A natural death: What exactly does that mean?

What is a natural death, anyway?

I get it – death is part of the cycle of life. Seasons change.  The moon waxes and wanes.  We are born. We die.  Death is natural.

But what is a “natural” death?  Seriously, what comes to mind when you think of natural death?  Here is a video of a natural death, taken from the Planet Earth series:

Death in nature is often violent, brutal, and messy.  The same adjectives could be used to describe a code.

***

If the video doesn’t make the point, perhaps a story will.  (Thanks to Amber Barnato for this story, I’m anonymizing it).

A man pressured his pregnant wife into trying a “natural” birth, without an epidural for pain.

Years later, the man started experiencing crushing chest pain.  His wife brought him to the emergency department.  He was diagnosed with a heart attack.

The nurse prepared to give him some morphine for the chest pain.  The man’s wife stopped the nurse, and said, “I think we should let him have a ‘natural’ heart attack.’”

Who decides why one things is natural, and another isn’t?

***

Now I’ll fess up. I use the words.  Or something like it.  I say, “This is about how your father is going to spend the remainder of his time.  I suggest we don’t prolong his dying, and let nature take its course.” It helps with framing.

There is something more natural about dying in our hospice unit than in the ICU with a big team of residents thumping the chest.  For many, including myself, the idea of a natural death is something more like a peaceful death, free from invasive medical interventions.  While peoples conceptions of “natural” death will vary, most people don’t think of sharks eating seals.

But do I worry about it?  Sometimes.  It’s hard for people to refuse to do the “natural” thing, right?  That’s one reason there is all this angst and guilt among women who plan to have a “natural” birth, but then relent and ask for an epidural.

There is an ethical line between persuasion (the use of facts to make a reasoned argument) and coercion (threat with injury).  Persuasion is ethically permissible, coercion is not.

CPR could be described as pounding on the chest, cracking the ribs, and electrocuting the patient.  On the one hand, that sounds like battery, and seems “un-natural” to me.  On the other hand, does the word “natural” attribute desirable qualities to a death without CPR, and undesirable qualities to death with CPR, without clear justification?  Is it too judgmental?  Do we cross that line from persuasion to coercion by using the term”natural?”

Alex Smith is an assistant professor of medicine, University of California, San Francisco who blogs at GeriPal.

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  • Suzi Q 38

    My FIL was experiencing kidney failure.
    He was 82 at the time and had lived 12 years after his 3 debilitating major strokes. He had “had it.”
    When his doctor suggested dialysis, he said “no way.”
    (He was aphasic, so he couldn’t say much).
    We were blessed with a PCP that listened and did not take huge steps to prolong his life. He just made him very comfortable.

    He ended up in the hospital again after several weeks.
    I left to check on another family member at a different hospital.
    I told him that I was leaving and I would return in about 2 1/2 hours.
    We said our goodbyes.

    He “coded” while I was gone. I knew it when the hospital left a message on my home phone.
    I found the nurse that cared for him and said, “What happened??”

    She said: “It was as if he waited for you to leave the room. (He was smiling when I left). He then started to “crash” (whatever that means).
    We wanted to give him a transfusion, but he grabbed my arm and said “NO!” I told him that if I didn’t give him the transfusion that he would definitely die in a few minutes. He calmly said :” That’s O.K.” He kept telling us that it was O.K…..”

    I was speechless and filled with admiration for everyone involved.
    I had the answer. He made his own choice to live or die. Even though I loved having him around for us, it was hard to care for a man that not only was aphasic, but had difficulty walking and moving around. Moreover, 12 years of a life like this was bearable but tiring for my father in law. He had to ask us to do everything. He couldn’t go to the bathroom without assistance.

    He died like he wanted, not in front of me, but in front of medical professionals that were ready to do whatever he wanted. He was in control, as he always wanted to be but was not for the last 12 years after his strokes.

    For that, I thank them and will never forget what they did for him.

    • Patricia

      Your story sounds like a movie. How brave of your father in law. Yet I can also imagine how tired he must have been to have lived that way. Thanks for sharing.

      • Suzi Q 38

        Thank you.
        I often felt tired helping him, but thankfully we had a good part-time nurse and two days of adult day care at a premiere rehabilitation hospital (almost a little city) 10 minutes from our home. Our nurse took him twice a week to a stroke club where they had wonderful activities planned everyday. They went to places that we did not have the time nor the energy to take him to.
        Getting possession of him in the first place was a huge legal fight, as his second wife of 2 years was only interested in his bank assets. We found him in a nursing home, 100 miles from us, that did not have the adequate care he needed.
        In the end, I realized that HE was the one that was really tired.

        Thank you for responding, you are so kind.

  • Bart Windrum

    Alex, I’m delighted that you wrote this piece. The terminology has troubled me also, and for similar reasons — applied ethics. As I’m sure you know as an MD (and something I had to learn as a lay person over the course of both of my parents’ hospitalized demises), medical ethics includes ever finer ethical “slicing and dicing,” as I think of and term it. Including goalpost-moving. We say “natural” and accept (no; expect) heavy-duty modern pain relief—not a bad thing, but a sure medical intervention). While death, and CPR, are huge events, the ‘nature’ of dying today involves much more ethical subtlety.

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