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Death with dignity is easiest to accomplish when the patient dies amid the surroundings that gave meaning to his or her life and in the company of those whose companionship provided most of the rewards of living. Physicians too often deny this, however, in the medically conditioned struggle to prolong life. Medical technology has advanced to the point that too few patients are permitted to die at home, even though improved diagnostic techniques identify the irreversible nature of a terminal process at an earlier stage. A sorry commentary, reflecting the abuse of technology, is the case of a man who had built his house with his own hands and wanted to die there but was prevented from doing so while physicians exhausted their therapeutic armamentarium in an attempt to prolong his life a few days or weeks. The family physician must remain in charge as the patient's advocate when the consultants want to continue aggressive therapy, yet all the patient wants to do is go to sleep. The family physician must have the courage to discontinue aggressive therapy when the evidence points to its futility.

Charles Lindbergh is an excellent example of an individual who insisted on designing his final days in a manner that would preserve dignity and allow him to die as comfortably as possible. When dying of lymphoma, he refused to remain in a medical center on the East Coast and returned to his home in Hawaii, where he made final arrangements regarding his estate and discussed with friends and family the details of his memorial service and burial site. His death was as he preferred—quiet, dignified, private, and in the company of family and friends—a striking contrast to what it would have been had he not insisted on leaving the medical center.

Although 70% of Americans still die in institutions (39% in hospitals and 31% in nursing homes), polls show that 80% of them say they would rather die at home (Farber et al., 2002). Jacqueline Onassis is an example of a prominent person whose wish to die at home was respected. Similarly, Richard Nixon's wishes were respected when his physicians and family knew that he wanted no extraordinary means taken to keep him alive if he developed an illness that left him seriously debilitated, particularly intellectually.

Some patients do not want to be a burden to their families and pride themselves on being able to afford hospitalization or nursing home care. For some of these patients, the gradual withdrawal from family may be an emotional "letting go"

that is necessary for all concerned in their particular family and circumstances. In other cases, the spouse simply may not be equipped physically or psychologically to deal with the loved one dying in the house over time. The important aspect is a network of support for all concerned, with no arbitrary judgment about the best approach. The family physician will be sensitive to the style of living and the style of dying that seem most appropriate in a given case once the options have been explained to the patient and family.

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