Planning for a graceful death is smart. Here’s how to get started.
A quiet, gentle death without ongoing medical interventions. That’s what Jimmy Carter and his family had in mind when, after a series of hospitalizations and with the support of his family and doctors, the 98-year-old former president said he would spend the rest of his life at home with hospice care. So now, along with his work for affordable housing, human rights, and mental health awareness, President Carter will be remembered as an advocate for knowing when to say “enough.”
How about you? Whether you face a slow decline or a sudden diagnosis, do you want to exhaust every possible option to extend your life? Would you favor the balanced approach of palliative care, which centers comfort but can include continuing treatment? Or would you prefer to spend your last days (or weeks or months) in hospice care, which emphasizes comfort without the expectation of a cure?
Advance Directives
Advance directives are the essential first step in preparing for care near the end of life. These documents spell out exactly what you’d like if you are unable to make decisions for yourself. Most people are familiar with “do not resuscitate” orders, but there are also directives that specify your wish to voluntarily stop eating and drinking as death nears. There are even documents that can be completed in the early stages of dementia to outline your wishes for your health care, finances, and personal relationships as you live into later stages of the disease.
The messages are clear: Planning is important. People’s Memorial Association urges Washingtonians to “Get Your Ducks in a Row.” End of Life Washington encourages people to be “End of Life Ready.” Rebecca Hudson, client services coordinator, says that while End of Life Washington is best known for its work in helping people access Washington’s Death with Dignity Act, “We are about choice in general. We are about making sure folks know all their options and are given the resources and support for whatever path they want to choose at the end of their life.”
That goes for people from all walks of life, she adds—not just educated upper middle-class folks. “We really want to make sure that everyone in Washington knows what their choices are, no matter what socioeconomic demographic they’re in … no matter if they have a concierge medicine doctor, or they get health care at a community clinic.”
You need to sign your advance directives before two witnesses (notarization is optional in Washington state) and file copies with your family, doctors, faith community, and preferred funeral provider. Hudson notes that it’s fine to complete whatever advance directives you can, even if you leave some parts blank. You can always change them later. “At least name a health care agent,” she says, and give that person a general idea of the extent of intervention you’d prefer.
Life-ending Medication
Although advance directives provide great peace of mind, Washington is one of 11 states that go further via laws that allow people to request life-ending medication if they have less than six months to live. Patients must have the ability to make an informed decision and self-administer the medication. End of Life Washington helped 319 people exercise the right in 2022, and this spring, the Washington legislature acted to strengthen its original death with dignity law. Key changes include:
- A 15-day waiting period was reduced to seven days. With this change, fewer people will need to suffer longer as death nears—if, for example, they lose their ability to swallow.
- Prescriptions can now be made electronically, and medications may now be delivered via signature mail or courier. These changes will make access easier for rural patients.
- Previously, two doctors needed to approve a request for medical aid in dying. Now one of the two professionals can be an advanced registered nurse practitioner or a physician’s assistant, who often serve as the attending provider on many care teams.
Even in its new form, the law has gaps, especially for people with advancing dementia. This leaves Washington’s law short of that in Canada, where residents with dementia can, under some circumstances, receive medical assistance in dying, and where doctors are much more involved in the process. And access is tightening in Washington since about half of its health care systems are affiliated with religious organizations that oppose medical aid in dying—and where doctors can’t even talk about it.
“I’m amazed at the number of oncologists who don’t even know it’s legal in this state,” says Dr. Roy Graves, a retired emergency room physician who volunteers with End of Life Washington. Another challenge is a proposed federal rule change that would bring back pre-pandemic restrictions to forbid physicians and hospice teams from prescribing comfort care and medical aid in dying drugs via telehealth. The overturning of Roe v. Wade may portend similar rollbacks for medical aid in dying.
Death with Dignity
Death with dignity is personal for Graves, whose own father chose the option last year at age 102 after metastatic disease, COVID, and diabetes ganged up on him, even though he was still living independently and still driving. But “it was getting to the point where he couldn’t walk, and he said, ‘You know, I’m ready.’ I saw how important it was for him.”
“I was an ER doc for 38 years,” Graves says. “I saw a lot of bad deaths, and in my experience, the people who are most interested in death with dignity are the ones who’ve experienced bad deaths within their own families. When you can’t control pain, these people are just miserable, just hoping they can die.” He notes that the laws in New Mexico and Oregon now require just a three-day wait—and even that can be waived if death is imminent, such as after a bad diagnosis in the ER.
“When you’re dying, you really lose the sense you have control over anything in your life,” Graves adds. “You become more and more dependent on everyone around you.” Death with dignity confers the possibility of options and control, of hope within a hopeless situation.
With that in mind, “these are conversations to start having now, with your loved ones and with your physicians,” says Hudson of End of Life Washington. “And find out: Is your doctor supportive of these choices?” If not, she adds, you may need to find a new doctor.
At its best, aging is about wisdom. While few of us want to think about final choices that may be years away, it’s wise—and kind, to ourselves and our loved ones—to weigh our options and express our wishes sooner rather than later.
Julie Fanselow is a writer and editor in Seattle.
Resources to Get Ready
End of Life Washington (endoflifewa.org) offers an extensive library of advance directive forms and offers online end of life ready webinars.
People’s Memorial Association (peoplesmemorial.org) holds regular “Ducks in a Row” presentations that cover end-of-life planning and funeral options.
Dignitas (dignitas.ch) is an international organization based in Switzerland that advocates for choice in end-of-life matters.
Dementia Action Collaborative funded by DSHS (dementiallegalplanning.org) offers free legal help in Washington state for health care directives, dementia directives, and powers of attorney.