At Peace
I’ve written many thousands of words in this blog, but this is only the second time I’ve discussed/reviewed AND strongly recommended a book here. Rather than try to write a coherent document, I’ll just offer quotes and comments on some of the important concepts in this important book and some of my own thoughts.
At Peace: Choosing a Good Death After a Long Life is a book for our times – for those of us who are living a long life and for those who are connected to loved ones who are at the end of life. Because, you know, we are all going to die. The only questions are when and how and who will be in control?
Are you one who would fight to the end? Be wary. To be clear: I am talking about older people with few physical reserves and no prospect of a long, independent life. For a young person, with physical reserves and the possibility of a long, independent life, fight on.
To every thing there is a season,
and a time to every purpose under the heaven:
A time to be born, a time to die;
a time to plant, and a time to pluck up that which is planted;
A time to kill, and a time to heal;
a time to break down, and a time to build up;
A time to weep, and a time to laugh;
a time to mourn, and a time to dance;
A time to cast away stones, and a time to gather stones together;
a time to embrace, and a time to refrain from embracing;
A time to get, and a time to lose;
a time to keep, and a time to cast away;
A time to rend, and a time to sew;
a time to keep silence, and a time to speak;
A time to love, and a time to hate;
A time of war, and a time of peace.
At Peace guides readers to the death they would choose (as much as death can be chosen), which, generally speaking would be in as much control as possible, at home, with loved ones, free of pain and other distressing physical issues, with dignity, and so on.
Hospice is NOT for the final few days of one’s life; to be most helpful and effective, hospice is best initiated when there are months of life left and problems are lesser rather than days or weeks left and after problems are severe. So much better to prevent problems.
Visualize the quality of your final days.
Planning on dying peacefully in one’s sleep isn’t much of a plan because that’s not usually the way it goes – unless one counts coma at the end of life as sleeping.
The cure for what ails us is not just around the corner.
The facts of CPR are that “the overall success rate… is 8-18%… and among the old and infirm (success) ranges from 0-8%” (p. 257; reported in the New England Journal of Medicine).
“…once intensive medical treatment is initiated, its momentum and outcomes are largely out of your control, and declining such treatment puts you back in charge” (p. xvii).
A person who reaches age 65 in “reasonable health” can expect to live almost 20 more years, almost half of which are “likely to be disabled years” (p. 33). How do we know when we are shifting from aging to disabled? When we need help cooking and cleaning? Toileting? When we fall and can’t get up? These are “milestones from which there is no turning back” (p. 43).
We already know these things are true – that it’s easy to be treated past rational hope and so spend the last months of life being tested, treated and in a hospital or nursing home. It seems like we often just kind of push reality out of mind because, you know, some pretty horrible things can and do happen and it may seem easier to not think about them except in general hypothetical terms AND, there’s that hope thing.
“Understand that with age the risk of treatment increases and the benefit decreases” (p. 48).
Medicalization as a means of “buying time” – what kind of time will it be and where will that time be spent? In the absence of some specific time goal (birth of a grandchild), the idea is to improve the quality of life in whatever time remains.
Dementia: At Peace offers a clause for progressive dementia in an Advanced Directive. I believe this alone is worth the price of the book. Some among us will have Alzheimer’s. It’s comforting that caregivers will know exactly when to discontinue all but palliative medications, when to discontinue doctor visits, lab tests, and so on – with the end goal being an early and natural death and less time in a demented state.
Terminal dehydration is a good option in “creating a good death because it requires a combination of disease, debility, and willful intention to institute” (p. 198).
“The paradigm shift we need is not a technical one; it is spiritual, emotional, or intellectual. We do not need encouragement to believe in miracles. We need to understand there will not be an endless series of miracles” (p. 215).
Visualize the quality of your final days.”…having no plan and no limits practically guarantees excessive treatment and increases the risks of a hospitalized death” (p. 48).
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Some tools
Who matters the most, what matters the most, I matter too (life review, wishes, goals). This is similar to part of what we did in hospice training and other venues. https://med.stanford.edu/letter.html
“The Conversation” https://theconversationproject.org/
Memorial Sloan-Kettering prognosis tool for some types and stages of cancer. https://www.mskcc.org/nomograms “On average, the most likely thing will happen” (p. 156).
UCSF risk/benefit tool. https://eprognosis.ucsf.edu/
National Hospice and Palliative Organization. http://www.caringinfo.org/
Formerly the Hemlock Society. https://compassionandchoices.org/
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“This getting old is getting old.” Fred Kling
Thank you Charles