When I evaluate an elderly person in a nursing home, I typically ask, "Are you afraid something bad is going to happen to you?"
And I'll get, "I wish it did."
Or, "Do you think it is wonderful to be alive now?"
And I'll get, "No. I'll be happy to be dead."
It's common for people, whatever the narrative arc of their lives, who suddenly find themselves frail, elderly, and institutionalized to look for an early exit.
I also ask, "Are you happy?"
And I'll get, "I was until I came here."
If it's only a death wish, I'll probably schedule additional sessions plus make a referral for a possible antidepressant. But if I hear, "I'm going to throw myself out that window," even if the person is post-stroke and in a wheel chair, it's the suicide watch for him-because who knows, maybe he could pull out his oxygen tube, and the throw myself out the window thing was only a feint.
Most of the time, we in the trade go with the keep on truckin' approach. Life can't be that bad even if what you have to look forward to is a couple of years of post-stroke wheel chair dependency on the kindness of nursing home strangers in a hospital-style room you share with a stranger, and your door is always open and the PA system is blaring, "Phone call for Dr. Rosofsky."
But what if you feel it's your right to put an end it.
There is a society, the Netherlands, in which-in at least some cases-your doc can help you if you're post-stroke and in a wheel chair.
The Dutch have been doing this informally since at least the 70s and formally since 2002.
In 1973, a true-life post-stroke victim was put to death with an injection of morphine by her daughter, a physician, Geertruda Postma. Mom was in a nursing home tied down in a wheel chair, and was deaf. She had trouble talking, but when she did, she repeatedly asked to be put to death. Dr. Postma was put on trial for "killing on request," and was sentenced to a token one-week suspended sentence and a year's probation. Despite the conviction, the court set standards for what it suspected was a fairly common practice. A patient could be assisted in suicide if the patient is incurably ill, finds the suffering to be unbearable, and requests help from a physician in finding death.
In 2002, the Dutch enacted The Termination of Life on Request and Assisted Suicide Act, which formalizes the rules for assisted suicide. It adds the provisions that a second physician reviews the case, and that the patient be at least 12, although parental consent is required for those between 12 and 16. It also says that the desire for suicide not be due to a "psychological illness."
So what happens to the depressed? Persistent thoughts of death and suicide are major-if not the only-diagnostic criteria for depression-a psychological illness. So, technically, you need to treat depressed people so they can be happy enough to say they want to die, which reminds me of the practice of saving the life of a condemned prisoner so he can be healthy enough for the execution. Only a third of the approximately 9,000 annual formal requests for assisted suicide are granted, which likely indicates that some people reconsider on their own and others are treated for depression. Thoughts of suicide are not in themselves the defining symptom of depression-at least in the Dutch psychiatric community.
And that may be the point of it all. If you're not mentally ill, you should be free to kill yourself, at least if your suffering is unbearable.
There are unintended-or maybe not so unintended-consequences of Dutch practice. In 1991, the government published the Remmelink Report on assisted suicide. It found that although about only 1 to 2 percent of deaths are from voluntary assisted suicide, much higher percentages are due-maybe as high as 15 percent-from termination of life sustaining procedures, and there may be a thousand annually who are sped on their way-perhaps with high doses of pain killers-without their consent, impermissible killing.
The slippery slope. When you lower the drinking age to 18, it becomes easier for 16 year olds to get some beer. When you make requested assisted suicide permissible, does it get easier to do it without permission?
In the mostly uncodified U.S. assisted suicide/euthanasia landscape, we're already on the slippery slope.
Pick up a nursing home chart, and on the cover you are likely to see a sticker that says either, "Full Code," or "Do Not Resuscitate."
Full Code means do everything to keep me alive. Do Not Resuscitate means do nothing-our form of assisted death.
When my father was in a nursing home with severe dementia and my brother and I had Power of Attorney (which means we could make medical decisions for our mentally incapacitated father), we were urged to go with Do Not Resuscitate.
They said: "In case of an arrest or seizure, do you want your father to be on Full Code, which means we may revive him to spend a short time unconscious all hooked up with tubes to beeping medical devices."
The explicit subtext: "It's more humane to let him die."
The implicit subtext: "It would cost a lot of money to keep him alive."
In the end, when my father became ill, the doctor in the nursing home said, if he didn't get to the hospital, he'd die that day, and we could let it happen, but we opted for the ambulance and Dad lasted a few more weeks, although there was a couple of days when he was conscious, sitting up, and taking nourishment-so what we did may not have been completely unreasonable.
Human feeling, whatever the preconceived rational plan, tends towards giving life a chance over no chance.
When there really wasn't any chance, and Dad had slipped back into unconsciousness, we withheld nourishment, which ensured death. The docs assured us that starving to death when you're unconscious is painless, kind of like what they say about the live lobster in the boiling pot.
Is the sin of omission, allowing someone to die, less egregious than the sin of commission, killing them?
Most of the folks I see in nursing homes have Do Not Resuscitate as their advance directive. And if their son just doesn't happen to be around, they will die the day of their cardiac seizure. The directive is there to be executed-so to speak-without consultation with the family.
Back in the Netherlands, there are some old people who carry cards that say, "Please, Doctor, DON'T Kill Me!"
In opposition to this is the group Out of Free Will (Uit Vrije Wil), which is demanding the right to assisted suicide for anyone over 70 who has had a "completed life." Not only are they asking for this right, they want to establish a new profession of specially trained medical professionals and psychologists who would ease the passage into oblivion.
"And how was your day at the office, hon?"
My book, Nasty, Brutish, and Long: Adventures In Eldercare(Avery/Penguin, 2009), was a Finalist for the 2010 Connecticut Book Award. Click here to read the first chapter It provides a unique, insider's perspective on aging in America. It is an account of my work as a psychologist in nursing homes, the story of caregiving to my frail, elderly parents--all to the accompaniment of ruminations on my own mortality. Thomas Lynch, author of The Undertaking, calls it "A book for policy makers, caregivers, the halt and lame, the upright and unemcumbered: anyone who ever intends to get old."