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We Americans have a weird relationship with death. Unlike other nations and societies in which I have lived, “death” is not a part of our lives. The elderly and terminally sick are hidden away from the mainstreams of society, we spend huge amounts of money and time trying to mask and delay the outward signs of aging, and we have nearly bankrupted ourselves and the national medical system trying to extend the lifespans of the terminally ill and aged by “just one more month”.

My peer group is in our fifties and early sixties. Our parents are generally twenty or thirty years older than us, making them seventy or eighty years old, which is the prime mortality age. Consequently many of my friends, co-workers, neighbors, and my wife and I have been dealing with sickly and terminally ill parents. We’ve cared for them, made agonizing decisions, said goodbye, and buried them. My wife is a medical professional and is continuously asked for her inputs and opinions regarding death. She and I have had long discussions about how we deal with death in contemporary American society while walking our beloved dogs in the evening twilight. We think about how we treat our dogs and our parents in their final months, and are baffled by the differences.

We have owned Anatolian Shepherds for almost thirty years. They are a large (up to 160 lbs) livestock guardian breed that we first obtained while stationed in Europe. We currently have two females. Due to their size, aggressiveness, and need for exercise, they have been a dominant factor in our lives. We spend at least one dedicated hour per day walking and exercising them, and they sleep in our bed when we’re at work. When we adopted our daughter thirteen years ago our friends told us that if we spent as much time on our human daughter as we did on our canine children, she’d grow up to be very spoiled. They have brought us years of comfort, companionship, and pleasure. We’re currently on our fourth generation of Anatolians, which means that we’ve got a lot of dead dogs in our past. None of them has been so thoughtful as to simply die peacefully in their sleep one night. As the dad in the family, it has been my duty to take our terminally ill dogs to the vet and hold them as we painlessly ended their lives. As many times as I’ve done that, I still find it to be one of the most miserable experiences of my life.

As hard and miserable as the euphemistically termed “putting the dog down” is, the decision to do so has never been that difficult. While it may be difficult to determine exactly when the time has come to do the deed, the fact that we would do so was never in question. We have always felt that we owed it to the dog. Anatolians have a life expectancy in the nine to eleven year range. We know that eventually all dogs must die. In return for all the comfort that our dogs have given us during their lifetimes, we feel that we owe them as much comfort during their lives and their deaths as possible. As the dogs age, they suffer many of the infirmities that humans do. They become incontinent, their eyesight and hearing go, their backs and legs start to give out on them, they get diseased more frequently, and eventually some level of dementia may set in. There comes the sad moment when you find your beloved companion laying splayed on the floor, embarrassed by the urine pooling underneath him, unable to stand even with assistance, uninterested in water or ice, unable to hold down food, unable to go out and walk or bark, and panting heavily while trying to get oxygen to failing lungs and a great heart. “Buddy, I think it’s time, isn’t it?” They’ve trusted us to make the right choices for them during their whole lives, and they trust us to make this life ending decision too. They’ve looked at me reassuringly as they take their last breaths. They know that their time has come, and that there will soon be an absence of pain. Their misery is over, and ours will be too after we finish our grieving.

The decision to “put the dog down” is a “quality of life” issue. Sympathizing with our grief, our friends tell us that it was a good decision, made with the dog’s interest in mind. “You know, it’s a quality of life issue. It was time. He was miserable. He just wasn’t enjoying life anymore. Why would anyone want to prolong his agony? You guys did the right thing.”

Why do we deal so differently with death when it involves humans? Last night we received a phone call from very good friends to inform us that one of their parents had died. Their prime feeling about the whole event; “Oh, thank goodness they finally let him go.” The parent was 82 years old, had recently lost 100 lbs, was on a respirator, had cancer, had multiple other medical issues, and could not live without being attached to a lot of medical implements. He had a heart attack in the hospital a few days ago, and the docs worked for eighteen minutes before restoring a heartbeat. What are we doing?

This particular individual was not going to go home again. He was living in a hospital bed attached by multiple tubes and wires to a wall of electronic and pneumatic hardware. He had wasted away to the point that he was unrecognizable to family and friends. The medical care he was receiving cost in excess of $3000 per day, every day. That’s $100,000 per month that someone, (insurance companies, taxpayers, charity), is going to have to pay. What are we doing?

I read recently that 80% of all the medical costs during an individual’s lifetime will be incurred during the last two years of that individual’s life. That’s sad. For the elderly individual above, 20% of all his medical expenses would have come during his first 80 years of life, and 80% of his expenses were incurred between 80 and his death at 82. Who benefited from that lopsided use of medical finances? Not the deceased. He spent his last two years in and out of hospitals, in pain and discomfort, exhausted as his mind and body shut down. His family? His aged wife was exhausted trying to care for him and suffered the ill effects of insufficient attention to her own health. His kids spent two years watching their beloved Dad become a husk of his former self. Did society benefit? This sickly gentleman was past the point of contributing physically or mentally to society. The costs of his medical care will be borne by society, and those assets were not available for care of the uninsured young. Did the medical community benefit? I think so. Society probably spent close to $2 million while delaying his death, and that all went to the medical-industrial complex.

Please don’t misunderstand me. I’m not a “Doctor Death” advocate wishing to euthanize the weak and infirm. I don’t believe in organized suicide either. I just think that we go to huge efforts to prolong the lives of those who are about to die, and the only ones to benefit from it are the medical community. If an elderly patient is semi-comatose with no hope of ever living outside a hospital environment again, let the poor person go. We’d do it for our dogs. Why can’t we do it for our humans?

I could have written that post Meteor. Keep in mind, I spent 7 years of my nursing career in a CCU, taking care of critically ill patients, many of whom fit the exact description you're giving here. Often, we kept patients alive on the ventilator and with vasoactive drips to maintain heartrate and BP, only because the patient's 'loved ones' didn't have the courage to do the right thing, and let nature take its course. Honestly, I felt like we were torturing these patients at times. Those that weren't cognitively aware (or weren't obviously aware - I always had my suspicions that they were indeed 'in there' suffering and experiencing it all, just not able to protest). I will also confess to you that, working primarily night shift, I frequently bathed these patients and when I felt it appropriate, spoke to them as I did so, telling them it was 'okay' to let go, to stop fighting, that their family members loved them and would see them again. Often (and I mean often), these patients would pass within hours/days of those kinds of conversations. Like your wife, I spent a lot of my time trying to help struggling family members come to terms with decisions they'd have to make. Despite the inherent pain in seeing your fellow human beings (both patient and loved one) go through those struggles, those were probably the most rewarding times I've experienced outside of my own family.

One of these days, I'll get around to writing a blog about some of the special patients I've taken care of. But I couldn't agree more with you. America has an obsession with winning. I dig that about us, but you can't beat death. As you so eloquently intimated, there are far worse and less dignified things than death - there is life with suffering and without quality. We really need to come to terms with the issue as a nation.

Btw...this wasn't a thread topic - thats a blog entry if I ever saw one friend. You really need to jump into the fray.

Awesome post.

I don't own any dogs. Therefore, I don't share this dilemma.

Just playing devil's advocate here, but who benefitted from keeping the 82 year-old alive? Maybe Medicine did. Maybe they learned something from his care that will help the next guy make it to 85. And then the next guy will get to 90.

It's a mountain. We climb it. Because it's there.

Arbitrarily deciding who's fit enough to live takes us down a dangerous path I think. In this world there are very few perfect solutions. And, given that, in this situation erring on the side of life may not be the worst mistake we could make.

I dunno Henry. There are some fields where I think you might have a point - oncology might be one. As cancers of a myriad variety are common in the elderly, having those types of patients around for an extended period probably has advanced research. But for many elderly (and I can only speak from my own experience here), its simply a matter of providing maintenance care to these patients to 'sustain' their core bodily functions. IV meds to keep their vitals stable, IV fluids to hydrate them, IV feedings to keep their metabolism going, and often respiratory, renal, or cardiac assistance to literally keep their lungs, kidneys, and heart going. These aren't advanced treatments - its stuff we've had around for 30 years. It's being provided in most cases for the exact reason I stated - theres no one with the courage to say 'stop' as Meteor so graciously did for his dogs.

Sure, there is some basis for your point. But I think in the majority of cases, Americans really have a problem accepting death culturally - and go to ridiculous lengths at times (and again I'm generalizing) to put it off for as long as possible. I've seen hundreds of instances of a patients very own 'living will' being totally countermanded by well-intentioned, but gutless family members who selfishly hang-on despite the inevitability of the final outcome. To me, thats just a crime plain and simple. I'll tell you what - if you don't want your life sustained by artificial means beyond reason, you'd better make sure someone you can rely on knows it - because paper documents won't save you from a painful extended death.

Just had to do this with my cat, the first pet my wife and I had together. One of the worst days I have had in years but he had aggressive cancer that there was nothing we could do about. He was no longer able to do "cat" things and I believe he was miserable. It was right.

At the time, I had many of these same thoughts Meteor although not nearly so well put together as this.

Reading this I am reminded of my grandmother, whom we lost in 98 at the age of 98. She had outlived her husband by 2 years and been in and out of the hospital more than some doctors I know for nearly 4. There was nothing majorly wrong with her. No cancer, no heart or lung disease, no nothing. She was just old. My aunt had moved back in with her to care for her full time. On one of my dad's last trips up to see her before she passed she looked at him and said something to the effect that she had thought living was hard but never imagined that dying would be so much harder.

There was no plug to pull in her case. She was not on a machine although there were IVs. No clue if any of it was directly life sustaining or not. What I do know is that her statement to my dad scared me. Still does. We make it harder than it needs to be and do so very unnecessarily.

Agreed. I thought this about your Christmas post too Meteor. Time to "hat up" and join the club.

Well Boone, I can't argue with your experience in the field. Certainly I think living wills should be respected, no matter what they say. (In the Shaivo case I was on the husband's side from the beginning.) And no doubt there are instances where keeping someone alive seems pointless and cruel.

My point was not that such cases didn't happen, but that there is no perfect answer out there. What do we do? Culturally decide to pull the plug at 60? 70? When is the right time to 'allow' people to die? Let me know that and I'll bow out of this discussion immediately.

Until then, I don't think erring on the side of fighting to the last breath is all that terrible a line to draw.

Boone, I'm afraid I have to disagree with you and Neophyte on one thing here; Yes, this would be a superb blog entry-but it is also a wonderful thread topic. This is another one of those areas that would qualify as a Forbidden Subject. It's very difficult to engage people in a conversation about death-we shy away from it...avoiding it, refusing to bring it to consciousness-which may partially explain the tendency, as you stated it so well, to "selfishly hang on". Death is a normal part of life yet it becomes one of those "taboo" areas, spoken of only in whispers as though too loud voice would call it forth. And, as Meteor asked, why here-why in this country do we seem to demonstrate such denial, such a refusal to accept reality, such demeaning lack of consideration for another, especially a loved one-a family member.

I am developing some thoughts on this-but I'm going to have to do some more thinking about it-and that is yet another reason why this is such a good topic for a thread.

Meteor, well done, my friend. Not only was your post eloquent-it's also thought-provoking.

I understand your point H. And my 'experience' is only relevant in that I've had a lot of opportunity to see families grapple with the issue. But I think it's less a medical/technological issue than a human one. I guess what I'd say is that the critical question is 'who's doing the fighting?'. In other words, a critical care nurse's/physician's job is to do as exactly as your suggesting, help a patient fend off death with every tool available. Thats a wonderful thing. But when death is inevitable, when a patient has even formally documented they don't want to be sustained by artificial means when there isn't a liklihood of recovery, or when its clear to anyone really paying attention that the patient wouldn't want to 'live like this', I think that's different.

You are absolutely right though - its incredibly difficult to navigate those situations, particularly if you are on the other end as most of us have been, and its a personal not clinical decision about someone we love. I do think culturally Americans generally have a harder time with end of life issues than do other cultures. I don't know why that is - maybe its as simple as pointing to that good ol' competitive spirit.

I know Om posted about self versus society and this may be one of those issues.

I think the northern European mindset (crass generalization I know) would be that there comes a point with medical intervention to prolong a life that is beyond saving is selfish. It is taking resources from the rest of society. A millionaire funding it themselves of course is a different matter. But if socialized medicine or insurance is footing the bill there has to be a time when society says "no more".

My father in law had cancer for which the diagnosis was that death could not be prevented but life could be prolonged. The approach in England was to provide care and comfort in the home as the illness progressed, including nurses who would visit and spend the night, not only for the patient but for the comfort and quality of life of the rest of the family too.

Yes - and the cold hard truth is that there are exhorbitant costs to prolonging lives - you really can't in the real world reality ignore that. I'm smack dab in the middle of the medicare crisis in my daily work where, because our government hasn't figured out how to make medicare work at a sustainable cost, we're now in crisis mode and services are going to be harder and harder to access.

There is a great use of the kind of model you're describing Fin in the US too - hospice care (both in home and at facilities) and other care models. The problem is that there is not always an advocate for the patient to make those decisions. And physicians and healthcare providers in general, given their paradigm (both medically and legally) which generally directs us to 'do everything' in a vacuum where no one is telling us differently, aren't the best artbiters of 'when is enough enough'. What gets lost in the shuffle sometimes, truly, is what would the patient want if they could direct their own care. I look forward to the day when a Living Will or DNR cannot be disregarded or set aside because of someone's discomfort level - not by a loved one, POA, or anyone else.

Finbarr, your expressed thoughts are very close to where mine were going-especially with the idea of prolonging a life for selfish reasons, however I believe it goes even deeper than being a drain on society's resources. I see it as a personal emotional selfishness that takes away the ability to imagine or consider what the sufferer might have wanted-or even explicitly stated in a "living will" as Boone spoke of. I attribute this to an excessive emphasis on the rights of the individual in this country to operate in a self-serving manner in all aspects of their life. I call this the "Dark Side" of individualism-an accepted and quite often encouraged perspective that-"one is free to pursue whatever what one wishes-materially, socially, psychologically and emotionally"-with little in the way of a caveat about it's potential for deadening consciousness of and therefore interest in the needs of others-until it gets to the point that individual emotional needs can become paramount to the exclusion of the needs of even those closest to us.

One baffling and counter-intuitive thing for me: We Americans are a far more religious lot than almost all other industrialized nations. All religions that I am familiar with assume the existence of a supernatural afterlife. Thus it would seem to me that most Americans believe that after their own death or that of family, they will enter The Kingdom of God, which is invariably described as a far more pleasant place than our Earth. If we assume that the terminally ill will soon be released from their Earthly travails and move on to Paradise and all that entails, why do we then struggle mightily to keep the afflicted here on Earth?

Religion is not nearly as prevalent in most other advanced societies. They do not assume that they will live on in some ethereal form. They assume that when they die, they'll be dead. You won't get a do-over following your demise. Yet in those cultures death is an accepted part of life. They do not desperately struggle to keep the aged alive for a few more weeks. Why does our religious society seek to avoid death as long as possible, yet most other (secular) Western societies accept the inevitability of death?

Meteor, I did some digging and came across a study done in Belgium touching on this very issue-The role of religion in death attitudes: Distinguishing between religious belief and style of processing religious contents a downloadable PDF file-here are a couple of quotes from the article that, I think, provide some possible answers to your question.

A literalist religious interpretation is notably more pervasive in America than in, say, Europe which could, at least to some extent, explain the difference.

My grandmother just passed this last September. She was 99 and lived a great life but this was my first experience with a close family member dying. She was like my mother and I lived with her for several years. She was the matriarch of the family and EVERYONE went to Grandma's house for the holidays.

When she died it hit me like a ton of bricks. I started wondering if I would ever see her again, was I a good enough grandson, what didnt I tell her that I wish I would have...you know, all of the things you do when you dont have a second chance. I had made sure to tell her that I loved her and what she meant to me, but was that enough?

I am a Christian man and I was raised going to church. I have a strong faith in what I believe but even I was worried that I wouldnt see her again. Never hear her laugh at me, never get that great advice my grandma gave, etc. In the end I just relied on my faith and her faith that she was going to heaven and I would see her again if I did what I was supposed to do.

I wouldnt trade a single day with her and believe that if there is something we can do to help keep them around we should until they decide differently. and if the kids come to a mutual decision and all agree to keep them alive then we should respect it. money shouldnt be the reason for ever ending a life. I know that I didnt want my grandmother suffering and we all knew what her wishes were.

Isnt that what living wills are for? I know that I do not wish to be kept alive on machines and I have let it be known in writing.

Keep in mind, I've been through the same thing with my own mother Mike, so I certainly understand how powerful your personal experience was. I think theres a line we cross, at some point, where 'another day' for us means another day of suffering for the person we are going to miss so much. My experience has been that its rarely the individual reaching the end of their life that necessarily 'wants to go on' - usually, they have little to no say in the matter due to circumstances - rather, its those they are potentially leaving behind that are making the decisions.

In the abstract, I agree with your premise that cost should never determine what we do. I believe that. But I also know, from a rational POV, that on a grand scale, extending lives by artificial means for extended periods is incredibly expensive, and the truth is, our healthcare system cannot survive long-term keeping everyone alive for as long as possible. It just can't. The bigger issue though, for me anyway, is that its not right to try and keep anyone alive when there is no real potential for full recovery or quality of life. I'm not talking about pulling the plug on anyone with the potential to recover, I'm talking about allowing for a natural life or death.

One thing I've told many a family - if a miracle is going to occur, it won't be because of our machines, drugs, and technology. Those things only provide us time. It'll be because the individual isn't ready to go yet, or some other grander force.

I'm glad you had the opportunity to tell your grandmother what she's meant to you - not everyone is so lucky.