Is Loss Of The Will To Live Conscious Or Biological? -- Death By `Natural Causes' Under Scientific Scrutiny

"Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light." - Dylan Thomas

When the poet Dylan Thomas advised us to rage, rage against the dying of the light, he hardly imagined living wills, durable powers of attorney, do-not-resuscitate orders - the so-called advance directives, all designed to give us some choices when the light starts to dim.

Nor could he have envisioned the quickness and sad surety of Dr. Jack Kevorkian's alternative and all the attention it would receive. But like all sensitive souls, Thomas understood that questions about death and dying are subtle, complex and emotional.

Death has always been a theme with poets, priests and philosophers, but science increasingly is making it possible to examine what lies behind the end of life.

Just as the brain cannot remember pain vividly, neuroscientists believe the organ refuses to comprehend its own death and will shut down beforehand. The coma that often precedes death may, in fact, be nature's ultimate anesthetic.

It is not generally talked about, but people always have willed themselves to die. When confronted by helplessness and hopelessness, they merely stop fighting and let go.

Is that choice conscious and rational? Or is it biological, a result of errors in brain chemistry? Very elderly patients, especially, may enter a downward spiral of decline even when not suffering from an acute or terminal illness. As they near the limits of the human life span, they become apathetic, refuse to eat or drink, and pass away.

Many medical specialists view the loss of the will to live as an aberration, evidence of depression and dementia that must be treated whenever possible. But other physicians contend that aging itself and the loss of the will to live are the most probable explanations for what they view as "natural dying," or death of natural causes.

The newest group to face the ultimate decision is patients who must undergo long-term dialysis for end-stage kidney disease. Many of them are elderly, and kidney transplants are not in the offing.

About 10 percent of the deaths among such patients are now occurring by choice: They decide to discontinue treatment, even though they will die without it.

Obviously, such decisions are distinctly individual and usually occur when patients deem their quality of life not worth preserving. But is suicide ever a rational decision? Many dialysis patients may be suffering from clinical depression - a treatable disease - and would possibly change their minds after therapy.

"People often can develop profound depressions that get in their way of making rational decisions," said Dr. Daniel Brauner, a geriatrics specialist at the University of Chicago and a clinical ethicist.

"But there's a real difference between clinical depression and someone who is sad about what's going on in his life," Brauner said. "Those are reactive depressions, and you may not want to treat them because the patient is responding understandably to life. Sometimes being sad about your life is a very rational decision."

Physicians are losing their hesitancy to speak out about such matters. Many are encouraging colleagues to stop viewing death as the enemy and to "assume the role of medical stewardship to help prevent the overtreatment and overtesting of modern medicine's approach to the dying," wrote Dr. Jack McCue, of the Berkshire Medical Center in Pittsfield, Mass., in The Journal of the American Medical Association.

The will to live is very poorly understood. "You can't generalize about it," Brauner said. "Some people have no will to live, yet they just keep going for years. Others have incredibly strong wills to live, but they die in 10 minutes.

"Clearly, we see people pull through because of it. But I think it's discussed more in movies and novels than in the day-to-day workings of hospitals."

Eight out of 10 Americans who die - or about 2 million people each year - will die in hospitals, nursing homes or under home hospice care, a contrast to the less than 50 percent that did so 50 years ago, and almost none a century ago.

Nor is the situation likely to change. As a society, McCue and others have noted, we are unaccustomed to the smells and sights of dying and unlikely to bring our dying relatives back into our homes, where even such basic palliative measures as administering oxygen and intravenous fluids are difficult.

Health-care professionals have assumed the burden, even though their mission is to keep people alive, not help them die. In fact, according to some sociologists, physicians may actually be more afraid of death than are non-physicians.

Studies are starting to reveal that medical professionals frequently ignore patients' wishes about death and dying even when known, and that such crucial issues as life support may not even be discussed.

Hospitals, in fact, may be the worst places for philosophies of life to be determined.

"Hospitals generally don't lend themselves to these kinds of discussions," Brauner said. "We're usually dealing with acute problems - respiration, potassium levels, sodium levels. Sometimes the bigger picture is lost to the emergency of the moment."

Nevertheless, the new attitudes among patients are starting to show up in the medical literature. For instance, in a 1995 study by the University of North Carolina School of Nursing in Chapel Hill, researchers interviewed 104 residents of a nursing home (average age 77.7 years) and found 51.9 percent had put on the record some sort of documentation about their wishes, including do-not-resuscitate orders, health-care powers of attorney, medical directives and living wills. Those interviewed, both with and without advance directives, revealed little anxiety about death.

Ideally, such matters are discussed before a person becomes seriously ill, but advance directives must be monitored and updated because minds often change when the reality of death looms. A Scottish study last year highlighted this.

A hundred very ill geriatric patients were interviewed about their opinions of cardiopulmonary resuscitation. They also were evaluated for depression. Ninety-two percent wanted CPR in the event of cardiac arrest. The eight others, who did not want it, scored high on the geriatric-depression scale.

However, after recovery from their acute illnesses, three of those eight who had depression subsequently changed their minds and wished CPR if required.

The researchers concluded that patients who are acutely ill may make decisions that are influenced by their condition at the moment, and medical teams should recognize that such attitudes may not be maintained.

Even so, suicides among the elderly are becoming epidemic. According to the National Center for Health Statistics, people ages 75 to 84 are more than twice as likely to take their own lives as members of the more publicized "teen suicide group," ages 15 to 24.

In fact, experts estimate that an older adult commits suicide every 84 minutes, and most of them are not terminally ill.

Often, they are depressed by their situation, the feelings of hopelessness aggravated by physical and economic problems, social isolation, and the loss of a spouse, friends, a job and the other things that make life worth living.

Although suicide among the elderly is their third leading cause of death from injury, after falls and motor-vehicle accidents, most older people do not believe physician-assisted suicide should be legalized, according to surveys.

Many younger people agree. A 1993 study investigated suicide rates and the maintaining, lessening and loss of hope among AIDS patients in New York City.

Despite the stress associated with a life-threatening illness, the researchers found low rates of psychiatric distress. Thoughts about death and wishes to die were reported by a significant portion of men, but they were context-specific, occurring almost exclusively during serious illness, accompanied by severe pain, or at times of bereavement.

Only two men of 63 had made a suicide attempt after being diagnosed. "While anger was a prominent effect," the researchers summed up, "hopelessness was not."