A landmark 2010 study from the Massachusetts General Hospital had even more startling findings. The researchers randomly assigned 151 patients with stage IV lung cancer, like Sara’s, to one of two possible approaches to treatment. Half received usual oncology care. The other half received usual oncology care plus parallel visits with a palliative care specialist. These are specialists in preventing and relieving the suffering of patients, and to see one, no determination of whether they are dying or not is required. If a person has serious, complex illness, palliative specialists are happy to help. The ones in the study discussed with the patients their goals and priorities for if and when their condition worsened. The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives — and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.

Two-thirds of the terminal cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did have discussions were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive care unit. Most of them enrolled in hospice. They suffered less, were physically more capable, and were better able, for a longer period, to interact with others. In addition, six months after these patients died, their family members were markedly less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.

terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression.

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.

We make something normal, we call it a problem, we pathologize it, and then we go to war with it. Sometimes that works pretty well, and oftentimes it works not at all. In the case with end of life and death, it's a mix. Medical science and our understanding of health has advanced, and we are able to live longer, and we have pushed back on nature in all sorts of ways that I'm happy for…But the bad news is we just keep orphaning this subject of death, and it becomes less and less familiar and then more and more surprising and gets harder and harder than it needs to be.

The only alternative for a terminally ill person and their dignity is palliative care, not euthanasia, which from the perspective of legality and false compassion, totally destroys the dignity of the patient and places medical personnel and caregivers in the difficult situation of having to betray their most genuine vocation, which is to heal and provide care.

How, then, do we know when a patient is giving up “too early” when we feel that a little fight on his part combined with the help of the medical profession could give him a chance to live longer? How can we differentiate this from the stage of acceptance, when our wish to prolong his life often contradicts his wish to rest and die in peace? If we are unable to differentiate these two stages we do more harm than good to our patients, we will be frustrated in our efforts, and will make his dying a painful last experience.

I think of two deaths. The last stages of my mother’s liver and bowel cancer were dreadful: don’t imagine morphine is a gentle floating away – it detaches the mind, but not always the pain, while blocking the gut until an undignified death, obsessed by constipation. By the time her state was bad enough to long for death, it was far too late for her plea to go to Dignitas in Switzerland: those who take that grim and expensive path to a desolate death room need to go early, long before life becomes insufferable.
Some people might never have reached that point, but fear accelerates their departure. My mother, despite good palliative care, begged her GP to help her die. It might have been done once upon a time, he said, but since Harold Shipman’s multiple murders of elderly patients, every ampoule is counted, making it far too dangerous for a doctor to do anything of the kind. "Oh, where’s Dr Shipman when you want him!" she said to him, with what was left of her laugh. So she suffered on needlessly to the bitter end, and we suffered with her helplessly.

Indeed, the scientific effort to improve performance in medicine — an effort that at present gets only a miniscule portion of scientific budgets — can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news.

It would not all be easy sailing from here on, but modern pharmacological medicine gave my father ten extra years of life and a peace he might never have had. He and my mother got to celebrate their fiftieth wedding anniversary. He got to know his grandchildren and we became much closer. He became easier to reach, to know and love.

A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

I was given this lifeline of targeted therapy and it put my cancer to sleep, but what people don't get about it is that on average people get about six months extra life and I got two and a half years.

A family meeting is a procedure, and it requires no less skill than performing an operation.” One basic mistake is conceptual. To most doctors, the primary purpose of a discussion about terminal illness is to determine what people want — whether they want chemo or not, whether they want to be resuscitated or not, whether they want hospice or not. We focus on laying out the facts and the options. But that’s a mistake, Block said. “A large part of the task is helping people negotiate the overwhelming anxiety — anxiety about death, anxiety about suffering, anxiety about loved ones, anxiety about finances,” she explained. “There are many worries and real terrors.” No

Depression and hopelessness are not the only reasons terminally ill patients wish to end their lives. Many individuals see nothing undignified about choosing to end their lives at the time and manner of their choosing — and many view such a choice as the meaningful culmination of a good life.