“If you don’t know how to die, don’t worry; Nature will tell you what to do on the spot, fully and adequately. She will do this job perfectly for you.”
– M. Montaigne (1533-1592)

In 2021, former U.S. President Bill Clinton was rushed to a California hospital suffering from a urinary tract infection that had developed into sepsis, a life-threatening blood infection. According to the National Institute of Health and Care Excellence, “Sepsis starts when the immune system overreacts to an infection and begins to damage the body itself, leading to organ failure” and death if not treated. Clinton surely would have died if he had not been treated quickly with antibiotics. Research shows sepsis can kill in as little as twelve hours, so time is of the essence in diagnosis and treatment. But what kind of death would it have been? According to Dr. Manisha Juthani-Mehta, it’s a peaceful death.

“Left untreated, a person with pneumonia (or sepsis) will slowly lose consciousness and pass away in his or her sleep.”

In 1892, Dr. William Osler, one of the founders of the Johns Hopkins School of Medicine, referred to pneumonia as “the natural enemy of the old man,” currently phrased as “The Old Man’s Friend.” In the years before antibiotics, people usually died from infections such as pneumonia and tuberculosis, the leading causes of death in the 1900s. My thirty-one-year-old grandmother died at home in 1933 from TB, ten years before the antibiotic, Streptomycin, was developed as an effective treatment. It is widely accepted that in 1863 Stonewall Jackson died of sepsis due to pneumonia. Jackson had many health issues, including an arm amputation around the same time, but five physicians who attended him said he had pneumonia and no infection at the wound site. Additionally, he, like Clinton, suffered similar symptoms as sepsis patients then and now, delirium, fever, and fatigue. Ironically, Dr. Osler died of pneumonia in 1919.

“The well-intentioned use of antibiotics may only prolong a person’s suffering.”

“But for some dying patients, the greatest harm of antibiotic use may simply be to prevent a relatively quick and peaceful death; for those enduring intractable pain, or struggling to breathe, or slowly deteriorating in a hospital bed, an infection might bring a painless end to their ordeal.”
-Timothy Sullivan, MD

Many doctors overuse antibiotics in end-of-life (EOL) patients; many times, “curing” them more than once. Wrongful Life Lawsuits have gained traction where doctors blatantly disregard advance directives and surrogates in administering antibiotics to incapacitated patients. In Greenberg v.Montefiore NR Hospital the doctor deliberately gave antibiotics to a severely demented, hospice patient who was near death from sepsis. The treatment went against a POLST, living will and his surrogate/wife. He brought the patient back from the brink of a longed-for death, prolonging his and his family’s misery and suffering.

“We may need to consider Osler’s view that pneumonia can be the friend of the elderly and focus our efforts on patient comfort and relief of suffering rather than treatment with a limited chance of individual patient benefit and a risk of harm to others in the ICU.”
– Michael Niederman, MD

How can I die? It’s a question I often get asked as an end-of-life counselor and consultant.

As Final Exit Network’s Surrogate Consultant, I often work with clients at the end of their rope, suffering from a litany of health conditions that, although may not be terminal, are hampering any quality of life. They wish to die peacefully but do not live in a state where medical aid-in-dying is offered, nor would they qualify if they did. In 2021, I wrote a blog How Can You Die When You’ve Had Enough of Life? In it, I share a list of EOL options, but the legal method I suggest most for a dignified and peaceful death is to stop all treatments, especially antibiotics.

Doing nothing and letting nature take its course, will likely lead to a quick and peaceful death, usually in hours or days.

If you are the surrogate or medical power-of-attorney for an incapacitated loved one at the EOL and wish to end their pain and suffering, you can say no to antibiotics. Simple, legal, and effective. However, be prepared for pushback from medical staff who routinely treat infections with antibiotics that often cause more harm than good to their patient. Legally, patients have the right to refuse or reverse any treatment, even if it will cause death. It’s the patient’s or surrogate’s choice, not the doctors, to treat an illness or to stop all treatment.

Mr. Montaigne got it right in the sixteenth century, “Nature will tell you what to do on the spot, fully and adequately.” If only we had the ears and the courage to listen.

Althea Halchuck is a patient advocate.