What Does A Good Death Mean To You: Medical Aid in Dying

The most uncomfortable end-of-life questions are often the most practical ones: Is medical aid in dying legal, who qualifies, and what does it mean for the people who have to live with the aftermath? We bring on Bob Ooslander, an emergency physician turned palliative care specialist, to walk through what “death with dignity” looks like in real homes with real families, not just in headlines.

We get specific about the core facts, including why medical aid in dying is treated as a legal process and why it’s typically limited to terminal illness with an expected life expectancy of less than six months. Bob explains two patterns he sees again and again: patients declining quickly who are likely to use the medication, and patients who want the prescription as an option they may never take because having control reduces fear. We also connect this to hospice and palliative care, where good support can sometimes ease suffering enough that people choose a natural death without ever using the medication.

Then we go where the tension usually lives: family dynamics, religious objections, and the fear of “indication creep.” Bob shares how patients often have to convince loved ones to accept their choice, why neutral counseling matters, and how safeguards are meant to prevent misuse while preserving access for those who qualify. We close on a message that applies no matter where you stand on physician-assisted dying: clarity is a gift. If this brought up feelings or questions, subscribe, share with someone you trust, and leave a review with your take.

Link to How Doctors Die Essay

https://empoweredendings.com/

Transcript

Dignity, Dying, And The Controversy

SPEAKER_00 0:00

Yes, yes, yes, and yes. I mean, we could spend an hour or more talking about every every element of what you just uh introduced.

SPEAKER_02 0:35

That is the voice of Bob Ooslander, who is an emergency physician, palliative care specialist, and he stirred up I was gonna say Horn's Nest, but it was not really. He created a discussion. First on MRAP, June 15th, he talked about medical aid in dying. That was part of it was part of a much bigger story about um dignity in death and dying with Ms. Ho Morrison. Go check it out on MRAP. But I specifically he didn't want to talk about the medicine of medical aid in dying. This is the concept that a physician might aid a terminal patient in dying in order to reduce their suffering, in order to uh have them live the life and end the life the way they lived. But we knew it would be controversial for some people that the ethics of that would be concerning. So I got Bob back on the line to go over some of those family dynamic issues because they're really important. And some of the questions were is it legal? In whom is it legal, and is it ethical? Is it right? So many questions.

SPEAKER_00 1:33

With respect to medical aid and dying, the the law uh is very clear. So, first of all, it's very clear that that this is not considered suicide. And I know that one of the one of the responses that you shared with me was kind of comparing a suicide of a 17-year-old who was depressed to a person going through medical aid and dying and making the decision to control the time and place of their death. So the people who for whom this law was uh created uh is people who are dying, people who are terminally ill and have a life expectancy of less than six months. Some of the people who are looking for this to take advantage of this option are it's clear that they're dying quickly. They have metastatic pancreatic cancer, lung cancer, or glioblastoma, or um, they've got ALS and and their lung capacity is at 30% and and diminishing. And so these are these are people who who are in their clearly their final stage of life, and they are now dealing with the struggles and suffering of dying, and they they don't want to have to go to the bitter end of that experience and have to be medicated into oblivion or you know, get deal with all the all that comes with that, losing all their dignity and independence and um and dignity is a self that that's a

What The Law Actually Allows

SPEAKER_00 3:10

self-determined thing, right? We we all have a certain amount of inherent dignity, and then people can decide whether the the experience they're having is consistent with that dignity. But but about half of the people in my experience who want to this who want to take advantage of medical aid and dying are are dying and they're going to die pretty quickly soon, within you know days or or weeks. There's another segment of people who have are terminally ill, but the time frame isn't quite as clear. They and they're not looking to fill this prescription and take the medication right away. What they're looking for is to have to know that they have this in place, which will give them a certain amount of peace of mind, that if their condition changes and they are now suffering and experiencing what they believe to be a quality of life that's below what's acceptable to them, that they'll have the option available. They'll have the means to just go to sleep and not have to suffer any for any more. So that's about that's an and those are people who have you know COPD. They have end-stage heart disease, um, they might have neurodegenerative conditions, Parkinson's disease, a number of different conditions that are that are stripping a person of their independence and and ability to function and requiring them to be cared for in ways that may not be consistent with with their values. Um and it's interesting because it of that group, the group that gets the of the of the people who who are dying soon, and it's pretty clear, the vast majority of them will fill the prescription and take the medicine. Sometimes they die, they they change too quickly, they decline and they require more pain medicine and they lose the ability to communicate effectively, and so they may not be able to. Of the other group, a pretty substantial percentage of them end up never choosing to take the medicine. And they have the option, they have the generally the medicines at the pharmacy, they haven't filled the prescription. And and what I'm what I find is that a lot of people fear the dying process. They want this in place because they they fear what will come. And and they don't want to have to endure that if there's an option. Um, and a lot of people just don't, they never get to the point where they're suffering the way that they thought they might. They can be cared for well through the the traditional models, palliative care and hospice and and good support. And they may just drift away and never end up making the choice. Because in my experience, nobody will do this. Nobody fills the prescription and prepares to take it and then takes it until they absolutely know that it's time. And if you never get to the point where you know it's time, then you won't do it, and and then you'll have a more natural organic end-of-life experience. So it's it's people who are looking for that sort of peace of mind. And a lot of the people who I who I see and counsel through this and support are people who have been a lot of them are doctors. It's a it's a very common way for doctors to go. Um, or it's this, or it's the family members of doctors, or lawyers, or CEOs, or people who have been pretty much in

Two Paths: Use Now Or Later

SPEAKER_00 6:40

control throughout their lives, and they want to, they, they want to die the way they lived. They want they want their death to be consistent with the way that they've lived their lives. Um, so so that's kind of that's just a bit of an overview of the people who who are looking for this kind of support.

SPEAKER_02 6:58

So this comes up very frequently in doctor circles. Um, for those of you listening that aren't doctors, we watch a lot of people die in various circumstances, slowly, fast, and almost all my physician friends say they don't want to die like many of their patients. They want to have control, they don't want to do what we would often call the spiral, um, where you're sick and you're in the hospital and you're out of the hospital and you're spiral and you're just getting worse, and your quality of life is just getting worse, and you just know that there is no way to get off this treadmill. We know where this goes. We've seen it so many times. So, is that your experience? It's just the physicians have been through this with their patients and, like, I don't want to do it that way.

SPEAKER_00 7:39

So, yes, the physicians, especially the ones who are paying attention, uh, very much so. Um, and it's but it's not just physicians, it's also people who have watched loved ones go through it. We have seen it mul time and again. And and um, so we have a, you know, we have a front row seat to it on a daily basis. But there's a lot of other folks who watched their mother go through this, the the spiral, right? Or they or their friend or their spouse or you know any any other relation. And and they they they realized that they did not, they weren't given information that would have helped them make the decisions that were more consistent with with their values. They weren't told what the what that next round of chemotherapy was likely to result in. That they, you know, not a lot of oncologists are willing to take the time to tell people, honestly, that there's a decent chance that that accepting this chemotherapy is going to end your life sooner than if you just let the the natural process on unfold. Um and and I think the statistics are pretty clear. The the people who utilize medical aid and dying generally are uh highly educated, more highly educated. They generate more of them are um Caucasian. They there's there's a certain demographic that is more uh that is more represented in that. But I have I I've taken care of patients all walks of life, all demographics. Um, you know, there's what's most common, and then and I think part of it is it's cultural, there's religious um issues that we can we can talk about. Um but I think physicians are much more likely to make choices that would um allow kind of their life to end without as many interventions and and without as much um feudal treatment.

SPEAKER_02 9:40

For our listeners, How Doctors Die was a essay by Ken Murray. It was about uh 20 2011. It's now available in the PDF and you can go and uh read it in lots of different places. Just do a Google search, How Doctors Die. And the premise of that essay is that doctors don't do all of those life-saving interventions like we do for our patients. We don't want to be on life sport, we don't want to have CPR, we do not want to go to the ICU, we don't want all of those things done. When we are diagnosed with pancreatic cancer, knowing that doing nothing, we're gonna be dead in four months, and doing everything we're gonna be dead in six months, although that may have changed for some cancers, just by the way, maybe more like a year and a half. They doctors don't want to do that. They want to have a much more simple death. Not exactly the same as what we're talking about here, but I can tell you from my experience

Why Doctors Fear The Spiral

SPEAKER_02 10:40

that given the choice, most doctors would like to take a potion at the time of their liking to end their terminal condition. Another aspect then that I wanted to touch on was family dynamics. You have a patient who's terminal who really wants to take control, but there are family members that really are against this. They don't want that to happen. They want grandpa or whoever it is to stay on the earth as long as possible, and they don't really care in what form, as long as they can say grandpa's still alive. How does it often play out? Do people come around, or are there just some people that never get on board? And how does the patient deal with that? Do they sometimes just say, Well, I can't do it because everybody's not on board? Or they say, I have to do it because it's me, not you?

SPEAKER_00 11:26

Yes, yes, yes, and yes. All of those you you brought up, I mean, I mean, we could spend an hour or more talking about every every element of what you just uh introduced. Um It's interesting because I one of the one of the opponents of this law, of the Medical Aid and Dying Laws, um, they they use this this notion that people are going to be sort of coerced, pressured. They worry that people who are elderly and frail or debilitated, that they're going to be sort of offed by their family members because they're too much of a burden or or too much work. Turns out that it's quite the opposite, that the people who are who are wanting to utilize this option, go through this process, are generally having to convince their loved ones that it's okay to do and to and to sort of support them and not try to keep them here when they're not, when it doesn't feel like it's it's the right thing for them to do any longer. Um I one of the things that my practice evolved primarily to support the families in in helping to care for their loved ones. One of the things as when I transitioned out of emergency medicine, started doing palliative care, I I just saw such a huge gap because patients would get their needs met in some form or fashion, not always optimally, but somehow the the they they got their pain medications and their oxygen and their what they needed to have more comfort and and support. Family members had very little support. And so we we we really focused on making sure that the families had a a voice and a place to go to get information. And it's it's just as important and more in in many cases more important to support the families through this process because the patients generally know what they want. They they realize what they're going through and they want, and if they and if they're open to it and learn about this option, they get on board often pretty quickly. And then it's just a matter of having their having these conversations with their loved ones. We so we spend a lot of time counseling and doing you know group sessions, and we have end-of-life doulas and social workers who are sp who are really focused on helping family members understand why a person might make this choice, right? It's not because they want to die, it's not because they're looking forward to dying, it's because they're getting to a point where life is no longer worth it for them to continue fighting and struggling. And so a lot of times it's like helping the family members see what it would be like to be in that person's skin and to try to experience the world through that lens. Um, that's a mixed metaphor. That's eyes and eyes and skin. So forgive me for that. Um, but but we and we do a pretty good job. And ult so, and so here's I I I'm with a lot of patients and families at the time that they make it, that they're ingesting the medication, and a lot of work goes into getting everyone ready. And and ultimately when when they get to that point, when we can help everyone get there, what uh what unfolds is the

When Family Members Resist

SPEAKER_00 14:50

family members understand that they're giving their loved one an enormous gift by allowing this to happen. Because the the patients typically aren't able to do it all on their own. They're not able to coordinate the visits and the call, the the work of doing this. Um, so families generally have to help. And they could block it because there are times when pay when families don't come around or they don't support the love their loved one and the loved one doesn't get to use this option because it's they just can't they can't do the the logistics of it, or they don't want to upset their children who who will not find a way to accept it. And so there are times when people will just say, you know what, I'm not gonna, I don't wanna, I don't wanna, you know, just ruffle things to that degree. I'll just sort of go the natural way. And um most of the time families come around. And if there's a family member who can't because of religious views or s or other issues, then we'll we'll request that they just don't participate, that they that they just stay neutral and and out of the picture as much as possible, because that becomes one of the biggest stress points in this whole process. It's stressful enough to be dying. It's stressful enough to be making this decision to convince other people that it that they should allow you to do it is um you know kind of sometimes beyond stressful.

SPEAKER_02 16:22

Now, my experience with people of various religious faiths, but I'm mostly surrounded by people with a Christian background, that really do not support this. Coming at it from a theological point of view, the sort of Saint Augustine point of view, that this is not your job. God decides when you die, you should not speed that process. Not your call, God's call, and I put those in quotation marks. Is this your experience as well?

SPEAKER_00 16:49

Oh, I encounter people who who have that. I they they generally so so occasionally people will will want to have the conversation um about the end of life options, and that and that's an element of it for some people who are either very religious, um or or just wanting to honor, even if they're not very orthodox or or very conservative, they they they they want to know that what they're doing is acceptable in the eyes of God. So I I don't I can't really weigh in on that. I'm not a priest, I'm not a rabbi. Um, but I do encourage people to seek guidance and support from from their pastors or for the from their rabbis, and but ultimately to make their own decisions, right? That because I I come across a lot of people who who have been very religious and and conservative in a number of ways, but when they're dying and suffering and struggling to breathe um or in diapers and all of the things that people want to avoid and and don't want to be part of their experience, when it comes right down to it, a lot of times they they they'll they'll think, well, God, does God really want me to have to suffer like this? And and sometimes people have that um that question of if God, if God wanted me to go, he would, you know, he would make a sign or you know, do something. And and and sometimes I I feel comfortable saying, hey, you know, God brought me here in front of you to have this conversation. So let's just, you know, I'm not trying to convince anybody that it's right or good or acceptable. My goal is to give people the information, it's it's neutral, and and then they can do with what they want, and to support everybody so that ultimately, if somebody does go forward, it's it's done in the way that's the least traumatic for everybody, uh including their loved ones, who are gonna have to live with this for years, decades after that person's gone. So again, I understand the rel I understand there's opposition, I understand there's discomfort, controversy, uh all of that. And I respect it completely. And I and I'm not trying to promote or convince. I'm I'm just I feel like we deserve to have the information because if we if we don't have it, then there's nothing we can act on. And if people when people learn about it after the fact, if family members or patients learn about it be after the the point where they'd be able to utilize it, that's a that can be extremely um distressing. And I feel like that is something we can avoid. And I think having up as have like promoting, not promoting, but exposing this, raising awareness of it is a real service that we can be doing to our people for our people.

SPEAKER_02 19:48

Another concern that's often raised, and actually was raised from a number of uh people who listen to the MRAP segment, was what about indication creep? Right now you're talking about patients at the end of their life, often elderly, terminal, in pain. Okay, a lot of people are gonna get their head around that. But what about indication creep? And we have seen this in some places where this now can be for people who just have mental illness, who just don't want to continue having mental illness, and maybe they've failed multiple treatments. And kids, kids saying, like, uh, I'm done here. Now often these arguments are a little bit straw man because you can always take the worst case scenario and blow it up and uh argue about that you know very tiny, tiny fraction,

Faith, Ethics, And Neutral Support

SPEAKER_02 20:30

but still it's a real question. Indication creep. Who should this be available to?

SPEAKER_00 20:36

I hear you. I say I hear you, and I and I have similar concerns about about the creep, about the possibility of this expanding to the point where it's um it's the the the uh criteria are are too loose. And I and I and I understand that that's a a concern, but it's also not a reality. We have safeguards in place. I think the medical community is being responsible in how it's approaching the these laws and these these processes. And uh what I wouldn't want to do is remove the option or the opportunity for people to go through this process when they when they qualify with this legal uh process that has been in place in in certain places for almost 30 years with with very very few if any reports of of misuse. People deserve to to have uh the access to this to these laws in the places where it's legal. And we need to be res we need to be thoughtful and considerate and responsible about making sure that we that we don't um Expanded too quickly, too loosely, um, if at all. That's kind of how I feel about it.

SPEAKER_02 22:08

Are doctors more comfortable with dying than the general public?

SPEAKER_00 22:12

I I don't know that doc the doctors in general are more comfortable with death than anyone else. So I also know that there are there are not there are many doctors who wouldn't go through this process, who wouldn't choose this because they they they feel that it's not their place, like many other people. There the the statistics are show that about 65 to 70 percent of people, certainly in California, which is a little bit more of a progressive state, um, are in favor of death with dignity and people having the option. Um and and it's a similar percentage in healthcare workers, but that means that there's 30, 35 percent of people who who don't. And and they they in a very personal decision. It's a very personal decision, all of this. There are people who who are are you know, not that they're comfortable, but they're willing to let things unfold according to God's will or according to their children's will or any somebody else's will. And then there are a number of many people who who who have this certain this they want agency, they want to maintain control, and they they equate sort of their own dignity with being able to make this choice and not have to not have to experience the things that that that they don't want to experience, whether they know where they're going or not. Yeah, most of the people don't. And a lot of them, like I just talked to a lady today who is she's she's excited about the mystery. She's 93 years old, she's got end stage C O P D, and and I I specifically asked her, like, what what do you think is gonna happen when when you're when you go? And she says, I don't know. It's a mystery. And and I could tell her, like she was I could see that it was exciting to her,

Indication Creep And Safeguards

SPEAKER_00 24:10

this this mystery. So she's not in a hurry. She's not she but but she knows this is a woman who has on a on a frequent basis, she has these horrible paroxysms of wish of coughing and not being able to get her breath and taking 20 minutes before she can actually start breathing normally again. And she's like she knows what it's like to suffocate because she's doing it on a regular basis, and then she knows that one of these times it's not going to, and she'll be in that position. So that's something that she's trying to avoid, but she's not right ready yet. She may not get ready. So the question about you know, doctors I I think there's a lot of doctors who are very uncomfortable with death. We never learned about death in medical school. There was no talk about it. If you like at the I don't know, Mel, you probably graduated on that I did at the same time I did. I finished graduated medical school in 88. Like you, you if you like death was never mentioned. It wasn't talked about. Is that still true? No, I think that they're doing a little bit better of a job. They have, you know, maybe one lecture about hospice care, and maybe then they have some electives and palliative care. They they give it about as much attention as they give nutrition, which is still pretty.

SPEAKER_02 25:25

Bobba, there are times when somebody comes to you and you say, no, no, this isn't right. Uh the timing's not right. There's other things we can do. Let me uh explore with you some of the other things that are not medical assistance and dying.

SPEAKER_00 25:38

I I I tend to have no agenda when I meet with people. I don't enter into it kind of thinking that this is gonna the way it's supposed to go, or I want to you know lead it this way. My my my agenda is to find out how I can best support that person in experiencing the best possible quality possible quality of life. And there are times when I identify things that absolutely they need they should be hearing, or they should be aware of, that could do that, that could enhance their quality of life, reduce their suffering, improve their their circumstances. Um and many times I will have I will I will one of the most I think beneficial things about what I do is I give people a safe space to talk about it. Yeah. And without judgment, without fear, they know that I'm not gonna be like 5150 them and and tell them that they're just depressed and suicidal and they need to see a psychiatrist. I will honestly hear their, you know, their experience and and then help them identify. Well, you know, maybe you need to dance, maybe you need to try a different kind of pain management, or you need to get caregivers in so that you're not alone, or you need to get a dog, or so there's a lot of discussion. The people who are dying of metastatic, aggressive pancreatic cancer, who have been in and out of the hospital with bowel obstructions and all of that. I there's there's still often something that can be done, but but I'm not it's not necessarily we're not we're not trying to extend, help help them extend their life because they're the the extension of that life would just subject them to more more misery. Um but there are a lot of times when I when I do help people. We have music therapists and acupuncturists and massage therapists, and we'll recommend cannabis or ketamine, or you know, there's all kinds of things that we can that we can try to introduce. Some people are open,

Alternatives, Peace Of Mind, And Clarity

SPEAKER_00 27:40

some people aren't. And um in some cases, one of the hardest things to to do is to tell somebody they don't qualify, that we that we can't sub give them, you know, we can't take them through this process now. But let's just stay connected, let's see what we can do.

SPEAKER_02 27:58

And what are the reasons for that? Why would you not offer it?

SPEAKER_00 28:02

So a couple different things. Um, the more common is that a life expectancy, it's hard, we just can't give them a six-month life expectancy. Things are just they might die in a month, they might die, but they might also kind of linger for for many months, and it's hard to make that call. Um, but then we also, for people who are really suffering and there isn't much hope that their suffering can be alleviated, then we also move into the conversation about voluntarily stopping and drinking, which is which is another really important topic, as is self-directed comfort feeding, other, you know, for for people with cognitive impairment.

SPEAKER_02 28:38

Um so Bob, you've said that a lot of people will get the medication, but they won't actually use it. They'll just sort of have it there as an option. Does that improve their quality of life, their outlook? What does that do?

SPEAKER_00 28:53

Well, I'll tell you what. One thing it does is it prevents suicide. It's a medical-aid and dying is a form of suicide prevention. Because people who are desperate because they're dying and they don't feel like they have any any way out, they often think about how they're going to die. So they hoard medications, they think about traumatic ways, and I've taken and I've taken care I've taken care of people who have attempted suicide um as a way out of this terminal condition before they knew that medical-aid and dying was an option.

SPEAKER_02 29:28

Uh-huh. I hear you saying it. I hear you thinking it. What's the difference? Them dying by suicide or them buying by medical-assisted means.

SPEAKER_00 29:37

One's a legal process that doesn't generally traumatize their loved ones and doesn't and doesn't nullify insurance benefits, life insurance. And if somebody is found to be to have been supporting, abetting that person, they won't be um they won't be charged with a felony. It's a it's a legal process. The death certificate for people going, yeah, for people going through medical aid and dying, the death certificate states that the cause of death is the underlying illness. No one, there's no mention of the fact that there was an ingestion. And it's very clearly laid out in all the laws in the states that that allow it. I do think that it improves quality of life. It definitely would you know improves people's um peace of mind and gives them a sense of peace and control when then when they have lost that their sense of control and agency. Things are happening to them. When you're dying and you're on hospice care, people just show up at your house all the time. They tell you what medications to take. There, there's no there's very little dignity for self-reported dignity. I'm I'm sensitive to this, to this other physician to Matt's comments, and I agree with him. Dignity is inherent in each of us. No one can take away another person's dignity, but we can certainly treat people in a way that's inconsistent with what they see as dignity and what their values are. So I do think that it probably enhances quality of life. It probably in some ways prolongs people's lives because they know that that they have the the means to the end. They know they have something that will allow them to do it on their own terms.

SPEAKER_02 31:20

So, Bub, as we wrap this up, this time, because I think we'll be back, maybe even with some of your patients. What would be the message that you want to get out to the world about medical aid and dying?

SPEAKER_00 31:33

The message that I would want to send to people is the greatest gift that you can give to your loved ones is clarity about who you are and what you want and don't want. Clarity and and so so having information, getting the information about what is possible, about the realities of of the sort of the healthcare system, the having clarity about what is possible and what you and who you are, so that they know well in advance how you how you will likely approach a sit when approach it when things having the clarity and then completing documents to give that guidance to your loved ones is is important. No one can take you through this process if you can't make the decisions for yourself. So you can't put it in your advanced health care directive that if you get terminally ill, you want someone to do this for you. But the clarity from an early time frame is incredibly, incredibly valuable and saves so much angst and saves families from fracturing. Clarity is the greatest gift that you can give yourself and your loved ones.

SPEAKER_02 32:48

Clarity is key. Knowing it's an option is key. Thanks to Bob for the work that he's doing. Thanks for coming on the podcast. Hope this has been helpful to you and your family members, and we will revisit this topic as required. Thanks for listening. Talk to you soon.

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