I recently asked a friend whether she prefers horses or dogs (I’d imagine there equestrian feline enthusiasts, but the closest I’ve personally seen is begrudgingly keeping a few barn cats on the premises as mousers). She pointed out that her own dog is 50-odd kilograms, and having mobility issues, so, on a pure efficiency basis, it was easier to help dogs with old age.

She doesn’t know how right she is. Ive watched a horse die, once — the first horse I rode regularly. Before any accusations of animal abuse or neglect come in; he colicked (when horse intestines get blocked — it’s a long, complicated veterinary story, but horse innards are actually quite delicate and need far more maintenance than evolutionary biology might lead one to believe). It was a uniquely awful experience to watch an animal that majestic and friendly suffer. Without hope; I might add. Most of the time, a vet can pump a horse full of various laxatives, oils, and eye of newt, and things will end up fine (that was the case of another horse who is still very much alive and well as of writing). It’s a big bet, though, because by the time you know if it’s worked, it’ll likely be too late for alternatives.

It’s not unlike cancer treatments, in that by the time you know if conventional treatment is working; you’re pretty much locked into that treatment for better or worse. Not infrequently, it’s worse.

Unlike horses, though, euthanasia is not an option. I feel obligated at this point to explain that euthanasia and medically-assisted suicide are two separate things, in that in euthanasia, a patient is not the one actually pushing the button on the Death-o-Tron 3000; it’s someone following a patients’ wishes. Those of us who’ve seen what a hash humans have made out of interpreting God’s will (apparently, God agrees with every single human on the planet — that’s a helluva coincidence) will note the immediate flaws in interpreting someone’s end-of-life wishes; you do not want to be wrong.

At the same time, as my EMT instructor pointed out; animals are a good universal touchstone for understanding the difference between extending life and prolonging suffering. In those final hours, my poor horse was definitely not himself, and that was the most-agonizing aspect of his death. But we’ve all had to make that difficult decision, when we know, on some fundamental level, that we’re no longer extending life (which, arguably, is all any medical intervention is), but prolonging suffering. And the grave issue at hand is, when does one outweigh the other.

I’m hardly an unbiased observer here; I have a chronic, dangerous disease that’s incurable (but treatable; that’s a critical factor); I have a living will on file (at one hospital, anyway), and I’ve made my general wishes known. But I also know a few other metastatic cancer survivors who are debating whether a fourth neurosurgery that didn’t work the first three times is really a viable option. I also have a 94-year-old grandmother with a life-limiting illness who requires lots of supervision to stay alive, and she’s not exactly using her bonus time allotment to suck at the marrow of life. Not that I’m in a particular position to judge, I know from personal experience that you never know how you’ll react in these life and death situations. I chose the former because I was given even odds I’d “graduate” from treatment and have a bit of time off treatment to carve out something out something more in this glorious corporeal existence. I honestly don’t know what I would have done if I was told, “Well, there’s a 10% chance we can keep you alive for three more years, but you’ll be getting weekly infusions and daily oral chemo, and after those three years, well…” In my grandmother’s case, the fact that she wasn’t exactly the world’s most joyous person to start with kind of muddies the waters (not that I’m exactly a ray of sunshine, but I’m pretty reliable in that, even though I may not be happy with this life, at least it’s entertaining)(I’ve also learned that if you can’t be happy, being amused and slightly smug is not a bad alternative).

In my grandmother’s case, she doesn’t even like to move. Again, she wasn’t Jane Fonda even in her spritely seventies, but now, she has osteoporosis, and there’s a solid chance that if she climbs out of her chair, she’ll break something important. So, she’s in a state of anxiety and constant pain (she has arthritis)(not that I’m trying to diminish her pain; just pointing out that she’s beyond a place where science can really do anything without some hardcore opiates)(which my grandmother undoubtedly would not tolerate — she hates needles and she’s mistrustful of anything that might get in the way of her latest mystery novel). Which is a horrible state of existence, I’d imagine, but we’re at the crux of euthanasia — I wouldn’t want it; I’m pretty sure you wouldn’t want it; I honestly don’t know if that’s what Grandma wants. And you can’t take back that bet. On the other hand, she is 94, and, ageist and ableist as it may seem, I have a hard time imagining her regaining her vigor and making it to 110 (although, as my father and I have both pointed out, with our luck, there’s a solid chance she’ll outlive every one of us).

Which is a roundabout way of saying that, joyous as puppies, and kitty cats, and horses, and llamas are, we do get them with the tacit knowledge that things likely won’t end well (I mean; I haven’t seen the Far Green Country, yet, so I can’t speak with total certainty). We don’t get that knowledge on Day 1 of existence — hell, we don’t even get it when we discover the death of our own beloved pets (pro-tip, children, there is no friendly family with a farm upstate) — far too often, it’s not until we meet a clearly-uncomfortable resident physician who asks us if we’re comfortable before they begin. Even though we’re never going to completely allay our fear of death, we can start discussing our mortality in terms we find individually helpful. The idiom I coined in a therapeutic writing class was, “we are merely guests in the art museum, we can neither burn it, nor take it with us.” But we’re going to depart this glorious meat-based existence eventually for parts unknown, and a critical aspect of that we rarely talk about are issues such as quality of life vs quantity of life, and life extension vs prolonging suffering. Again, with human beings, it’s a little harder to predict when it’s time to pull the plug — I’ve lived with/around animals of varying intelligences and levels of humanity to know — or suspect — that last-second thoughts are unique to our species (which is also why I’m against euthanasia — you can always give Grandma a lethal dose of morphine; it’s a bit harder to undue that if she suddenly wants to reread her latest thriller novel). At the same time, I know that my end is likely to be muddied and harder to predict, because of organic brain disease. Which is why it’s somewhat trickier to predict when I’d appreciate that lethal morphine dose (for everyone wondering; I’m not suicidal or anything, but I’m very familiar with how terminal brain cancer plays out, and I’d like to avoid that by being shot by a jealous husband when I’m 80)(but, if that doesn’t happen, I do have a living will on file, and have communicated my wishes to my family, and I’d prefer ducking out gracefully and early to withering away horribly).

In my own case; cancer treatments are tough on the body, a tough sell to patients, and it’s even harder for us to survive treatment (at my last estimate; I’d only ever heard of maybe a half-dozen glioblastoma patients making it through treatment without disastrous, dangerous side effects; I’m one of ’em and I’m only certain about two or three of the others). Total honesty, my treatment was utterly miserable in a way that fully met my horrified expectations before the end. But what keeps us going is that vague promise that either science will catch up to us before the disease does (this is the case with one of my “cancer mentors,” Jenna, who’s in weekly infusions for the foreseeable future, until a better treatment comes along)(she also goes through a mind-bending amount of Rick Simpson Oil, which I probably would’ve done, too, if a major side-effect of MRZ wasn’t hallucinations), and/or that we’ll get well enough to go off treatment for a few years. I don’t know how to sell the idea of undergoing constant, painful, debilitating treatment indefinitely with absolutely no promise of relief or getting better.

Which is kind of a roundabout way of saying that, as a society, we need to get a lot better about having “the talk” — that is, what we want our friends, family, distant aunts, etc. to do when we are faced with our own inevitable demise. Again, I’m not making an argument for social Darwinism or euthanasia or anything that extreme; it’s simply that no one makes it out of here alive. Unfortunately, on a biochemical level, you have more in common with a Chevy Suburban than a Sequoia or Galapagos Tortoise — we’re built to run fast and well for a few years, but not indefinitely. And I’m not saying that people who want treatment on the off-chance it might work this time should be denied, but, after a certain point, like my horse, we’re just a bag of failing organs defined by pain and fear (okay, so that could describe our entire existence in some cases).

The point of this piece isn’t to make anyone eager to go after the useless eaters (not my idiom; Google it and you can understand why the US’s tilt toward fascism is especially terrifying for me), it’s to encourage everyone to get comfortable with the distinctively uncomfortable concept that you will, eventually, die. Even if you’re like me and have every intention of going into that good night kicking and screaming (as one friend put it), there will, eventually, be a point at which all the technology, black magic, and prayer in the world won’t help me out, and, when that inevitably happens, yeah, I would like to discuss options for a quick, clean, and relatively painless death, as opposed to spending a few more months hooked up to a machine in an impersonal hospital room that I will never leave. I suspect most of you out there would like that as a backpocket option when your own medical team runs out of options. The time to start that conversation on a local level is NOW. Call your spouse/partner/kids/parents/whatever, and start easy; tell them that if you were in a coma and the physicians gave you a 75% chance of making it out of the coma, keep you plugged in; 50% or lower, don’t bother. Literally do this now, right after you finish this article, because you do not get points for putting it off. And tell your friends, colleagues, and family members to do the same. If we all have massive binders full of intricate instructions on what to do if the third cateracts surgery goes wrong after the successful hip replacement, you want folks to know you’ll live happily with that missing visual field, BUT, if that goes south and the hip replacement goes bad, you do not want to spend the rest of your life — brief though it may be — being the center of arguments about what Grandma would’ve wanted. Obviosusly, Grandma would not have wanted to die hooked up to tubes and being ravaged by opportunistic infections, but that’s why you want to have these talks early and frequently.

I’m not going to lie; having a plan in place for how to deal with your own death isn’t going to make things well, emotionally or physically, but just knowing you have that backpocket cyanide option in case things get worse than you can bear is a good thing. And we need to start the national conversation about it.

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Science journalist, cancer survivor, biomedical consultant, the “Wednesday Addams of travel writers.”

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