Download PDF
Download audio part 1
Download audio part 2
Download audio part 3

Advance Directive/Physician’s Orders to Permit Natural Dying(PDF’s)

Determining the decision-making capacity of a patient who refused food and water(PDF)

Les Morgan interviews Stanley Terman on Voluntary Refusal of Food and Fluid(PDF)

A Memoir: "An October Morning"

A court case: What we learn from Mrs. Elbaum

A joke: Save the Strudel

A story with questions: "A Time To Be Sure"

A family conflict: "Should we let Nature take its course?"

Legalizing Physician-Assisted Suicide: A position statement

The BEST WAY to Treat People Who Have Lost Their Minds: Shall Our Laws Permit Natural Dying?

An alternative to changing laws and fighting over names: Individual Peaceful Transitions

Who will make sure that others will honor your Last Wishes if they are to refuse food and fluid?

THE ONSET OF DEMENTIA

These criteria are intended for future decision-makers to use as a guide to determine WHEN the time has come to Permit Natural Dying. The described items must be irreversible and progressive. Some items refer to patient's thinking, memory, feelings or behavior; others are preferences or value statements. To satisfy the criteria for Natural Dying, patients need not, and rarely will, meet all items. Any symptom or behavior may qualify an item. Patients can revoke the use of these criteria or modify any of them-as long as they possess the ability to make medical decisions.

Abstract: A terminal patient expressed the wish to hasten her death and refused nutrition. The psychiatrist asked to render an opinion relevant to her competence employed questions in a semi-structured interview derived from a new instrument originally designed to determine competence to create Advance Directives. Although the patient ultimately demonstrated her resolve by totally ceasing fluid intake, the complexity of the case including the question of the stability of her choice illustrates the need for specific patient safeguards.

On February 15, 2008, for the Education Channel of Growth House Radio, Les Morgan interviewed Stanley A. Terman, Ph.D., M.D., Medical & Executive Director of Caring Advocates, on "The Option of Voluntary Refusal of Food & Fluid." The topics covered included: Why some terminally-ill people stop eating and drinking; psychiatric assessment for depression, anorexia nervosa, mental competence, and control needs; legality and ethics of this choice; the medical effects of dehydration and ketosis; how the family may respond to the patient's decision; assisted feeding of dementia patients; and advance care planning.

The thought of dying didn't bother Mary Evelyn in the least. It was all those peripheral issues: the crippling osteoporosis, the near-blindness, the heart failure that had left her almost immobilized, the constant pain, and the frustration that no symptom ever got better.
"Everything's gone except my mind, and now, that's going too." It was a grim joke. Not long ago, Mary Evelyn admitted that dementia was creeping in. As the winner of several poetry awards, she found her frequent struggles to remember simple words quite embarrassing.

For sixty years, Mrs. Jean Elbaum was medically well. Then she suffered a stroke at her Long Island home. For long-term care, she was eventually transferred to Grace Plaza, a skilled nursing facility in Great Neck, New York. According to her husband and children, she had previously expressed her wish that if she were in a vegetative like state, she would not want to be kept alive by a ventilator like the celebrated legal case of Karen Ann Quinlan. She also voiced not wanting to be given antibiotics and tube-feeding like her mother who lingered on and died slowly from terminal cancer. After Mrs. Elbaum extracted promises from her husband and other family members to honor her wishes, the whole family was united in this commitment.

Grandpa's children and grandchildren assembled around his bed. After a very long and productive life, his doctors had pronounced him very near death. He was lying so still that his visitors wondered if he was in a coma.
Suddenly the old man opened his eyes. "Was I dreaming of Heaven? I swear I smelled grandmother's strudel."

My father had generally been a happy man who enjoyed many aspects of life. Sadly, during his last four years, several strokes led to major deterioration. Once a successful electrical engineer and active in both golf and tennis, now, all he could was sit in front of the TV in our living room, and open his mouth to eat when someone (usually me) fed him or gave him a drink. I tried to make his life more interesting by sharing the daily events of my life and by commenting on what I noticed he watched on TV. I also tried to bring joy to his life by preparing his favorite foods, even though they had to be pureed.

I am the oldest child of three. Starting in her early eighties, our widowed mother suffered from severe, progressive dementia. Two years ago, we had to place her in a skilled nursing home. For a year, she had not been able to recognize anyone or communicate. One day after I visited her, her doctor asked to speak to me. He stated we needed to talk about her future because eventually, she would no longer be capable of feeding herself and sometime after that, she would lose the physical ability to swallow. He asked me if my mother had discussed either with her previous doctor or with me what level of feeding assistance she would want, or if she had given any other indication of how long she wanted her existence to be prolonged.

In the novel, Lethal Choice, the main character presents two different ways to hasten dying. One is Physician-Assisted Suicide. Over the past two decades, this option has been debated almost as heatedly as abortion. Why? Because it is almost as difficult to say when a life has ended, as when a life begins. Increased interest in legalizing Physician-Assisted Suicide was due in part to a 2006 U. S. Supreme Court ruling that affirmed that individual states have the right to decide what constitutes "legitimate medical practice."

We live in a culture where exercising individual choice to select the best for oneself is unquestionably a revered goal. For some, the all-consuming drive to accumulate money and to attain power serves to maximize their ability to choose what they have diligently concluded is the best. Anyone who solely devotes his or her life to the opposite goal to help others is considered a saint. On this continuum, most readers of this volume are likely to be closer to side of giving than to the side of using.

In 1999 I was asked to lecture at the first Caring Friends organizational meeting of Hemlock of San Diego. I compared reasonable end-of-life depressions for which "self-deliverance" could be a rational decision to end pain and suffering, versus psychotic depressions that could lead to suicides that were emotionally based and possibly treatable. As I attended the meetings, I found a disparity between the name and the means of the Hemlock Society. Rather than educating members on the use of Hemlock or more modern kinds of poisons to hasten dying, they promoted the use of plastic bags. I learned some things that caused me great concern: A) Do plastic bags always work? (Two were reported to have failed.); and, B) Is dying with a plastic bag peaceful? (The cause of death is SUFFOCATION, which increases the level of carbon dioxide and can lead to the greatest anxiety humans can ever experience.)

"I may reach a point in the progression of a serious illness when I will no longer want nutrition and hydration by any route whether its administration is considered 'medical' or 'artificial' because it enters my circulatory system or gastrointestinal system via tubes; or considered 'non-medical' and 'natural' because the route is oral; that is, I still can swallow what another person puts into my mouth."