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The Best Way to Say Goodbye: A Legal Peaceful Choice At the End of Life

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"Death is not something any one need be afraid of. It is peaceful. What I fear is suffering a long time before I die."

The above is found in this extremely well researched, well-written, and empowering book authored by psychiatrist Dr. Stanley Terman. (It was Terman's mother who said the above quoted statements to her then young son.) Clinical professor & medical ethicist Dr. Ronald Miller and attorney & social worker Michael Evans "provided professional oversight" during the creation of this book by being "critical readers and contributors" to it.

Thus, any potential reader of this book can be assured that the information on its pages is completely accurate especially from legal, clinical-medical, psychological-sociological, ethical-philosophical, and religious perspectives.

This book deals only with the process of dying, not death. It specifically has two goals:

(1) To provide a description of a legal and peaceful choice or method of dying for most of those who are suffering from devastating, terminal conditions (such as permanent brain damage or incurable, progressive dementia). Two things should be mentioned about this method:

First, it gives the suffering patient sufficient time to reconsider his/her decision with no residual effects if the patient does reconsider. Therefore, there is some control.

Second, the author tested the method out on himself!!

(2) To maximize the probability that others will honor your Last Wishes especially if you cannot speak for yourself. Thus, Terman explains why we must create precise, non-ambiguous, strategic, written documents or forms that correspond to our Last Wishes and he shows us how to do that.

The bulk of this book is devoted to questions on the choice of dying advocated by this book and the comprehensive answers to these questions. However the book strives "to maintain balance in the presentation by revealing pros and cons, and by suggesting other strategies [or choices] that may be effective, so you can decide whether or not you wish this option [the one advocated in this book] for yourself or for your loved one." After a chapter that presents five general questions with answers, there are questions with answers that form the basis of chapters pertaining to:

(1) medical aspects (9 questions)
(2) religion versus science (4 questions)
(3) legality, civil rights, and safety (7 questions)
(4) competency, brain function, and Alzheimer's disease & related dementias (4 questions)
(5) creating strategic advance directives with regard to your Last Wishes (7 questions)
(6) the dying patient's family (5 questions)
(7) the role of physicians (4 questions)
(8) obtaining advice, securing a proxy (person designated to make medical decisions for you) , and to feeling secure that others will honor your Last Wishes (5 questions)

Besides having a book set up in a question and answer format where readers can zero in on those questions that pertain to their particular situation, there are many other features of this book. Here are the ones that I found to be particularly interesting and useful:

(1) Patient stories and legal cases (there are sixty):

It is important to read these for their instructive value. One specific thing to especially look for is to see what happens to patients when the advice in this book is not followed or not followed adequately.

(2) Humorous tales and cartoons (over twenty):

Included for two reasons: (i) to provide some comic relief since the book is dealing with a serious and difficult subject (ii) to provide instruction by highlighting a major point found in the main narrative or story. These can be skipped if the reader finds them inappropriate.

(3) Forms (six):

These are what you must create in writing (using the forms or documents in this book as guides) to insure that the probability that your Last Wishes will be honored.

(4) Choice of how to read this book (one page at the very beginning):

You can start at the beginning and read everything or you can choose one of the seven options of different ways to gain immediate value from this book. Especially note the option that gives a "quick overview" of the entire book.

(5) Comprehensive glossary (defines over fifty key terms):

Even though key terms are defined once in the main narrative, this glossary comes in handy if you forget a key definition. It also provides more information about key terms.

Finally, it should be emphasized that the important information in this book is not designed for minors, or for people with serious emotional disorders, or for use for illegal purposes.

In conclusion, Dr. Terman says the following in his preface:

"I hope that my writing this book honors my [deceased] mother."

From one who has thoroughly scrutinized this book and has been wowed by its comprehensiveness and sensitivity, I can confidently say that she would be quite honored and proud of her son for writing this much-needed and necessary tome!!

(first published 2007; your reading choices; foreword; acknowledgements; preface; prologue; 12 chapters; conclusion; epilogue; main narrative 440 pages; medical references and legal citations; glossary; further resources; index; about those who provided professional oversight; about the author and his end-of-life beliefs)

<<Stephen Pletko, London, Ontario, Canada>>

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After my Grandpa's massive stroke he could not speak. Some family members argued he'd want 'to join' his recently deceased wife of 70 years and would not want to live so inactive. Yet others interpreted statements in his Living Will as wanting to live. I dreaded that a conflict was about to begin. We'd never go to court, like Terri Schiavo's family, but old feelings and different perspectives on what it means to provide care and reduce suffering could have divided our family. A crisis was impending. Then, we all read a story in this book, A Time To Be Sure, and discussed using its series of questions. On three occasions, Grandpa was consistent as he shook or nodded his head to indicate what he wanted: To my surprise, he wanted to continue tube feeding. All of us felt relief. We could be sure that we knew what he wanted, and we were all united to provide that. My Grandfather passed in August of 2007. This time he looked at his caregiver and she told him its okay to go if he is ready and he died then. Peacefully and the way he wanted. This is an amazing book that helps us when making decisions about death. I recommend everyone read it!

Dr. Terman offers many suggestions on how to make the process of dying peaceful... for patients, for physicians, and for family members--all of which makes this book both comprehensive and useful. He presents a compelling case for a legal and peaceful alternative to Physician-Assisted Suicide, which he terms: 'Physician-Aided, Patient-Hastened Dying.' He also provides a step-by-step guide for those who want to avoid lingering in a state of total dependency and indignity that can result from illness, including Alzheimer's and other dementias.

We learn that voluntary refusal of food and fluid is legal and has significant advantages for terminally ill patients: They have opportunities to change their mind, and precious days to make amends and say goodbye to loved ones. This was particularly meaningful for me, as I had a dear friend who was dying from a brain tumor recently who ended her life this way. Now I more fully understand her difficult decision and that of the late Mrs. Billy Graham who also refused tube-feeding.

The book gains depth from the contributing editors: a medical ethicist and an end-of-life attorney. Psychiatrist Terman strengthens his argument by sharing captivating and poignant memoirs by recognized authors (a favorite 'An October Morning'), as well as many from his patients. One, 'A Time To Be Sure,' so intrigued the attorneys for Terri Schiavo's parents that they included it in Dr. Terman's declaration to the Florida court, after asking him to help determine if Terri really wanted to continue tube-feeding.

Also included is: the importance of creating effective Advance Directives and why Proxy Directives can be more powerful than Living Wills to ensure our last wishes; a fascinating look at fourteen religious views on the refusal of food and fluid; and Terman's personal story of experimenting with a total fast, which taught him so much about controlling the symptoms of dry mouth he created a site called ThirstControl in addition CaringAdvocates.

-Jacqueline Marcell, Author of 'Elder Rage', International Speaker on Eldercare & Alzheimer's, and Host of the 'Coping With Caregiving' Internet Radio Show at wsRadio

Review of "Lethal Choice"

Intellectually stimulating and emotionally charged drama that keeps you reading into the night and continues to haunt you into the daylight hours. Lethal Choice should be at the top of your must-read list of books. Dr. Stanley Terman not only expertly weaves a plot of intrigue and suspense but delves into the moral dilemmas facing individuals as they approach death. It is a book for everyone...a thriller for readers seeking "a tale of terror" and an educational thought-provoking story for readers who desire "a tale of substance." Lethal Choice is a powerful novel that embraces timely issues relevant to the medical, legal, and religious communities but more importantly to the average person who is at the mercy of the controversies surrounding end-of-life decisions.

Review of "The Best Way to Say Goodbye"

In his book The Best Way to Say Goodbye, Dr. Stanley Terman examines the process of death from multiple perspectives. He proposes a peaceful and dignified way of dying when a person is in a minimally conscious state, or perhaps suffering from Alzheimer's or dementia. Dr. Terman proposes that one can make his or her final wishes known though a clearly set out and legally enforceable proxy directive.

In this enlightening, engaging, and easy to follow book, Dr. Terman provides practical advice on how to avoid protracted litigation resulting from unclear proxy directives. According to Dr. Terman, "To Delay is To Deny." He gives valuable advice ranging from factors to consider in selecting a proxy to anticipating possible changes in the law or pitfalls in its interpretation.

Dr. Terman uses a belt and suspenders approach in explaining why a "Directive to Physician" or "Living Will" may be insufficient to ensure full compliance with a person's last wishes. The book also provides useful forms which estate planning attorneys can use as a guide in preparing their clients' documentation.

This is an important and useful book, but it is not "The Best Way to Say Goodbye for Dummies." That doesn't mean it is not entertaining, which is surprising, given the subject matter. Yet for me, the best parts of the book were the excellent memoirs that made me feel spurred on to action. They motivated me to learn how to avoid using a distasteful plastic bag, for example, if someone like a suffering grandparent asked me how to hasten his or her dying. Clearly there is a more aesthetic and peaceful way to die.

I enjoyed the jokes; for instance, the one about the man who could not remember if the woman answered "Yes," or "No," to his marriage proposal. And the jokes were relevant to the author's message. Yet the average reader needs to remember that this is a "book-within-a-book," that many portions can be skipped by paying attention to the symbols, and that the reader need not worry about the references or glossary, unless interested. I understand Dr. Terman wanted to provide the comprehensive basis for Voluntary Refusal of Food and Fluid so that readers could bring the "text" to their physician, attorney, or psychologist -- who can check the original references.

Actually, the entire book should be required reading for any professional who deals with patients or relatives of patients who must cope with planning for how they want their lives to end.

Yet the book is so well organized that, if someone had a specific issue they needed information about, they could find it easily and pursue it in as much depth as they wish.

I highly recommend this book to anyone who has anyone in this world that they love and care about, so that these loved ones are not left wondering what end-of-life decisions were wanted. This book is also for any person who wants to have control over their lives, not only when they live, but until their dying moment.

As a RN Geriatric Care Manager, I frequently assist families deal with this tough question on quality of life vs. quantity of life. In most instances, we have this discussion in a family meeting prior to having to deal with it in a crisis situation. The Best Way To Say Goodbye deals directly and comprehensively with all the challenges a family has to make regarding end of life issues.
It is okay and perfectly natural to not to eat or drink when you are dieing. Food and water are the way's we energize our bodies, keep it going, moving, alive. A different kind of energy is needed as you die. A spiritual energy will sustain from here on.
This is how I have explained to my client's this very difficult concept for a family to accept. I am now glad that Dr. Stanley Terman has published a book that explains this choice and I will recommend it to families to help accept this natural Best Way To Say Goodbye.
Barbara (Bobbi) Kolonay RN BSN MS CCM
Geriatric Care Manager
Owner: Options For Elder Care
www.OptionsForElderCare.com

I have read many books about death and dying; some are sensational and some are morbid. The Best Way to Say Goodbye is neither of those. It's a good and, believe it or not, enjoyable read.

Dr. Terman has designed the book in such a way that you can find what you need so you don't have to read the whole thing if you don't want to - but I recommend that you do. The information he has is well researched and well written so that it is easily understood by the health consumer, yet detailed enough for the professional.

Although it is a book for Americans, being Canadian, I still got a tremendous amount of information out of it and much of what Dr. Terman says can be researched and applied - albeit differently perhaps - in Canada.

The examples he uses do bring home the message and I hope that many people take this message to heart. Dying is an unavoidable part of life. However, if we are in a situation where how we die is in our control, it not only helps the dying, but those who are left behind.

As a professional geriatric care manager I confident that this book will change many lives. It is a provative look at dying in a peaceful, comfortable, and humane way, something that we are all entilitled to.
Monique Snyder, MA, CMC Owner of www.Aboutmyparents.com

The Best Way to Say Goodbye: a Legal Peaceful Choice at the End of Life has some excellent information. However, the book is so redundant that its information is not useful. As a counselor and a professional geriatric care manager, it is not a book I would recommend.

Basically the book is an extensive exhortation to use starving and dehydrating as a way of ending your life. The author, a psychiatrist, actually tried the method himself for 4 days. Oddly, he was not bothered by hunger pangs or thirst. He spends most of the 450 pages justifying this method of dying, which he calls Voluntary Refusal of Food and Fluid. Whenever this method is mentioned in the book, it is typed in bold face, which gets annoying.

Refusing food and fluids may not be experienced as an easy death by patients to whom taste is a primary source of pleasure, other pleasures having been removed by the effects of their disease. The initial deprivation before onset of a coma could be psychologically painful. The author neglects to mention that Azotemia, a normal and comfortable biological reaction to lack of food and water, is well known by hospice workers for the sedating side effect on dying persons.

The book is poorly organized. The same topics come up in almost every chapter, and the author says the same thing over and over again. It would be more useful if there were 1/10 of the words and a comprehensive index, plus addendums on thirst-reducing aids, medications that can be taken other than with fluid, and possible legal complications. A short chapter on the various religious views would be helpful.

The book needs statistical data to support the statement that "Medicare will most likely be bankrupt years before Social Security." In today's political climate, that sort of absolute statement cries for explanation.

Despite its failings, the book does contain some excellent information that might be beneficial to families of patients with a terminal diagnosis. Dr Terman mentions the financial repercussions to families and the financial burden on Medicaid of keeping patients alive in a vegetative state for the years that it is medically possible. He notes that there is no good way to die, especially not from a progressive disease such as Alzheimer's or ALS. The legal difficulties with euthanasia and physician-assisted suicide are described, and the value of being as explicit as possible in your directive to physiciansis emphasized. There are helpful discussions on comfort care and the downside of tube feeding.

Dr. Terman shamelessly uses the text of this book to promote his novel on the same subject.

A Good Death by Chuck Meyer is a far better choice on this topic.

Dr. Terman has clarified the many different aspects of a complex process, dying. It is about the family, medical, legal, financial, and religious choices one needs to make, as the best hope of death as one would wish it. The lesson for me was to complete three documents: a Will, a Financial Power of Attorney, and an Advance Healath Care Directive (also called a Living Will), appointing a Surrogate with Durable Health Care Power of Attorney. AND one also needs these wishes to be entered in one's medical record by one's doctor. It seems that one can take charge of when and how to die: no liquid, no food. It takes about two weeks. It is not uncomfortable, with care for one's dry mouth. I bought two copies, hoping people I love could read it and plan good deaths.