Kirkus Star Review of Death with Dignity (April 4, 2011)  

* Note: The Kirkus Star is assigned to books of "remarkable merit, as determined by the impartial editors of Kirkus Reviews—the world's toughest book critics."

Orfali’s compelling manifesto explores the fraught ethics and surprisingly convenient practical details of physician-assisted dying.

In his Grieving a Soulmate, the author recounted the painful closing hours of his wife’s battle with cancer, an experience that inspired this call for voluntary euthanasia as a merciful way of ending the suffering of terminal patients. Here, Orfali surveys the typical American modes of dying and finds them wanting. Death in a hospital intensive care unit, he writes, is “a high-tech nightmare,” and while hospice care is more humane, it too relies on a kind of passive or slow euthanasia—deep sedation and the withholding of life support, food and water—that he finds full of pitfalls. Orfali prefers Oregon’s system of legal euthanasia by self-administered overdose of the barbiturate Nembutal in liquid form—a drug widely used by veterinarians to put down pets—that, he contends, quickly and reliably induces unconsciousness and a peaceful death. He argues that this is “the ultimate form of existential self-empowerment”—a painless, dignified demise on the patient’s own terms and timetable. Orfali presents a knowledgeable and spirited defense of euthanasia against its detractors: studies of assisted dying in Oregon, the Netherlands and Switzerland, he notes, show no slippery slope toward mass euthanasia nor any evidence that the elderly, the disabled or the poor are being pressured into suicide; and “pro-life vitalists” who insist that life should be prolonged no matter the circumstances, he argues, end up imposing unbearable pain on others in the name of an abstract religious moralism. Orfali approaches this agonizing subject with common sense informed by extensive research and an acute sensitivity to the dilemmas faced by dying patients and their families and doctors. The result is a thought-provoking contribution to the debate over this explosive issue.

A lucid, powerful argument for letting dying patients go gentle into that good night.

                                                                                                                                           — Kirkus Star Review



5.0 out of 5 stars  A book every mortal must readMay 1, 2011
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This review is from: Death with Dignity: The Case for Legalizing Physician-Assisted Dying and Euthanasia (Paperback)
As we will all die, this is a must read book for everyone. 

In this well-researched book, Robert Orfali takes us on a tour of the American end of life system. He writes about how we die today in hospitals, ICUs, nursing homes and hospices. In this age of "slow dying and chronic disease" there is just too much unnecessary "torture" at the is not a pretty picture. Orfali believes that some of this torture can be mitigated if we learn how to navigate the system and inform ourselves about our end-of-life choices. He tells us we must learn how to protect ourselves from the high-tech medical machine. We must become better consumers of death. Learning about death and the end of life system certainly will not kill us. 

The modern end-of-life system appears to be a minefield filled with dangers. Even our hospices can be an unpredictable terrain. Orfali's data shows that there is only a 50/50 chance that you will receive palliative sedation in a hospice if you need it--it's all up to the attending physician. Orfali believes that terminal pain must be treated like an emergency. For example, he suggests that if you're experiencing unbearable terminal pain or suffering, why shouldn't you be able to call 911 and get hooked to a morphine pump? Orfali is a big advocate of end-of-life choices. He argues that we need all the choices that we can get at the end--including physician-assisted dying. He sees this last option can be a form of torture insurance in case all other options fail. For some, that option could be a first choice. Orfali makes a very strong case that "assisted dying complements hospice." He uses the latest data to demonstrate that, by providing both, "Oregon now has the best palliative-care system in America today." I totally agree. 

During my long career as a firefighter and first responder in the state of Oregon, I have repeatedly witnessed death up close. I know for sure that with some preparation much of the suffering could have been avoided. Over the last thirteen years, the state of Oregon has taken great strides to improve its end-of-life system. The rest of the American end-of-life system is in need of some serious tweaking. I agree with Orfali that Oregon can serve as a proven model that works. 

Death will never be easy. You must read this book to protect yourself and your loved ones. By familiarizing ourselves with how we die in America today, and with a bit of luck, we can make our deaths or those of our loved ones a little gentler. Read this book and make sure your friends also read it. At only $0.99 for the e-book, it's a wealth of information. 

Michael McGuire 
Deputy Chief (retired) 
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5.0 out of 5 stars A compelling, and well-researched, case for legalizing physician-assisted dying,May 22, 2011
In 2009, author Robert Orfali lost his soul mate Jeri to ovarian cancer. After nine years of battling the disease, Jeri's fight came to an end in her home, surrounded by friends. With the aid of hospice, Jeri's late-stage pain was eased but Orfali knew that if she had been allowed to use Nembutal (a life-ending drug), her suffering could have been lessened. This book is Orfali's tribute to his soul mate, and his effort to get Jeri's Law, a death with dignity law, passed in his home state of Hawaii. 

Death with Dignity is broken down into eight chapters. The reader is first given an overview of how death occurs in the United States today, with examples of terminally ill patients begging family members to end their suffering. This is followed by examples of how some people would prefer to die, specifically in cases of the terminally ill: with dignity and as little suffering as possible. We next learn what hospice offers, how other countries deal with death and euthanasia, the arguments against assisted dying and perhaps the most intriguing chapter of all, point and counterpoint where the author takes on an extensive list of arguments against euthanasia and through research, statistics, and his own personal experiences, debunks those arguments. 

Orfali advocates "...the legalization of physician-assisted dying modeled after Oregon's Death with Dignity Act" (pg. v) and presents many compelling reasons for such a bill in his home state of Hawaii and indeed, for the entire country. It is interesting to note that study after study shows that people overwhelmingly support physician-assisted dying, with some studies reporting upwards of 70% of those polled favoring it. Why then have just three states, Oregon, Washington, and Montana, legalized self-administered, physician-assisted (note: not "physician-administered") euthanasia? Because, notes Orfali, while the majority of citizens are in favor, they are poorly organized and do little to promote such bills. It is, as the author notes, not a pleasant topic and not one most people want to even talk about, let alone spend time advocating for. In contrast, those opposed to such bills, such as the Catholic Church, pro-life groups, and the American Medical Association "hierarchy," are well-funded and organized. To get any form of euthanasia passed in this country will be an uphill battle. 

While hospice offers relief and comfort to many, and the author is at all times respectful and grateful for the aid they gave his soul mate Jeri, he strongly believes that their palliative sedation (sedation to the point of unconsciousness), is not always enough and also finds that not all hospices use palliative sedation. "According to the National Hospice and Palliative Care Organization (NHOCO), its use on terminally-ill patients `ranges between 1% and 52%.'" (pg. 60). The author feels that this fact, combined with the NHPCO's position on limiting palliative sedation to those "imminently dying patients" is not acceptable. More must be done. 

As noted earlier, the chapter where the author takes each argument against euthanasia and dismantles them one by one, with facts, studies, anecdotes from other countries and here in the States, is quite interesting. For example, the slippery slope line of reasoning, which was used to argue against Oregon's bill before it passed, is shown to have no validity. Indeed, since the bill's passing in 1994, "only 460 patients died using the Act, accounting for 1 in 1000 deaths in Oregon...however, 1 in 50 dying Oregonians now talk to their physician about the possibility...has resulted in a more open conversation about death..." and "...opponents' dire predictions of a "death stampede" did not materialize." (pg. 100-101) 

There is no doubt that legalizing physician-assisted dying is an emotionally charged issue. To his credit, the author keeps emotions at bay and instead uses his analytical skills, born from his experiences as a client/server programmer, to deal with the subject matter logically. While you may not agree with each and every point Orfali puts forth, this book will definitely make you think and possibly re-examine how you feel about euthanasia. 

Quill says: Regardless of which side of the debate you are on, you will find this book a compelling, and well-researched, case for legalizing physician-assisted dying.

Foreword Magazine Clarion Review
, July 28, 2011  (Five-Star Review

Death with Dignity makes a compelling and informative argument for self-administered, physician-prescribed medical euthanasia. Scholars looking for factual information will find a thorough, impeccably referenced discussion of the topic, and activists will find a great source for sound bites. But it is the eyes-wide-open look at how life ends that makes it required reading for anyone who plans to die in the United States. 

Straight away, Orfali tells us that the painless “Hollywood style” passing we imagine isn’t in the cards for eighty percent of us. The diseases that formerly killed us quickly have been conquered. Most of us will die by agonizing degrees in a “sterilized torture chamber.” We can expect harrowing life-saving procedures, ventilators, feeding tubes, and pain too severe to be mitigated. As multiple organs begin to fail, modern medicine supplies the equipment and technology to keep almost any organ functioning. Before long, the dying person is engulfed in tubes and slowly dying in unbearable pain. “Among hospice patients who were asked about their pain level one week before death, 5% to 35% rated their pain as severe or unbearable. . . . Of course, hospice is much better than the ICU alternative where 50% die in pain.”  

At present, some physicians provide “palliative care” in which the fortunate patient receives sufficient pain medication to be rendered unconscious. Death comes slowly either from the progressing disease, pneumonia, or starvation. This method is  legal only because its intent is not death and because it is the patient’s right to refuse treatment. Those sufficiently motivated to resort to illegal means may also be able to acquire unregulated Nembutal on the black market for upwards of $10,000 a dose.  Having made the case for euthanasia, Death with Dignity looks at the impediments to its legalization: “50% to 71% of U.S. citizens support euthanasia. But the 20% opposed are strongly-motivated, well-financed and highly-organized.” Existing right-to-die laws in Oregon and the Netherlands are compared to the status quo and to each other. And readers are warned that doing nothing is not a viable option. A “peaceful pill” made from legal ingredients is in development. Orfali points out that unlike physician-prescribed Nembutal, there would be no safeguards and it would be readily available to anyone who might commit suicide on impulse. He is more sanguine about a two-phase pill: The first is ingested to enable the process; the second, taken a day later, provides a built-in waiting period. 

Although Orfali is open about his bias in favor of physician-prescribed euthanasia, he remains thorough and evenhanded to the point of setting down every argument against euthanasia. He counters these arguments with facts and reassurance rather than rancor. He is always respectful. He never resorts to the half-truths often found in debates about hot button issues. 

Because Death with Dignity is comprehensive, objective, and well documented, it belongs on every public library shelf. Because it avoids hyperbole, it is essential reading for those on either side of the issue. Because it is honest and compassionate, it is a must read for anyone who wants to understand this challenging issue.
Marilyn Berry, Foreword Magazine 

Pacific Book Review, Top-Five Review (August, 2011) 

Death With Dignity:  The Case for Legalizing Physician-Assisted Dying and Euthanasia, by Robert Orfali is dedicated to the loving memory of his wife, Jeri Edwards Orfali.  Robert Orfali clearly states his book is not about Jeri, but rather he uses her life and what she went through as an example to interpret the matrix of laws, cultural taboos and religious concerns people currently confront when faced with a terminal illness.  Like a 58 faceted diamond, Robert Orfali shines the light of understanding, logic and honesty through each of the prismatic cuts on the issue of terminal illness; revealing a spectrum of colors of clarity of thought, determinations  and options. He has an uncanny ability to “peel the onion” of such a complex situation, layer-by- layer, into meaningful and easily understandable deductions of reason.   What one gets from reading this book is a sober reality-check on how to deal with the end of life decisions, events and protocols of caring for the critically terminally ill, or yourself.

This book is for everyone, not just those currently fighting a disease, as “we all are only one heartbeat away from death.”  Mortality is the common dominator of all life.  If we have self-control granted to us for how we live, why are we faced with no decision when it comes to how to die?  The concepts of euthanasia, both self-administered and physician-administered are key discussion points throughout Death With Dignity. The States of Oregon and Washington, and the Netherlands prove most pro-active in their humane approach to administer the drug Nembutal; a 100% effective and painless drug used to cease life.  The legal pre-requisites and procedures necessary along with the patients’ decisions are clearly identified to result in a lawful self-administered death.   This may be viewed as suicide to some, or if assisted brought under the umbrella of murder, however Robert Orfali removes all of the religious and sociological “spin” on the topic.

It is truly beyond the scope of this review to even scratch the surface of the minutiae of detail, scores of examples and postures of reason brought forth in this expertly written book.  Suffice to say this is the most comprehensive and thought-provoking current research I have seen on the issue, as well as an easily assimilated platform for understanding the complexity surrounding suicide.  The humble and sensitive character of Robert Orfali is revealed “between the lines,” as one reads many of his transcripts of conversations with his late wife.  Can this book help people suffering from cancer?  Certainly; but that’s not only why it was written.  It helps all people.  It helps the patients, their families, the medical profession and society when the issues within Death With Dignity are openly discussed and understood.  

Professionally footnoted in a scientific literary fashion, the book has appendixes with data on further reading available, helpful organizations, websites and more.  Robert Orfali has certainly taken time to bring an expert understanding quickly to those who need to know this information - to some before it is too late.

---Beth Adams, Pacific Book Review