380 APPENDIX TWO essentially dead patient is pumped full of drugs, stabbed with dozens of needles, and jolted with electric shocks. Our dying moments are closely documented by heart rate, levels of oxygen in the blood, brain wave readings, and so forth. Finally, when the last doctor has had enough, this technohysteria comes to an end, 2 You may not wish to have life-support mechanisms or be resuscitated, and you may want to be left undisturbed for some time after clinical death. How can you ensure that your wishes for the kind of peaceful environment recommended by the masters for dying will be respected? Even if you state your wishes about wanting or refusing certain kinds of treatment in the hospital, your requests may not be respected. If your next of kin does not agree with your wishes, he or she may ask for particular procedures to be started even while you are still conscious and able to talk. Unfortunately, it is not uncommon for doctors to comply with family's wishes rather than those of the dying person. Of course the best way to have some control over your medical care when you are dying is to die at home. In some parts of the world, documents known as Living Wills exist, through which you can state your desires for treatment in case the time comes when you can no longer make decisions for your own future. These are a sensible precaution, and help doctors if they are faced with a dilemma. However, they are not legally binding, and cannot anticipate the complexities of your illness. In the United States you can draw up what is called a "Durable Power of Attorney for Health Care" with a lawyer. This is the most effective way to state your choices and ensures, as far as possible, that they will be respected. In it you name an agent, a legal spokesperson who understands your attitudes and wishes, who can respond to the special circumstances of your illness, and who can make crucial decisions on your behalf. My advice (as I indicated in Chapter 11, "Heart Advice on Helping the Dying") is to find out whether or not your doctor is comfortable honoring your wishes, especially if you want to have life-support measures withdrawn when you are dying, and you do not wish to be resuscitated if your heart stops. Make sure that your doctor informs the hospital staff and has your wishes written onto your chart. Discuss the issue of your dying with your relatives. Ask your family or friends to request the staff to disconnect any monitors and IV lines once the process of dying has begun, and to move you from an intensive care unit into a private room if feasible. Explore ways in which the atmosphere around you can be made as quiet, peaceful, and as free from panic as possible.
ALLOWING DEATH TO HAPPEN QUESTIONS ABOUT DEATH 381 In 1986 the American Medical Association ruled it was ethical for doctors to remove life-support, including food and water, from terminally ill patients about to die and from those who could linger in a coma. Four years later a Gallup poll showed that 84 percent of Americans would prefer to have treatment withheld if they were on lifesupport and had no hope of recovering. 3 The decision to limit or withhold life-sustaining treatments is often called "passive euthanasia." Death is allowed to happen naturally, by refraining from medical intervention or heroic measures that can only lengthen a person's life by days or hours, and where their condition is not amenable to treatment. It would include terminating aggressive treatments or therapies aimed at curing the dying person, refusing or discontinuing life-support machinery and intravenous feeding, and dispensing with cardiac resuscitation. This passive form of euthanasia also takes place when the family and doctor choose not to treat a secondary condition that will result in death. For example, a person dying in the final stages of bone cancer may develop pneumonia, which if not treated may lead to a death that is more peaceful, and less painful and prolonged. What about people who are terminally ill and decide to take themselves off life-support? By ending their lives, are they committing a negative action? Kalu Rinpoche has answered this question very precisely: The person who decides that they have had enough suffering and wish to be allowed to die is in a situation that we cannot call virtuous or nonvirtuous. We certainly cannot blame someone for making that decision. It is not a karmically negative act. It is simply the wish to avoid suffering, which is the fundamental wish of all living beings. On the other hand, it is not a particularly virtuous act, either,,,, Rather than being a wish to end one's life, it's a wish to end suffering. Therefore it is a karmically neutral act. What if we are caring for a dying person who asks us to remove life-support? Kalu Rinpoche said: We may not be able to save the patient's life. We may not be able to relieve the person's suffering. But we are trying our best, motivated in the purest way possible. Whatever we do, even if it is not ultimately successful, can never be thought of as karmically damaging or karmically negative.. When a healer is instructed by a patient to remove life-support systems, that puts the healer in a difficult position, because the instincts of the healer may be telling them, "If this person stayed on the life-support system they would remain alive. If I take them off, they will die," The karmic consequences depend upon the healer's intent because the healer will be