SPIEGEL Interview with Dr. Michael de Ridder 'What Is So Bad About Dying?'

Michael de Ridder, the head of the emergency ward at a Berlin hospital and author of a new book on dying, discusses how modern medical advances are making death more complicated for patients with little hope of living. His book makes a plea for doctors to allow people to die with greater dignity.


SPIEGEL: Mr. de Ridder, as an emergency physician, you fight to save lives every day. Which makes it interesting that you, all people, are now calling for a new definition of death in an era of high-tech medicine. Isn't that a contradiction?

De Ridder: In my field in particular, I see how the limits of life are constantly expanding, without regard for the well-being or will of the patient. In some emergency rooms, half of all admissions now come from nursing homes. If someone who is chronically ill has a heart attack or gets pneumonia there, the most sensible thing to do is to make sure that they don't suffer, and to refrain from doing anything else. But this is all too rare. Instead, old people, who are dying, are torn out of their familiar surroundings, rushed off to hospital in an ambulance, resuscitated and given artificial respiration. If they're unlucky, they die in the elevator. These are horrible, undignified situations.

SPIEGEL: Why does it happen like this?

De Ridder: Dying a simple death is no longer an option in our society, even in places where one might expect to. Hardly anyone dies without an infusion or artificial feeding. For a long time, dying has not been natural.

SPIEGEL: What do you consider "natural death"?

De Ridder: I'm reminded of a woman in her late 80s who was still very vigorous. Her daughter brought her to our emergency room with massive intestinal bleeding. A colonoscopy showed that it was caused by a tumor. The bleeding could only have been stopped with an operation. She didn't want it. She said that she had lived a full life and now preferred to die rather than embark on an indefinite path of suffering. The daughter agreed, and the woman died that same day. It was a totally plausible decision that no one could object to, particularly as bleeding to death is a gentle way of dying. But the doctors felt snubbed. There were bitter discussions over whether this should even have been allowed to happen.

SPIEGEL: But don't doctors see themselves as guardians of human life?

De Ridder: The mandate to heal is primary, of course. But the mandate to allow someone to die well is equally important in terms of ethics. In reality, however, the chain of resuscitation and treatment often takes on a life of its own. The person who is supposed to benefit from it, with his or her individual ideas about living and dying, is no longer relevant. Here's a classic example: A doctor arrives here with an old man from a nursing home. After having a stroke two years ago, the man stopped eating, could no longer communicate and seemed to have lost all interest in life. He had now contracted a serious case of pneumonia, and the people at the nursing home didn't want the responsibility. Just as the doctor was transferring him into the emergency room, he went into cardiac arrest. Her automatic response was: intubation, oxygen, ICU! I said to her: "Slow down. This man is dying, and now we are going to allow it to happen."

SPIEGEL: In the past, doctors had no other choice. It was said that pneumonia was the old people's friend.

De Ridder: And rightly so. Because it allows the patient to slip away quickly and, for the most part, without suffering.

SPIEGEL: Today's technical advances force these sorts of ethical decisions on doctors. Are they prepared for this?

De Ridder: Poorly. Often they do not have the internal systems in place to deal with this. Because of that, their first concern is to be on the right side of the law. They think: I did everything possible, so nothing can happen to me. This can have grotesque results. I remember a very emaciated old man with septicemia. Presumably it was a perforated intestinal tumor or something like that. Whatever the case, it was a hopeless situation. While the doctors were waiting with him in front of the X-ray machine, he went into cardiac arrest. They agreed not to resuscitate the man or do anything else. A completely responsible decision. But the file says something different: "Resuscitation discontinued after 25 minutes." The doctors wanted to cover themselves because they felt the hand of the state prosecutor on their shoulders.

SPIEGEL: An understandable fear?

De Ridder: No, it's a perversion of medical thinking. If I resuscitate someone like that, I am failing in my mandate. And in the face of such undesirable developments, we must ask ourselves: What is so bad about dying? It happens anyway, and it is never particularly nice. With palliative medicine, we now have the ability to make death happen the way people want it to: Peacefully. But all too often we work against that principle and turn death into a horrible experience for many.

SPIEGEL: To avoid this, more and more people have living wills, in which they specify exactly what they don't want.

De Ridder: And those who don't have living wills are automatically treated with everything that is technically possible? What a perverse world, in which people have to walk around with notes in their wallets that say: "Please, no tubes!" because doctors pursue the technological imperative instead of first considering the welfare of the patient or the medical signs.

SPIEGEL: So what do you propose?

De Ridder: We need a concept for the treatment of hopeless cases. We can delay the time of death almost indefinitely with dialysis, artificial respiration and feeding tubes. But at what point does this no longer serve the welfare of the patient? As an intensive-care doctor, there have been times when I've treated patients and said to myself afterwards: That wasn't a good decision. I too have experienced the long-term consequences of medical aid that doesn't make sense.

SPIEGEL: Do you have something specific in mind?

De Ridder: The many patients who have been resuscitated only to remain alive in a vegetative state, for example. Medicine puts 3,000 to 5,000 people a year in this awful state, in which they will remain suspended, unless they happen to have a living will. It was different in the past. In the 1960s, just about every other patient left the hospital in reasonably good health after resuscitation. The others died, partially because at the time you couldn't just keep feeding the unconscious. Today about one in 20 patients survives resuscitation. Take away those who leave the hospitals requiring long-term intensive care and the success rate drops.


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