To the Editor: "He died a natural death when
he was 90. Just keeled over," a young man once said to me, describing the
death of his grandfather. When I talk with patients about end-of-life issues,
I sometimes ask them what manner of death they would prefer, if they could
choose. Many say that they hope for a quick death and fear a prolonged death.
It was therefore intriguing to read the article by Dr Marenco and colleagues.1 They found that automated external defibrillators
(AEDs), a technology intended to avert sudden death, are rapidly infiltrating
public spaces. As one who talks with people daily about choices, I like to
imagine some supernatural being, perhaps a guardian angel, entering the scene
as a woman who has collapsed in an airport is about to have an AED applied
to her chest. The angel wants to learn the patient's preferences for end-of-life
care and fortunately he can stop time briefly, thus not exposing the patient
to further risks, while the angel conducts his discussion. Important topics
would include the person's current state of health (other illnesses and their
expected course); the likelihood that this is the only chance the patient
will get to die suddenly as opposed to slowly; the diseases from which she
might die the next time—those most likely, and those most unpleasant.
She might, for instance, want to ponder the possibility of death from Alzheimer
disease, breast or colon cancer, stroke, or amyotrophic lateral sclerosis.
For the fact remains that she will eventually die of something. The angel
might also feel obliged to mention the possibility that the patient will outlive
some of her children or that she might spend years in a nursing home.