End of Life Issues

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Table of Contents

Introduction
The Autumn Years
Aging Affects Perception of Identity
Perspectives on Dying
Euthanasia: Murder or Mercy?
The Great Debate
A Good Death
Opposition Argument
Conclusion
References

Introduction

The end-of-life issues for an elderly person are numerous and complex involving physical, emotional, psychological, and ideological dynamics. A person’s perception of their own natural aging process is generally at least somewhat divorced from reality, a common condition that perpetuates constant internal conflicts for the aging person. While attempting to deal with the debilitating physical and mental and psychological issues, those nearing the end of life must prepare in a multitude of ways for death, a daunting task. Euthanasia is a hotly debated and important issue for those at the end of life and their families. Many believe the practice to be humane and necessary yet others cite practical and religious reasons for opposing it. End-of-life issues can also be liberating and a time of spiritual and personal growth. It’s a multi-faceted subject that all are happy to face considering the alternative to growing old.

The Autumn Years

Mental/Physical Changes

For most people, the entrance into the state of grandparent represents a shift into the realm of the older adult. Physically, there are several stages an individual can look forward to as they age. This stage begins roughly around the age of 60, depending upon how well a person kept themselves healthy and stress-free throughout their life. “With improved diet, physical fitness, public health, and health care, more adults are reaching age 65 in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining … While some disability is the result of more general losses of physiological functions with aging (i.e. normal aging), extreme disability in older persons, including that which stems from mental disorders, is not an inevitable part of aging” (Boeree 1999). Although it is generally believed that aging is synonymous with mental decline, studies have shown that older adults are often characterized by stable intellectual functioning, a great capacity for change, and demonstrate a productive engagement with life (Boeree 1999).

Reflection and Liberation

The older adult is an individual who must resolve the ego integrity vs. despair crisis in which the individual must either accept their failures and successes in life to develop a sense of wisdom or those who cannot accept their disappointments and develop a sense of despair and dread regarding their coming death (Niolon n.d.). However, increased health and longevity into the later years have prompted two additional human potential phases for those individuals who reach this stage of life with adequate resources for their support. These are labeled Retirement/Liberation and Summing Up/Swan Song. “Most people fare well in retirement. They have the opportunity to explore new interests, activities, and relationships due to retirement’s liberating qualities. … In short, the liberating experience of having more time and an increased sense of freedom can be the springboard for creativity in later life. Creative achievement by older people can change the course of an individual, family, community or culture” (Boeree 1999).

Aging Affects Perception of Identity

Self Identity

The external perception of an older person can be quite conflicting thus damaging to their sense of identity. They have little desire to associate themselves with a person of their own age because they perceive a person of a similar age as being older than they themselves are. The person they see in the mirror thinks looks and acts younger than the age listed on their driver’s license. This deluded circumstance was molded absorbed over the years as a result of common social biases. The older a person becomes the more restricted in his/her abilities and capabilities they are perceived to possess. While younger people might be perceived as having a wide variety of potential characteristics and attitudes, the elderly person is associated with only a few possible identities. “The most detrimental aspect of bias is that the objects of that bias share the attitudes of the other members of their society, tending to stereotype, distort and look down upon themselves” (Troll, 1984, p. 1).

Stereotypes

Stereotypes of old persons have remained relatively constant over the past 15 years, characterizing the older person as poor, stupid, and unattractive. This stereotype is reinforced by statistical data that suggests that most people who live below the poverty line are people over the age of 65 and practical knowledge that indicates younger generations often have more education, or more up-to-date education, than older generations. The example of the digital universe is only the most blatant of these discrepancies in education levels. Elderly persons are never seen to be the great powerhouse of companies in today’s societies as many old men might be and the only old women considered remotely attractive are those who have been able to afford plastic surgery and injections to give themselves a more youthful appearance, thus placing themselves within a younger-seeming age bracket and denying the wisdom of her true age.

Regardless of what the woman believes of herself, if she appears to be older, external perception expects her to be powerless, clueless, and unappealing. (Troll, 1984, p. 8).

Perceptions of Aging in the Media

The typical stance taken by advertisers and the media in general regarding older people has been to de-emphasize their role in daily living, turning the focus away from the elderly and back onto the youth.

This is because it has been perceived that the youth have more money to spend now, more potential to gain more money to spend later, and can potentially be turned into a lifelong consumer no longer needing to be wooed to the product or company before purchasing. For a majority of television history, old age has been seen in negative terms, as a time of life dominated by decline, frugality, and isolation from greater social spheres. One study analyzed a number of documentary television programs in relation to their depictions of older people and discovered that most cases illustrated a negative impression of what it meant to age, even when negativity was not the intention.

“The usual public affairs special about old people in the community is likely to focus on the visible elderly who have multiple health losses” (Davis & Davis, 1985). In contrast, fictional representations of older people were found by the same study to present more than 90 percent of its older characters as healthy, economically active, and adventurous – particularly when compared to their younger counterparts. The reason this image has not seemed to communicate to the greater public is believed to be a result of a tremendous underrepresentation of older people as compared with younger people in the media and the severity of real social issues that affect the small percentage of elderly who actually fall into the negative categories of poor, ill and/or disabled.

Life After 90, a Depressing Thought

Older adults experience less diagnostic depression than younger or middle-age adults even though older adults showed a greater prevalence of the earlier symptoms of depression than middle-age adults.

However, this effect cannot necessarily be attributed to age as it has been found that older adults born later in the twentieth century are experienced more depressive disorders than their age group showed previously, those individuals born earlier in the century tested during the same age bracket. The study suggests that a milder form of depression may be apparent in older adults that escapes the attention of earlier and recent studies as the types of symptoms reported by older adults are different in nature and content than those reported in younger people. In addition, the study shows that older adults tend to have increased levels of depression after age 89 when interest in life begins to fade and social connections become more limited. Likewise, anxiety disorders, though experienced more often than depression by older adults, are seen to occur less frequently than in younger people. (Magai, et al., 2006)

A possible reason for the earlier onset of depression symptoms in women as compared to men might be related to an earlier departure from the workforce and the flight of children as they begin their own adult lives.

Men tend to remain active members of the workforce midway through their 60s or later, delaying the disengagement period. However, by showing that women and men tend to report approximately equal symptoms of depression by age 80, it becomes evident that withdrawal from life roles can have a damaging effect upon the older adult. However, the study also demonstrated that while depressive symptoms were reported, these symptoms were often not severe or prevalent enough to lead to the actual diagnosis of depression. This supports the socio-emotional selectivity theory in that older adults, with greater experience and skills in dealing with adversity or negative experiences also have better ways of handling these issues. Although older adults tend to focus more on the emotional aspects of their lives, they are also better able to focus on those aspects of their lives that are positive, keeping them from sinking completely into the spiral of depression following retirement from major life roles. (Magai, et al., 2006)

Perspectives on Dying

A Real Surreal Eventuality

A final aspect of the study of human development as it relates to the adult much include a discussion regarding the different approaches an individual might take as it relates to death and dying. Various cultures approach the idea of death with profoundly different perspectives. Religion often plays a large role in how one approaches the topic, whether the individual believes there is life after death, what form that life will take (i.e. – life at the right hand of the Father or reincarnation on earth), or if the individual believes death is simply the end of existence. The approach one takes to death will determine whether death is feared or embraced, and this cannot be reasonably predicted by a belief in an afterlife. Some who believe in an afterlife may yet fear death because of a perceived punishment for deeds committed in life. Others who feel death is the end of existence may well welcome the thought.

A Matter of Perspective

While Western society almost goes out of its way to ignore or forget about death as is evidenced by its obsession with youth and the appearance of youth, it is nevertheless fascinated by the concept of death and what might follow after it as is shown in the dominant religions and poetry (Craig & Baucum 2001). There is a similar contrast in the way in which young people view death as compared to how older people view death. While young people may consider the idea of death once in a while, primarily as something that happens to other people or that is too far away to worry about, older people tend to reflect upon it a great deal more, either fearing it or looking forward to it depending upon how they traversed previous life stages. In dying, there are actually two processes at work: the physical process of the body shutting down its various functions and the mental/psychological/spiritual process of letting go. “The spirit of the dying person begins the final process of release from the body, its immediate environment, and all attachments.

This release also tends to follow its own priorities, which may include the resolution of whatever is unfinished of a practical nature and reception of permission to ‘let go’ from family members … These two processes need to happen in a way appropriate and unique to the values, beliefs, and lifestyle of the dying person” (“Preparing” 1996). Because of the various views on death, there have been significant difficulties in coming to terms with ideas such as human euthanasia and suicide. Although the spirit may be ready and willing to go, the body may not always be so willing to accommodate.

Preparing for Death

From the time an individual leaves the home of his or her parents to the time of his or her subsequent death, there is still much growing and developing to be done. As they learn to work with others to the point of being able to exchange love, the young adult becomes more aware of how their actions and beliefs affect others and becomes more conscious of their behavior. As they acquire additional life experiences, such as marriage, having and raising children, they also acquire certain coping skills that will help them better deal with additional situations in their future, such as the loss of a loved one, the changing relationships they will have with their growing children or aging parents and the changes in themselves as they also age and begin to decline.

The older adult is increasingly seen as an individual who is gaining a new freedom and ability to explore interests that had been relegated to the back burner while the individual got on with the business of life. As more and more people work to take care of their health and well-being throughout their life cycle, they are living longer and retaining their health into the later years, enabling them to experience this exhilarating development. However, their response to the idea of death will still vary depending upon their ability to accept the successes and failures of their own life, their acceptance within the greater society, and their cultural, religious, and personal views regarding what happens after death and what their role will be within it. (“Preparing” 1996).

End Time Decisions

Arguments for euthanasia center around the rights of the patient to stop suffering and needless pain in situations for which there can be no relief as well as to allow individuals who are incapable of making this decision on their own, again with no hope of recovery, from becoming a significant drain upon the family in terms of trying to provide medical coverage.

Arguments against it are typically centered upon the religious question of whether one can take a life without committing a sin and around the legal issues regarding the definition of murder.

Euthanasia: Murder or Mercy?

What is Euthanasia

Euthanasia, otherwise known as mercy killing or assisted suicide, has been a controversial subject for many centuries. The word euthanasia is of Greek origin meaning ‘good death.’ Writers of 1700’s Britain referred to euthanasia as being a preferential method by which to ‘die well’ (“Definition”, 2007). Euthanasia describes a situation in which a terminally ill patient is administered a lethal dose of medication, is removed from a life-support system, or is simply allowed to die without active participation such as by resuscitation. A doctor’s involvement in the procedure could be to either prescribe a lethal dose of drugs with the express intent of ending a life or by intravenously inserting a needle into the terminal patient who then activates a switch that administers the fatal dose (Naji et al, 2005).

For/Against

Proponents of the practice believe that individual freedoms of choice that exist in life also extend to the end of life. They also argue that the sentiment of humane treatment afforded animals that are terminally ill or injured and are suffering should be given to humans as well.

Opponents suggest that euthanasia is a ‘slippery slope’ that would allow increasing instances of coerced suicide, with family members pressuring the elderly not to postpone their inevitable demise for financial reasons. In addition, the practice would lessen the urgency to develop new medicines designed to prolong life. Those who oppose the practice on religious grounds argue that it is ‘playing God’ therefore sinful. Health care professionals cite the Hippocratic Oath which forbids them from carrying out this procedure. This end-of-life issue is substantial both for the afflicted and the family. Literally a life and death decision.

The Great Debate

Individual Autonomy

Physicians, lawmakers, and philosophers have debated the notion of euthanasia since the beginning of recorded history but the wide public debate regarding its legalization has only surfaced over the past three decades. In the 1970’s it became lawful to draft ‘living wills’ which allow a patient to refuse ‘heroic’ life-saving medical assistance in the event they were incapacitated and could only survive by artificial means (Rich, 2001). In other words, it gave the next of kin the right to direct doctors to ‘pull the plug’ if the patient’s condition was considered hopeless, a practice that is now broadly accepted. However, these wills did not eliminate the potential problem of individuals being kept alive for incredibly long periods of time in permanent unconscious states as there were often no provisions for withdrawing nutrition and hydration when no other life support interventions were necessary.

This oversight has been largely addressed through power of attorney. “The durable power of attorney allows an individual to designate in writing a proxy or surrogate decision-maker (the attorney-in-fact) who has the same degree of authority to consent to or decline life-sustaining treatment as the patient would if he or she were competent” (Rich, 2001: 68-69). While this, too, has its drawbacks in that there is frequently no room to designate the individual’s wishes to any great extent, the debate regarding euthanasia has moved beyond the realm of the unconscious patient and into the realm of patient rights. Today, the debate centers on individual autonomy, whether or not patients who suffer from extreme pain and have terminal or degenerative diseases such as Alzheimer’s, AIDS, and multiple sclerosis have the right to an assisted death of the type and time of their own choosing (“The Fight”, 2004).

States Debate

Only one state, Oregon, and three countries, Switzerland, Belgium, and The Netherlands, allow assisted suicide (Hurst & Mauron, 2003). The law in Oregon was challenged in the U.S. Supreme Court early last year and was upheld by a vote of six to three. In 2001, former President Bush attempted to derail the Oregon law permitting euthanasia stating that assisted suicide wasn’t a ‘legitimate medical purpose.’ The justices, however, were not convinced by Bush’s argument.

“Justice Sandra Day O’Connor pointed out doctors participate in the administration of lethal injections to death row inmates” (Roh, 2006). The Oregon laws are shaped after those in the Netherlands and are designed to ensure second opinions have been consulted and there is an imminent resumption of death within a reasonable time frame of when the procedure is requested (“Court Defends”, 2004). In addition, the patient must make multiple requests for the procedure, all spaced out over a period of weeks, and must be willing to administer an overdose of drugs themselves. While there are several individuals who have written against Oregon’s laws, including Lauren O’Brien (2005) and Kay Olson (2007), these are usually addressing abuses in the system or personal cases in which counseling would or should have been able to prevent mistakes.

Olson, for instance, details the case of a particular woman who was incompetent to argue for her own case and, through numerous abuses in a system focused upon capitalistic concerns rather than humanitarian ones, was a victim of the Oregon euthanasia laws. O’Brien illustrates how a successful writer might have inadvertently cut short a brilliant career had euthanasia been an option at the time he first suffered a paralyzing accident.

Humane Considerations

The euthanasia debate embraces compelling and impassioned arguments on both sides of the issue. Proponents of euthanasia are concerned with human suffering. Many diseases such as cancer cause a lingering and excruciatingly painful death. Watching a loved one as they wither away from the disease eating away at their organs is tough enough on family members, but to see them suffer even when drugs are administered is unbearable not to mention what the patient must endure. This emotionally and physically torturous situation is played out in every hospital, every day of the year but serves no purpose. To many, it is unimaginable to allow anyone, for example, a sweet old grandmother who has spent her life caring for others to spend the last six months of their life enduring constant pain, unable to control bodily functions, convulsing, coughing, vomiting, etc. The psychological pain for both the family and patient is unimaginably horrific as well.

If grandma were a dog, most all would agree that the only humane option would be to ‘put her to sleep.’ U.S. citizens are guaranteed certain rights but not the right to ‘die with dignity.’ This right is not prohibited by the Constitution but by religious zealots who evidently put the quality of life of a dog above grandmas. Patients suffering from Alzheimer’s may not suffer physical pain but endure a different type of pain and usually for a long period of time. Alzheimer’s is a degenerative disease causing the patient to ramble incoherently and lose their memory. Many people who led vibrant, active, and purposeful lives are remembered by their family members in this state (Messerli, 2007).

A Good Death

For the Patient

Proponents of euthanasia argue that the time of health care professionals, of which there is a perpetual shortage, especially nurses, could be used in a more productive manner such as on patients who are not certain to die.

Numerous studies have established that understaffed medical care facilities provide a diminished quality of care to all (“Massachusetts Patients”, 2005). Those that could benefit from quality care sacrifice their health for those that are suffering a slow, agonizing and undignified death.

The cost of health care overall would be reduced as people with no hope of survival no longer drain the available resources and manpower which translates to lower insurance rates.

Health care costs have skyrocketed over the past decade and as the ‘baby boom generation ages, this problem will increase exponentially which does not benefit anyone. “Consider the huge cost of keeping a dying patient alive for several months. You must pay for x-rays, lab tests, drugs, hospital overhead, medical staff salaries, etc.

It is not unheard of for medical costs to equal $50,000-100,000 to keep some patients alive” (Messerli, 2007).

It’s a burden on everyone especially on the family that must pay it. Elderly, terminal patients do not want to be responsible for the financial ruin of their children, but do not have the option to call for an end.

For Others

Euthanasia also allows for organs such as livers, hearts, and kidneys to be harvested for transplant into otherwise healthy individuals with the potential for many more years of life.

While it may be emotionally morbid to think of things in such terms, in a world where medical miracles can occur every day that permits another human being a chance at a more fulfilling life, these considerations must also be made. In the real world, it is more likely that an individual will opt first to save the young child from an oncoming bus rather than an old man. By the same token, it seems incredible that today’s society would opt to allow a child to die so that a terminal patient might be forced to live a few more agonizing months. This, in effect, is the result of not allowing people to die with dignity.

Many terminally ill people choose to end their own life to evade the previously discussed detriments of a terminal illness. Suicide rates are by far the highest among the elderly population for this reason.

“If these people are going to commit suicide, which is better, controlled, compassionate doctor-assisted suicide or clumsy attempts like taking sleeping pills, jumping off a building, or firing a bullet into one’s head?” (Messerli, 2007).

Opposition Argument

Suicide is Irreversible

Opponents to legal euthanasia rightly claim that the practice would be in violation of the Hippocratic Oath. It also would cause a devaluation of human life. Life is held as sacred in the U.S. more so than in many other countries therefore the decisions other countries make regarding euthanasia are not relevant.

The legalization could lead to the assisted suicide of patients whose conditions are not necessarily terminal.

Though the vast majority of doctors are ethical beyond reproach, not all are. It is common knowledge that some doctors write prescriptions for drug addicts.

‘Diet pills’ are handed out to ‘patients’ who do not have a weight problem but are simply feeding a habit and the doctor is well aware of this. If a minority of doctors can be convinced to prescribe illicit drugs then it is not difficult to imagine a situation where a doctor can be convinced to assist in the suicide of a person who is temporarily depressed due to emotional or psychological reasons. There is a big difference between the two situations, however. A person can decide to end their drug abuse but suicide is irreversible. While most doctors are ethical and are dedicated to quality patient care, insurance companies are concerned with profit, not patients, and may begin to pressure doctors into ending the lives of patients who are costing them thousands of dollars per week. The evidence of this possible eventuality can be plainly seen today. “Many doctors are already prevented from giving patients certain tests or performing certain operations despite what the doctor believes is truly necessary. Legalizing assisted suicide would likely invite another set of procedures as to when life-sustaining measures should be undertaken” (Messerli, 2007). Another example of this can be seen in the previously cited report of Olson (2007) in which a non-verbal special needs woman is illustrated to be a victim of such abuses of power and financial balance sheets.

Insurance companies already have too much power to influence health care decisions. Legalized euthanasia would only increase this power.

Family Affairs

Another likely scenario of legal suicide involves patients who are told that they have a few months to live and decide to not endure this remaining time and end their life sooner rather than later. This not only deprives the family of precious time with the patient but eradicates any chance of recovery or remission of the disease. Plus, suppose the doctor made a mistake in their diagnosis? No one could ever know if they did or didn’t but this possibility would always weigh heavily on the minds of the loved ones left behind. Again, the previously cited case reported in O’Brien illustrates how even when the doctors are right, the man was told he would remain paralyzed and could only reasonably expect 36 years of inactivity, that did not preclude him from living a fulfilling and productive life for at least 24 of those years and counting as of the date of the article (2005). Another consideration is one of religion. If a patient decides to depart this life expeditiously, many of his or her family members could be against this decision based on personal religious convictions.

What may have been a good relationship with loved ones throughout the entirety of life would be soured at the very end (Messerli, 2007).

The Elderly’s Will be Done

The unfortunate reality is the majority of people in the U.S. die a ‘bad death.’ A study determined that “more often than not, patients died in pain, their desires concerning treatment neglected, after spending 10 days or more in an intensive care unit” (Horgan, 1996). Most Americans (53 percent) believe euthanasia to be not only compassionate but ethically acceptable and 69 percent would support the legalization of euthanasia according to a Gallup Poll conducted in 2004 (“Public Grapples”, 2004).

Opponents of a doctor-assisted suicide law often cite the potential for doctor abuse. However, recent Oregon and UK laws show that you can craft reasonable laws that prevent abuse and still protect the value of human life. For example, laws could be drafted that require the approval of two doctors plus a psychologist, a reasonable waiting period, family members’ written consent, and limits the procedure to specific medical conditions.

Conclusion

The end of life presents many multifaceted issues for individuals and their families. Health concerns, psychological, physical, and emotional matters are magnified as the end nears. Elderly persons must make difficult practical decisions usually while suffering from difficult personal circumstances. It is a time we hope we all face and as in anything else, the more we understand about end-of-life issues the better we can cope in this critical time of life.

References

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“(The) Fight for the Right to Die.” (2004). CBC News. Web.

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Magai, Carol; Consedine, Nathan S.; Krivoshekova, Yulia S.; Kudadjie-Gyamfi, Elizabeth; & McPherson, Renee. (2006). “Emotion Experience and Expression Across the Adult Life Span: Insights from a Multimodal Assessment Study.” Psychology and Aging. Vol. 21, N. 2, pp. 303-317.

“Massachusetts Patients Say Nurse Understaffing Harms Patient Safety, Undermines Quality Care.” (2005). Massachusetts Nurses Association. Web.

Messerli, Joe. (2007). “Should an incurably-ill patient be able to commit physician-assisted suicide?”Balanced Politics. Web.

Naji, Mostafa H; Lazarine, Neil G. & Pugh, Meredith D. (1981). “Euthanasia, the Terminal Patient and the Physician’s Role.” Journal of Religion and Health. Vol. 20, N. 3, pp. 186-200.

Niolon, R. (n.d.). “Erikson’s Psychosocial Stages of Development.”Resources for Students and Professionals [online]. PsychPages. Web.

O’Brien, Lauren. (2005). “Opposing Legalization of the Right to Die.”Emmitsburg Area Historical Society. Web.

Olson, Kay. (2007). “Euthanasia in Oregon.”The Gimp Parade. Web.

“Preparing for Approaching Death.” (1996). North Central Florida Hospice [online]. Web.

“Public Grapples With Legality, Morality of Euthanasia.” (2004). The Gallup Poll.

Rich, Ben A. (2001). Strange Bedfellows: How Medical Jurisprudence has Influenced Medical Ethics and Medical Practice. New York: Springer.

Roh, Jane. (2006). “Supreme Court Backs Oregon Assisted Suicide Law.” Fox News. Web.

Troll, Lillian E. (1984). “Poor, Dumb and Ugly: The Older Women in Contemporary Society.” Annual Convention of the American Psychological Association.

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