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PermaDeath however IS the fully proper way to play it.
Plus most of the achievements require this mode of play to gain them, since it makes things that much harder compared to simply being able to respawn when you die.
So without PermaDeath, I've always thrown around this idea of "respawning" is that when you're hit by vehicles, have an active crash while inside a vehicle... however it is that you "died" would be basically that with PermaDeath=Off is that you just get a Hospital stay, you survived, and you wake up at home... in a basic sense... since you can also die from; Exploded Bladder, Sleep Deprivation, Starvation, Thirst, Stress (Heart Attack basically)...
PermaDeath=On also gives the player a much more urgency to fulfill the need for player health management and also be more careful while driving, or near areas of traffic while on-foot, etc.
Now even with PermaDeath=Off, you're not fully off the hook and given an "easy" button. And keep in mind I'm referring to playing the game 100% without any mods that could aid you in anything at all. I mean let's say you crashed Satsuma out on the highway (or anywhere not fairly close to home); well when you wake up at home from that "respawn" you're going to have a some work ahead of you to get Satsuma where you were going, and not only that putting it back together, if she's even still in running condition after a major crash. Plus it's not only crashes, you can blow your engine, leaving you stranded and having to figure out how you're going to reach another accessible vehicle so you can tow Satsuma home or where needed so you can fix it back up again.
Yes, just backup your save files as you go...
Yes one could consider this a means of cheating, but again, at least til you better get the hang of things perhaps. This option is always there and it's just a matter of copying your save files to another folder after saving the game. If you are going to just rely on the ALT+F4 option, well you need to ensure you do this before the newpaper shows up, as that is when it deletes your save files. I mean, in Perma-Death, once you see that blood scene, you're done for...
If I die I dont alt f4, I live with my stupidity and start over or stop playing for a while.
Only when I die due to some bug I use my last backup.
Once the gifu clipped into stratosphere over a postbox at a sewage house.
You won't lose anything anyways if you backup your save as go, can't be any easier.