Is there such a thing as a good death? Certainly, it should involve a minimum of suffering. Hopefully, it is one in which you have a chance to say good-bye to loved ones and family. Is it possible to die with peace and dignity? Dare I say it, death is a fact of life. It is a given the day we are born, an inevitable occurrence. We will all shuffle off this mortal coil. The cliches and platitudes on the topic abound.

Yet modern medicine has advanced to the point where many people can be kept alive almost indefinitely. The technology available to sustain life is impressive, with various machines able to take over life-sustaining functions. This allows so many of us to be kept from death’s doorway, hovering on the edge. Does this make for a good death? Many say no, although palliative medicine has made strides. This is the branch of medicine devoted to alleviating suffering for people living with a serious or life-threatening illness. This type of care is focused on providing relief from the symptoms and stress. The goal in palliative care is to improve quality of life for both the patient and the family.

A question asked in many modern-day societies, how long to hold on to life? Is death preferable to that of continuing distress and chronic pain? Throughout recorded history, the answers have varied. People want to live, but without unbearable suffering. When life is too painful, and the end is certainly in sight, what good options are there? The Hemlock Society was founded on the belief that people should have the right to die when they have reached that point, of unbearable suffering without a hope of recovery.

Certain inarguable facts are clear regarding our ability to provide for this nebulous concept of a good death. One of these is that death, even in this age of technological wonders, can be associated with intolerable suffering. Despite our best efforts, medicine as it currently exist is not able to relieve all the pain and suffering of many individuals. Some distress may only be relieved by death. What is the physician’s responsibility in this scenario?

Physicians providing palliative care wrestle with the concept of euthanasia. The technical definition of the word is “a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering”. The word originated in ancient Grecian culture and meant ‘a good death’. Put in simpler terms, euthanasia can be thought of as the “painless inducement of a quick death”.

How much control should the patient have over their own life, specifically the end of their life? Laws regarding assisted suicide vary greatly in different countries. Attitudes on this subject differ throughout the world. In the US, the terminal patient who is suffering has no legal right to assistance from their physician to stop their pain by ending their life. Australia is one of the more progressive on this hotly contested issue, while Canada is one of five countries with true active euthanasia. They, like these other countries, limit it to specific circumstances and require the approval of counselors and doctors.

In the US, passive euthanasia is legal. This entails the withholding of treatment necessary for continued life. Passive euthanasia is not the same as active euthanasia, which, in turn, can be contrasted with PAS, ‘physician-assisted suicide’. The terminology varies, as do the laws pertaining to this ‘hot-button’ issue.

Physician-assisted death is still illegal in the United States. Yet, in 10 states physicians may supply lethal doses to terminally ill patients although the patient must administer the medication to themselves. Although a majority of Americans support euthanasia, 72 percent according to a nation-wide poll in 2018, changing federal laws on such a hotly contested issue is not going to occur easily.

Passive euthanasia is manifested in the DNRO, the “Do Not Resuscitate Order”. This is a legal document which prevents the provision of CPR or advanced cardiac life support when someone’s heart or breathing stops, as per the patient’s decision. Why would someone sign a DNR? One common reason is CPR is unlikely to be successful or prolong life for long. CPR can be traumatic and result in various injuries for the frail or infirm. Or they may fear becoming dependent on a machine to breathe. Most commonly, patients with a terminal illness may decide to allow the natural process of dying to occur rather than being resuscitated.

The DNRO is much different from a living will. This is a document typically created by a healthy person as part of a plan for advanced care. The living will deals with different aspects of end-of-life care. The DNR is a real-time medical order and would typically not be in place for a healthy person. Generally, the living will is made by an individual who would want to be resuscitated in some life-threatening medical emergency.

Some might see the phrase a ‘good death’ as an oxymoron. Perhaps more accurate, more realistic, would be the term the ‘least worst death’. But isn’t it as much the business of a physician to alleviate pain, and thus to smooth the avenues to death when unavoidable, as to cure diseases? No one will argue this is a simple question, with personal mores and beliefs holding sway over facts and figures. Clearly, this remains a subject of bitter debate. Subjectivity reigns, with definition on what is regarded as a ‘ good death’ an extremely personal issue.

Some would argue if euthanasia is legalized, health care would reduce its efforts to maintain life. Another concern is that family members or others will push suicide when care becomes burdensome. There are also fears that people will make the choice when they are emotionally vulnerable or have not been offered proper pain relief or palliative care. Then there are the religious implications, with all the nuances and theological ramifications. A discussion on this component of our subject has filled many tomes and is beyond the reach of this article.

Shouldn’t a peaceful death be a legitimate goal of medicine? No one will argue a part of a physician’s responsibility is to relieve pain. Should family members be the driving force in keeping the patient alive, sometimes at all costs? Many experts would say American health care favors quantity over quality regarding life and specifically the end of life. Regardless of your personal opinion, this will likely remain a subject of bitter debate, eliciting strong emotions and hotly debated for years to come.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.