Death with dignity and death certification

In several states physicians are permitted to prescribe terminally ill patients lethal doses of medication expressly for the purpose of ending their life. By the terms of the statutes authorizing this practice, these patients must meet certain medical, psychiatric and physical criteria, including the ability to self administer the medication, and they must administer the medication themselves.

In at least one of these states, the statute also specifies that deaths occurring in this context are to be certified by the prescribing physician as natural deaths with the cause being the underlying terminal illness.

Longstanding state law also stipulates that deaths thought to be due to unnatural causes, such as drug overdoses, are required to be referred to the medical examiner or coroner for investigation. If the investigation determines that the death was due to an overdose, and the overdose is deemed to have been intentional and for the purpose of ending one’s own life, the death is certified by the medical examiner or coroner as a suicide with the cause of death being the drug overdose.

I’m wondering what people think about this - not so much about the ethics of death with dignity / assisted suicide / etc. But more about the legal stipulation that these deaths be certified as natural due to natural disease.

I disagree with certifying them as natural deaths. It just muddies the waters, especially since there is some research suggesting that depression is overlooked and underdiagnosed in terminally ill patients seeking assisted suicide (example here).
In some cases, the physician may not honestly be able to state that it was the cancer rather than depression that motivated the person’s suicide. At least if you label it a drug overdose, that is something that you can state objectively.

For a terminal patient, morphine at very high levels is often the Rx as death nears. If unstated as a “death with dignity”, it still happens. I think the COD should be the terminal illness.

How does a COD of suicide affect insurance, pensions or Social Security payments to surviving spouses or family?
Until we are able to list “Cancer / Assisted death”, and have it treated the same as “Cancer”, than I think it needs to be listed as the terminal illness.

Time to read the script or try to view the movie version of “Whose Life Is It Anyway?” with Ian McShane as the main character. In this play/movie, a severely disabled man wants to die, and the medical professionals around him want to keep him alive, no matter what.

I’ve worked 35+ years in health care; I’ve been told, by many patients, that death is a merciful release, earnestly wished for. They tell me that when life becomes too much of a burden, it’s time to turn out the lights.

I totally agree with this summation. I recall reading, some years ago, about how keeping terminal cases alive just days longer fueled a steep, steep rise in cost -
and for what? As Ian McShane’s character says, “I don’t want to live on as a medical achievement.”

Some people are afraid to die. Some professionals see death as the enemy.
Perhaps it’s now an educational quandry; let your heirs know what your wishes are re: end of life care. I have.

an seanchai

I will say that any system that requires someone to spend an extra couple weeks in horrible, agonizing pain in order to leave their family life insurance that they paid for (and in every meaningful way qualify for) is screwed up, and I’d rather have a 100 legally fudged death certificates than one person have to go through that.

I plan on suicide when the alzheimers hits. I am going to be in a wheelchair and need to be in a home and I will probably end up with the rampant familial parkinsons.

I refuse to live on as a brainless shaking husk that can’t even walk to the toilet.

I can’t speak for insurance or company pensions, but cause of death is not an issue in determining eligibility for Social Security survivor benefits.

My late wife’s death certificate shows only “End stage Parkinson’s Disease” as the cause of death. She was on home hospice care the last two months of her life, with her only source of nourishment a feeding tube. We had both agreed years before that neither of us wanted to be kept alive when it was obvious that there was no mental function. I held out my hopes for her recovery as long as I could; she actually seemed to be improving when she was first brought home from the hospital, but then her condition deteriorated to the point where she was totally unresponsive and I chose to stop her feeding (after being assured that she would feel no pain), effectively letting her starve to death. Did I kill her? No, I let her life end with what little dignity she still had left.

Discussions about this topic always gravitate around the eithical issues, which is understandable, as those issues are very weighty. But for the present discussion, I’m most interested in the more nuts and bolts question of what people think about how these deaths should be certified. How should they be entered into the public record? How should they be recorded as vital statistics?

(a) As suicides: the declared intentional ending of one’s own life through the direct consequences of one’s actions; or

(b) as natural deaths, deaths caused solely by natural disease?

Also, I wonder what people think about the fact that the way in which DWD/AS deaths are to be certified is stipulated by law. To my knowledge, this is the only context in which a law mandates how a physicain must make a diagnosis.

I don’t think you can avoid the ethical issues because they are the reason for the law: basically, no one wants "suicide (b/c of terminal pain) to be a reason to deny someone’s family life insurance, and the law exists to make sure that doesn’t happen. If it weren’t an issue, of course I’d want more accurate death certificates, but at this point the price of technically accurate paperwork is literally someone having to decide between horrible agonizing pain and their family’s future. The light’s not worth the candle.

I have to agree with Manda JO. Yes, I’d prefer that the cause of death on birth certificates be the actual cause of death, just 'cause I’m funny about Permanent Records like that. But if there’s the slightest chance that having “Suicide” or even “Assisted Suicide” on a death certificate will cause a scumbag insurance company to alter their payments to the family, then the factually incorrect death certificate is worth it. Might piss of the genealogists, but I think that’s an acceptable price to pay for allowing both dignified death and financial compensation due.

So I think focus should be on the insurance companies. Force them to pay out for medically assisted suicide as they would for cancer first. Then we can address truth in death certificates without fear.

Apologies. I meant to address the insurance question in my previous post.

Patient (and survivor) protection as far as insurance is concerned is already built into the law. From the statute: *A qualified patient’s act of ingesting medication to end his or her life in a humane and dignified manner shall not have an effect upon a life, health, or accident insurance or annuity policy.” *

If that’s the case, then I think the death certificate should read something like, “Medically assisted suicide/ Liver cancer”. But never having seen a death certificate, I don’t know if that fits in the form.

I would like to offer one set of consequences of not fixing this problem.

The problem as I see it is this:* it is difficult if not impossible for a citizen in this country to legally master his or her own life’s end. This is true even though this country has the technology to allow every citizen to plan for a life’s end that affords dignity and maximum comfort. In addition, the life’s end process is economically catastrophic. This no more true than with retired or elderly couples who, when one dies in a hospital or after a long stay in a nursing home, the other is all too frequently left destitute.*

That’s just wrong.

I am a 66 year old man, in good health, comfortably retired, and happily married for 20 years. I am ten years older than my spouse, so she will most probably live at least a decade longer than I will. I retired from a 35 year career as a project manager in information technology at age 62. We are not wealthy, we are not poor. We live on my Social Security, my small AT&T pension, a small annuity from my 401k, and on my wife’s salary. My wife will retire in 4 years, using her 401k as an income bridge until she reaches her earliest Social Security retirement date in 6 years. We recently refinanced our home on a new 15 year loan at a very low interest rate – and we have in excess of 75% equity accrued. We are comfortable – life is good.

I have never purchased life insurance. I abhor gambling and purchasing insurance is gambling; just like in a casino, the odds are heavily stacked for the house. I’ve been accused of being pig-headed about this – but I don’t care – right or wrong, it is how it is.

I am very aware of the possibility of catastrophic illness in my future leading to death. I am determined that this natural course of my life will proceed in dignity, and will not leave my spouse destitute. I am determined not to spend extended time in a hospital for any reason unless I am certain I will leave that hospital alive and well. I am determined not to enter a nursing facility at all, ever, for any reason. I have many reasons for these refusals, but the reason most pertinent to this discussion is the astronomical cost.

I realize that the various systems in our culture will contrive fiercely to defeat my determination not to do these things. I know I can be physically forced into either a hospital or a nursing home, and physically restrained from leaving either of those organizations. This does not affect my determination in the least. In fact it helps me to understand the seriousness of my decisions and how carefully I must plan if I expect to ensure a dignified, reasonably comfortable death that will not result in economic disaster for my spouse. After a successful career as a project manager I have the skills for effective planning, so, time permitting, I know I can create and execute an effective plan for a dignified life’s end.

I’ve researched suicide extensively and have finally determined that the most effective method, the one that has the most potential to provide a quiet, clean, and reasonably comfortable death, is heroin. It is a reasonably stable drug and if kept in a vacuum sealed container in a cool, dark place, will remain potent for many years – so I can purchase it ahead of time and not be concerned that it will be impotent when I need it. I am now in the process of researching how I can purchase a sufficient quantity of this drug for my purpose and ensure its level of purity. Obtaining the “kit” should be relatively easy. Once everything is assembled my current plans include vacuum packing the drug, placing kit and caboodle in a water-proof container, and burying it in an unfinished portion of my basement where it will be easily accessible.

I have not told my spouse about this. She, of course, knows my feelings about hospitals and nursing homes (death-and-illness-profit-centers), and about the obscene attitudes in our culture concerning death, but I will never let on what I’m planning because just as I do not want her to lose everything because of my death, I do not want her facing liability or criminal prosecution for how I chose to die. Also, as it turns out, my life-long refusal to purchase life insurance shows a bright silver lining since, as a result, there is no death-and-illness-profit-center out there that can refuse to pay off because of the way I chose to die.

So you see, the consequence for me of the attitudes toward death in our culture being so draconian and obscenely barbaric is that I must become a lawbreaker if I have any chance of a dignified and economically reasonable death. In my planning for my life’s end I have to consider the dangers of being arrested, the very real possibility of purchasing bad drugs that will only make life’s end worse, and I have to plan on how to protect my wife from the law after I am gone. You have no idea how angry that makes me. I’ve been a law-abiding citizen all my life, and it is absurdly unfair to force me to become a criminal at the end.

In spite of my anger I am optimistic that our culture will one day wake up and these problems will be considered yesterday’s news. I only wish it could have happened in my life time.

If you’ve read this far, I applaud your patience and thank you for your time.

In most states, the exclusion period for suicide is two years from the date of the policy. If you decide to commit suicide after that, the insurance company will have to pay the claim, whether the suicide is due to terminal illness or mental illness or a drunken game of Russian Roulette.

If this is indeed the case, then the falsification of the death certificates makes it a certainty that there won’t ever be an accurate statistical examination of implementing the law. It is akin to the legislature saying, “We really don’t want to know how many terminally ill people kill themselves or get medical help to do so”.

Having given this a few more minutes thought, and assuming again that fudging the death certificate isn’t necessary in regards to survivor benefits, than I am quite sure that it is done to avoid accountability by the legislators who voted for it.

It is possible that reporting such deaths as suicides could… double?.. triple?.. the previously reported suicide rate for the state. Even more? I dunno, but as an aggregate they would be added to all the other suicides. And in future elections, they would face such accusations as “voting for a law which tripled (or whatever) the suicide rate of our state”. Or even worse, “Candidate Doe’s law directly resulted in five thousand deaths last year alone.” And there’s no real easy way to refute charges like that. The intent of the law was in fact to increase suicides, even of only as a side effect of decreasing suffering among the terminally ill.

The termnial illness still caused the death; it just happens to be a slightly less proximate cause. I’m ok with it.

I was thinking of this, also.
So, this wouldn’t really apply to insurance companies, usually.
Also, it would skew medical research. IMHO.

Best wishes,