The cycle of life and preparing for its end

Debra L. Glasser, M.D.

PHOTO BY GLORIA TOWNE

“The ancient Irish bards knew the Salmon of Knowledge as the giver of all life’s wisdom. In the salmon’s leap of understanding like a leap of faith, we see ourselves ‘in our element,’ immersed in the river of life. The cycle of the salmon’s journey reminds us that all rivers flow to the same sea,” Lynn Culbreath Noel

We in the Pacific Northwest are given the gift of witnessing the salmon completing their life cycle every autumn, to both observe and reflect upon the cycle of life and the inevitability of death.

Last week I witnessed the annual drama of the salmon spawning in the Dosewallips River along Hood Canal. In the hundreds, the salmon were swimming upriver and finding their spawning grounds (where they will die) right before my eyes. They followed their genetically wired path to their death, seemingly willingly and with much effort. Do they know it is their end?

Perhaps it is a blessing and a curse that we humans with our complex brains and frontal lobes can be aware of when death is approaching. And even if its approach is not imminent, we know it will be part of our life experience.  A blessing because we can prepare, emotionally and logistically.  A curse because we are afraid and tend to avoid the truth if it feels painful or difficult. Unlike how it appears for the salmon, letting go is not natural for most of us.

“I cannot escape death, but at least I can escape the fear of it.” Epictetus

Choosing a decision-maker

Choosing a Decision-maker at the end of life is one important way to face and be sure your wishes will be honored when the end is near. Even if one does not need a decision-maker, the process of preparing can help us clarify for ourselves and our loved ones, our end-of-life wishes. Conversations with my former RN colleague (see below) informed me of an important law our state has passed to help each of us face and plan for our deaths.

Washington State law RCW 7.70.065 is a law that allows us to choose and appoint an individual to make decisions regarding our medical care if we cannot choose for ourselves.

This law is important for us individually and for our families and friends who will be with us when we are seriously ill or injured and facing important healthcare-related decisions. It is also important to take responsibility for our health and impending death because this time of life heavily impacts our seriously overburdened healthcare system. When our wishes are clear and communicated, it helps the healthcare team proceed to care for us according to our wishes and not more or less.

What are your wishes for the end of life?

Do you know the wishes of your loved ones? Or your own? Have you talked to each other about it? Has someone been designated (in a legally binding way) to make decisions regarding healthcare interventions when you cannot? To help you face and answer these and other important end-of-life questions, the Washington State Hospital Association and the Washington State Medical Association (physicians) have an immeasurably useful website with resources to help in all aspects of this process.

Honoring Choices is that site.

On the site are posted important forms and tools to help – including the legal form to name your surrogate decision-maker(s) in the event you cannot make your own. This 2-page form on the site is all you need once you know who you are going to name as your decision-maker. Click here for the form.

On this form, you can designate your HEALTH CARE AGENT (also called your Durable Power of Attorney for Healthcare or your Surrogate Decision Maker in the event you cannot make your own decisions) and two alternates. It needs either be signed by two witnesses (rules for them are on the form) or a notary.  No lawyer is necessary! It is important that you choose these people carefully and that you talk with them regularly about your wishes as those may change over time and circumstances in ways that we cannot predict.

If you do not have such an agent designated, the law has delegated who will make health care decisions for you when you cannot. Honoring Choices has an easy-to-read list of that hierarchy.  

Hierarchy of choices in Washington State of who will make health care decisions if you cannot.

Hierarchy of choices in Washington State of who will make health care decisions if you cannot.

An important situation to consider is if you do not have a spouse or REGISTERED domestic partner and have not yet designated them as your health care agent.  In such a circumstance, the hierarchy list skips to people and groups of people you may or may not want to make decisions for you. If a group is listed (such as children or your siblings), said group must agree to the care.  Whose families are harmonious enough to come to a group consensus about you or your partner?

When are these considerations VERY IMPORTANT to sort out?

There are situations where the possibility of such need is omnipresent and potentially imminent:

• When you are reaching the end of life due to age or disease
• When you have end-stage organ or life-threatening diseases– e.g., especially ones that can affect your ability to make decisions for yourself. Encephalopathy (which includes a loss of cognitive ability) is not uncommon for those on dialysis for kidney failure, liver failure, and cancer with brain metastases.
• When dementia is early or a disease process may impair a person’s ability to talk and express their wishes; this includes Parkinson’s disease and strokes.
• When your preferred decision-maker(s) do not conform to the hierarchy, such as long-term domestic partners noted above.

For everyone else, we never know if or when we might lose decision-making capacity, leaving loved ones to make decisions for us. This situation is stressful enough for them, more so if they have not been advised of your wishes.  Planning for this time is a life responsibility that is no different than attending to other affairs (having a will, files in order, financials, and funeral plans) before you die.

Equally important to picking a surrogate decision-maker, are the broad and deep considerations of what to contemplate as your wishes. Honoring Choices again has this laid out in a simple way to at least begin. There is A LOT to examine. For instance:

• Where do you want to be cared for and die?
• What matters most to you near the end of your life?
• Who do you want to be with you?
• What are your values and religious beliefs around death to be considered?
• What about treatments? Life-prolonging and otherwise?

The site includes comprehensive discussions and ideas for starting the conversation about end-of-life wishes and writing it down. There are abundant resources – websites and books, videos, articles, and even games! One book is a favorite of mine: When Breath Becomes Air by Paul Kalanithi, M.D. This is an autobiography and philosophical treatise by a successful young doctor facing a terminal illness and decisions about life and death.  These decisions are not always for the elderly.

Dying is a stage of life we all will face and we owe it to ourselves and our loved ones to ‘start the conversation.’  

“Every man’s life ends the same way. It is only the details of how he lived and how he died that distinguish one man from another,” Ernest Hemingway.

With gratitude for the inspiration to write this column:

My yoga teacher Rhett Fonseca who passed away peacefully on September 20^th just 14 days after his sudden and unexpected cardiac arrest at the age of 67.

My mother, almost 91, recently went through a heart attack, angiogram, and stent. I was grateful to have had many conversations regarding her wishes as her durable power of attorney for healthcare over the last few years. These turned out to be very helpful in assisting her decisions regarding the interventions.

Kara Evans, RN, MPA Palliative Care Nurse par excellence at Providence St Peter’s Hospital where she and her colleagues undergo these discussions with their patients daily.

The Salmon of our beautiful Pacific Northwest rivers and streams.

Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com