Grandpa's life was traditional and trying to prolong life is new-fangled. He can be encouraged to feel guilty for the very things he previously thought were right and proud of the very things he previously thought were wrong.
It is very hard for an individual to hold his own point of view when he is surrounded by authoritative-sounding people who think the opposite way. Psychology experiments have shown that many normal people will even say that a shorter line is longer if everyone else says it is. They will even pull a switch that they think will give someone an electric shock if they are told to do so by an authoritative figure.
The fairy tale about the family of the past accepting Grandpa's death is one of the tools of the right-to-die movement. Like other fairy tales, it isn't true.
© Copyright 2005 Catholic Exchange
Dr. Olevitch is a clinical psychologist and author of Protecting Psychiatric Patients and Others from the Assisted-Suicide Movement: Insights and Strategies (Praeger, 2002).
At the Bedside of Life and Death