Deferring Termination of Life Death with Dignity

A century ago, most people who suffered traumatic injuries or contacted serious infections died soon afterward. Even those who developed heart disease or cancer had little expectation of a long life, after the disease was diagnosed. Death was familiar experience, and most people expected, little more than comfort care from doctors. Today, death is often seen as an event that can be deferred indefinitely rather than an intrinsic part of life.

The leading causes of death for people over age of 65 years in the developed countries are heart disease, cancer, stroke, chronic obstructive pulmonary disease, pneumonia, and dementia. Medical procedure commonly extend the lines of people who have these diseases, often giving people many years in which quality of life and function are quite good. Other times, procedures extend life, but the quality of life and function decline. Death often seems unexpected even though the family knew that the person who died had a serious illness. To say that a person is dying typically means that the person's death is expected to occur in hours of days. Also, people who are very old and frail or who have a fatal disease such as AIDS are often said to be dyeing.

Most people with chronic disease - such as heart disease, certain cancers, emphysema, liver, or kidney failure, Alzheimer's disease, and other dementia - live for years, although they become limited in physical activities. Honest and open communication between patient and doctor about the patient's performances for care at the end of life is essential for the best possible quality of life during a fatal illness. The doctors provides a candid assessment of the likelihood of recovery and disability during and after various treatment options, and the patients tells the doctor and his family what he wants and does not want to experience. The patient should state his preferences for treatment, the limits he wants placed on that treatment, and his wishes concerning where he wants to die and what he wants done when death is expected When choosing a doctor, a person should ask about care at the end of life. Does the doctor have substantial experience caring for dying patients? Does the doctor care for the patient until death in all settings - hospital, nursing home, or home? Does the doctor treat symptom fully (palliative care) at the end of life? Is the doctor familiar with the home health, physical therapy services available nearby?

Predicting when a person will die of a chronic disease is sometime required. Doctors can make a fairly accurate short term prognosis for an average patient with certain conditions, based on statistical analyses of large groups of patients with similar conditions. For example they may accurately estimate that 5 out of 100 patients with similar critical conditions will survive and leave the hospital. But predicting how long a particular person will survive is much more difficult. The best prediction a doctor can make is based on odds and the degree to which the doctor is confident in those odds. If the odds of survival are 10 per cent, people should acknowledge the 90 per cent likelihood of dying and should make plan accordingly.

When statistical information are not available a doctor may not be able to predict a prognosis or may make one on the basis of personal experience, which may be less accurate. However, gravely ill people and their families are entitled to the most complete information available and the most realistic prognosis possible. Often the available choices are between dying sooner but remaining comfortable and living slightly longer by receiving therapy (aggressive therapy), which may prolong the dying process, increase discomfort and dependence, and decrease the quality of life.

Dying may be marked by deterioration over a long period of time, punctuated with bouts of complications and side effects, as in some patients who have cancer. Usually about one month before death, energy, function, and comfort decrease substantially. The person is visibly falling, and the fact that death is near becomes obvious to all.

Dying follows other time courses. Sometimes, a person being treated aggressively for a serious illness in a hospital abruptly worsens and is known to be dying only a few hours or days before death. Increasingly common, however, is dying with a slow decline in capabilities over a long period of time, perhaps with episodes of severe symptoms.

Neurological diseases such as Alzeimer's disease follow this pattern, as do emphysema, liver failure, kidney failure, and other chronic conditions. Severe heart disease disables peoples over time and causes severe symptoms intermittently, but it usually kills suddenly with a disturbance in the hearts rhythm (arrhythmia).

Knowing the likely time course of a disease enables a person who has the disease and the family makes plans. When death from an arrhythmia is likely, they should be prepared for death at any time. For people who have cancer, the decline that precedes death usually gives some warning that the final days have arrived.

According to doctors, man dies in stages - rapidly or slowly, depending on circumstances. First comes the clinical death, when respiration and heart bear cease. The brain dies as it is deprived of oxygen and circulating blood, the biological death occurs. Life can be restored in the moments between clinical death and brain death if circulation and respiration are continued through the use of medical devices which stimulate the heart and lungs. After the brain ceases to function, cellular death begins. Life is not considered to be completely lost until the brain stops functioning. It is possible for doctors to remove viable organs after biological death for transplant or other use.

Many doctors and religious leaders insist that we need more honest communication about death, as such communication is probably the single most useful measure to avail unnecessary suffering. Sound knowledge never made anyone afraid.

And although death will probably always remain essentially a mystery to man, scientists will continue to search for a better understanding of it's nature by such means they many learn a great deal more about life.

Many doctors reports that death, except in unusual cases, is not accompanied by physical pain.

Rather, there is often a sense of well-being and spiritual isolation. Doctors think this feeling is often caused by the anaesthetic action of carbon dioxide on the central nervous system and by the effect of toxic substances. Earnest Hemingway wrote," The pang of death a famous doctor once told me, is often less than that of a toothache."

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