 We have all sorts of detailed stats about dying, but little about the experience of death. For the minority who die under the palliative care teams, one's death could probably be described as good, but there's a suspicion that for the majority who die in hospitals or nursing homes, the experience is bad. And that's where most people die. In spite of widespread preference to die at home, in almost all populations, most deaths occur in institutions. And this doesn't just have consequences for the patient, but for the bereaved caregivers as well. Patients with cancer who died in an intensive care unit or hospital experience more physical and emotional distress and worse quality of life at the end of life. And their caregivers suffer five times the odds of suffering post-traumatic stress disorder and nearly nine times the odds of severe prolonged disabling grief. Now this was an observational study. They weren't randomized to die in different locations. So this doesn't prove cause and effect, but certainly raises concerns. When researchers have looked into the care of dying patients in hospitals, it hasn't been pretty. Basic interventions to maintain patients' comfort were often not provided. Check with dying patients was minimal, and the distancing and isolation worsened as death approached. For example, a 52-year-old woman with metastatic cancer spread to her liver. She had gross abdominal distention, was jaundiced and very breathless. But alert, her eyes were swollen and she shed yellow tears. The patient received no care from the nurses delegated to give care. But in the nursing record it was recorded that attention had been given to her personal hygiene and pressure areas to prevent bed sores or hygiene in eyes, but it was all a lie. The only attention she got was to receive a commode from a nursing assistant. Contact time totaled six minutes over the four and a half hours the researchers kept track. In contrast, what would a good death look like? Retaining control. Privacy, pain relief. You choose where, you choose how. Emotional support, respecting your wishes, saying goodbye and being able to leave when it's time to go and not have life prolonged pointlessly. One's best bet for all that is access to hospice care. Palliative care is comfort measures to relieve symptoms and improve quality of life, utilized at any stage of serious illness, whereas hospice is just comfort measures. And focus shifts from curing the disease to improving the quality of one's last days. Hospice is often framed as giving up, but ironically when you compare hospice versus non-hospice patient survival, the patients in hospice actually live longer. Patients who choose hospice care live on average about a month longer than similar patients who do not choose hospice, randomized those with advanced lung cancer to early palliative care, and they don't live a month longer. They live two and a half months longer. I mean, that's like the survival benefit you might get from a standard chemotherapy regimen. And in fact, that's one of the ways hospice could extend survival by avoiding the risk of over-treatment with chemo and its related toxicity. There are however limits to palliative care. Even under hospice, where one would assume excellent palliative care, there are those who appear to unavoidably spend their last months in uncontrollable pain. And this unbearable suffering, despite our best efforts, leads to requests for ending a patient's life prematurely. Although physician-assisted suicide is gaining acceptance, it's only legal in eight states plus DC. In contrast, V-S-E-D is legal throughout the US. Voluntarily stopping eating and drinking, V-S-E-D, can be defined as a conscious decision to voluntarily and deliberately choose to stop eating and drinking with a primary intention of hastening death because of the persistence of unacceptable suffering. I've talked about fasting to extend one's life. What about fasting to shorten it? We hear a lot about physician-assisted suicide, but V-S-E-D has not gained nearly as much attention. This is presented as perplexing, since supposedly it's relatively peaceful and a comfortable way to die. But is it really? How long does it take? How would you do it? I'll talk about the pros and cons and practical implications next.