I went from being a labor-and-delivery nurse to a death doula. I help people who want to die on their own terms by refusing food and water.

• Nancy Simmers is a death doula whose clients decide to end their lives by refusing food and drink.
• A former labor-and-delivery nurse, Simmers says the process of death is similar to birth.

This as-told-to essay is based on a conversation with Nancy Simmers. It has been edited for length and clarity.

Most people are taken aback when they hear that I'm a death doula. They're shocked when I say that I work exclusively with people who want to die on their own terms, by voluntarily stopping eating and drinking.

The method, known as VSED, might seem terrible at first. But it lets you take control of the circumstances of your death.

Most people support the idea of the power of the individual. They understand someone who says, "It's my life, let me get on with it." But they feel uncomfortable when someone says the same thing about their death.

I used to be a labor-and-delivery nurse. Over the years, I've come to see death and birth as physical, emotional, and spiritual thresholds. They are similar processes. They involve uncertainty, fear of the unknown, and transformation. Both require courage, surrender, release, compassion, and support from others.

Some people reach a point in their life and decide they're done

The US law largely doesn't prevent people from choosing to end their life by VSED, which doesn't require permission from a physician.

Many people who opt for VSED have a terminal illness. But it's almost impossible to get a firm prognosis for neurological diseases such as ALS and Parkinson's. People can suffer for years as their bodies and mental capacities deteriorate. Some people reach a certain point and say, "I'm done." A person in their 90s who has lost their vision, hearing, and bladder control may feel that their quality of life is nil.

If a doctor won't certify that you have less than six months to live, you are not eligible for "death with dignity." The laws — which apply in eight states and Washington, DC — allow people to take lethal drugs under medical supervision.

VSED is another version of death with dignity. Each VSED death I've attended has been different, but not undignified. Most of my clients die in their own homes surrounded by their loved ones. It's a gift. It wasn't VSED, but when my father was dying of cancer in 1991, my sons — 8 and 5 — were in and out of their grandpa's room. It doesn't do anybody any favors to be frightened of death.

VSED requires a lot of planning

A lot of people know nothing — or very little —about VSED. There are some scary myths. People think that it involves great suffering and that it goes on indefinitely. They assume it will affect your life-insurance policy.

VSED is not to be considered lightly. It needs lots of careful planning. It's reversible up to a point, and there are medications to ease the transition. Family members usually know about the decision and agree that it's the choice of the individual concerned. Life insurance is mostly straightforward because the doctor does not write "suicide" as the cause of death; they note the person's underlying condition, such as cancer.

People considering VSED in my home county of Whatcom, Washington, find me via word of mouth or online. I'll arrange to meet with them and their family. My partner, Andrea Fenwick, and I give frank and honest answers. There's no sugarcoating. We're part of the nonprofit VSED Resources Northwest, though we advise people across the world.

We can understand why families question their loved one's decisions. It depends on the case, but we might tell them: "This is your beloved person, and your beloved person is suffering. It's their body and their choice."

We'll tell the family, "Although you will suffer because you'll miss this person, it's their choice to end their suffering — how can you be supportive of this choice?"

Once things are decided, we mark the start date with a little ceremony. We celebrate the person and their life and their choice. We thank them and shower them with love and gratitude.

Many families make a small altar. It's the focal point of their room. They'll decorate it with family photos and precious items that remind the loved one and their visitors about their interests and skills. It's a reflection of a life well lived.

I like to light a candle, symbolizing the person as a spirit. After the death, it becomes part of a leave-taking ceremony and is blown out.

VSED is a serious commitment, but it doesn't have to be a solemn affair. My last client lightened things up with a touch of humor. We'd ask how she was feeling during her first few days of VSED — she joked about wanting a cold Pepsi.

I tell my folks that dying has been around for millions of years. Your body knows what to do. Just trust your body. Our bodies know how to breathe. Our bodies know how to process food. Our bodies know how to birth. They know how to die.

It can be hard for families to watch as their loved one becomes confused because of dehydration

VSED takes an average of nine to 11 days. The person is usually up and about for the first few days. But the middle stage, which can last almost a week, is the marathon.

They'll need medication — a mixture of morphine and anxiety drugs — to help them through the confusion and delirium caused by dehydration. It's hard for the family to watch. A designated person will step in if the loved one calls for food or water.

The final stage lasts about three days. Dehydration makes people sleepy. It's reassuring for everyone because you lose consciousness when your body goes into crisis mode.

The lack of fluids affects your kidneys and liver. The excess bilirubin makes the skin look yellow. The feet and the fingertips turn blue. Breathing becomes shallow or agonal.

Friends and relatives gather at the bedside to say goodbye. It reminds me of families coming together to welcome a newborn. We want the very best for the baby; we support them when their journey in life begins. People deserve the same support when the journey ends.

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