ONE
MILLION CHOSEN DEATHS PER YEAR?
OUTLINE:
I. ESTIMATING THE NUMBER OF CHOSEN DEATHS IN THE USA.
II.
WHAT DO WE MEAN BY A "MEANINGFUL ELEMENT OF CHOICE"?
A. WITHDRAWING OR WITHHOLDING LIFE-SUPPORTS.
B. WITHDRAWING OR WITHHOLDING FEEDING-TUBES.
C. ROUTINE DECISIONS TO DISCONTINUE ALL CURATIVE TREATMENTS.
III.
WHAT
DOES IT MEAN TO BE "TREATED-TO-DEATH"?
IV.
WHERE ARE THE SAFEGUARDS?
V.
PUBLIC AWARENESS OF THE PRINCIPAL SAFEGUARDS.
VI.
RIGHT-TO-DIE LAWS THAT PERMIT THE USE OF LIFE-ENDING CHEMICALS
BRING THEIR SAFEGUARDS TO BEAR ON
ONLY A TINY PROPORTION OF ALL DEATHS.
VII.
USING PUBLIC SAFEGUARDS FOR LIFE-ENDING DECISIONS
FOR ONE MILLION DEATHS EACH YEAR.
ONE
MILLION CHOSEN DEATHS PER YEAR?
by
James Park
How many deaths in the United States include some
meaningful element of choice?
About half would be a
good guess.
The other half are treated-to-death.
If this is so, then in practice we already have the
right-to-die,
but it has not been very clearly acknowledged by the medical profession
and it has not been fully grasped by the public.
All of these chosen deaths have some informal
process
for making the life-ending decision.
But the principles used have not been discussed or validated by the
public.
This also means that no
public safeguards are been applied
to these one million chosen death each year.
There is no way to know what percentage of these
chosen deaths were premature.
But if we were to apply safeguards to every life-ending decision,
we could be confident that some
premature deaths would be prevented.
Perhaps one chosen death in 1,000 would be judged to have been premature
if public safeguards were applied to all life-ending decisions.
The exact number would depend on which public
safeguards were applied.
And at the same time, the application of public
safeguards
would assure some others who are trying to make terminal decisions
that they have actually taken all appropriate care
to achieve a wise and compassionate life-ending decision.
I. ESTIMATING THE NUMBER OF CHOSEN
DEATHS IN THE USA.
How should we determine the best estimate of chosen
deaths?
In the United States at the beginning of the 21st century,
about 80% of all deaths take place in medical institutions
such as hospitals and nursing homes.
These are not the unexpected
deaths
that happen to healthy people every day,
which are reported in the news media.
But these are the routine
deaths
that come at the end of some process
of medical care.
They are reported on the obituary
page of every newspaper.
Most of the readers of this essay
will have a death
coordinated with medical care.
Under modern medical care, a high percentage of
deaths
include some meaningful
element of choice.
Some people have estimated as many as 80% of hospital deaths
come after a medical decision
to give up treatment aimed at cure
and to provide comfort care only.
If these guesses are correct, then 64% of all American deaths
include some meaningful element of choice.
But even if this estimate is not accurate,
—if,
say, only 50% of hospital deaths include choice—
then 40% of all American deaths might be called "chosen deaths".
But because we cannot easily define what we mean by
a "meaningful element of choice",
we will leave the guess at about half of all deaths in the USA,
which leaves us with a nice round number of 1 millions deaths per year.
(Two million Americans die each year.)
People with access to more detailed data about
hospital deaths
are welcome to provide more accurate estimates.
[And such
data can be linked from here.]
II. WHAT DO WE MEAN BY A
"MEANINGFUL ELEMENT OF CHOICE"?
The most common expression used by laypeople and doctors alike
when acknowledging the turn toward death is: "Nothing more can be done."
What we actually mean is that our care will now shift from cure to comfort.
There are still many things that can be done to ease the passage.
And the best terminal care can begin
once we shift away from using medical technology
that was intended to save the patient from death.
A. WITHDRAWING
OR WITHHOLDING LIFE-SUPPORTS.
One example of a life-ending choice which we can all
understand
is the removal of
life-support machinery and tubes.
When we are receiving terminal care
in a hospital, nursing home, or
hospice program,
we are probably receiving drugs
that are intended to maintain our vital
functions.
And we might also be connected to some form of medical technology
that is supporting a vital function such as providing nutrition or
oxygen.
If we are on life-supports in the intensive-care
unit,
then the options are: (1) to
keep
the machines running or (2) to pull the plug.
Laypersons generally favor keeping the life-supports in place.
They do not want to let death take the patient.
And the medical profession has generally gone along with this option.
This means that the patient will remain attached to the life-supports
until the patient dies despite
being maintained in those diverse ways.
Such deaths would be counted as taking place without any choices.
Such patients were "treated-to-death".
However, if and when the prognosis for the patient
is
clearly terminal,
then everyone concerned wonders
whether the life-support measures should be discontinued.
And increasingly, this is just what happens
—after
considerable discussion among
the doctors and the patient
and/or the proxies.
Specialists might give independent assessments
of the patient's condition and prospects.
If no recovery seems likely—if
death is inevitable no matter what is
tried—
then everyone might agree to discontinue the life-supports.
Hospices generally do not use life-support measures.
But the choice to enter a
hospice program is already
a choice on the way toward
the death of this patient.
One of the requirements for entering a hospice program
is that the patient has given
up all medical treatment aimed at cure.
The doctor officially declares the patient to be in a "terminal
condition"
—meaning
that the patient is expected to die within the next 6 months.
The duration of hospice care is usually much less
—often
only a few days or weeks.
There are probably some scientific studies
to discover just how often life-supports are terminated
for deaths in hospitals and nursing homes.
Usually the physician who is providing terminal care
will recommend that the life-supports be shut off
and the patient allowed to have a natural death.
Then the family (perhaps also the patient)
will think about this prospect for awhile
and authorize it if they are also convinced that no
recovery is possible.
B. WITHDRAWING
OR WITHHOLDING FEEDING-TUBES.
Another common example we can all understand is a feeding-tube.
Some of us will be sustained at the end of our lives
by tubes that will provide nutrition
either into our stomachs or directly into our veins.
If such is the only way we can receive sustenance,
then giving up the tube is a life-ending decisions,
since we all know that we cannot survive without food and water.
Here again, there must be scientific data
summarizing the number of patients
who were being sustained by some form of artificial nutrition and
hydration
at the end of their lives
and how many of these were removed,
precipitation death within a few days.
And how many patients sustained by such tubes
died while the tubes
were still in use.
[Links to
actual data can be provided here.]
Here again, there will be some discussion among all
concerned,
including probably some medical professionals who have special expertise
in the disease or condition that is likely the cause the death of the
patient.
And all will explicitly know that removing the tube
will be the immediate cause of the patient's death.
In either of these cases
—life-supports
generally
and feeding-tubes specifically—
the certificate of death will name
the underlying disease or
condition as the cause of death.
And the death-certificate might not mention
the support-measures used
at the end.
(However, the complete medical record will certainly have details
about the drugs, tubes, & machines used to keep the patient alive.)
C. ROUTINE
DECISIONS TO DISCONTINUE ALL CURATIVE
TREATMENTS.
Most life-ending decisions made in the hospital
setting
would fall under this very broad category: ending curative treatments.
When all reasonable efforts have been made to cure us,
when we have received drugs, surgery, radiation,
transplants,
etc.,
and nothing medical science can offer is going to prevent our deaths,
then the life-ending decision comes in the form of
discontinuing the medical
treatments that have not worked.
The patient and/or the proxies consult with the
doctors
to see if there is any reasonable hope in further medical efforts to
cure.
And when they collectively decide that more treatments would be futile,
they shift to comfort care
for the patient.
The curative drugs and treatments are discontinued.
Only those drugs that will ease the dying process remain in use.
In such routine life-ending decisions,
most of the safeguards become irrelevant.
The medical facts are the most compelling reasons for allowing death to
come.
III.
WHAT
DOES IT MEAN TO BE "TREATED-TO-DEATH"?
The most common scenario for hospital deaths
is maximum application of
medical methods to cure the patient,
followed by the decision to end curative treatments
once it become clear than no further treatments would do any good.
But some patients will be "treated-to-death",
which means receiving all possible medical treatments
up until the last moment of life.
Would it be correct to say that a minority of
patients in hospitals
will continue to receive curative treatments until they die?
It used to be standard
medical procedure
to apply all possible cures,
all of the time.
If no one makes a move to depart from that standard protocol,
then the patient would continue to receive
life-supports and curative treatments until everything fails anyway:
The patient dies no matter what medical care is provided.
Would it be fair to call this being "treated-to-death"?
And would it be correct to say
that something less than 50% of patients who die in hospitals were
"treated-to-death"?
IV. WHERE ARE THE SAFEGUARDS?
Most life-ending decisions are made
without any
explicit reference to "safeguards".
Implicit safeguards
underlie all medical decisions.
But it might be well to make these safeguards more explicit
so that some hasty deaths are avoided.
Would it be wise to insist on some explicit use of
safeguards
in all life-ending
decisions?
This does not need to be a complicated bureaucratic process.
But those who are deciding that this human life is now at an end
should employ some safeguards of their own choosing
to assure themselves as deeply as they wish
that the death they are considering
will be a wise and timely
death,
not a foolish, rushed, or
premature death.
One way to
apply safeguards to all life-ending
decisions
would be to create a new law against
causing premature death.
Then everyone would know that fulfilling the safeguards
would protect them from any suspicion of causing a premature death.
Here are 26 recommended safeguards for
life-ending decisions:
http://www.tc.umn.edu/~parkx032/SG-A-Z.html
These are conveniently named for the letters of the Roman
alphabet—A-Z.
Thus those who are discussing which safeguards would be most appropriate
can refer to them by their letters in the list above.
Each recommended safeguard is linked to a full explanation.
The details for applying each safeguard
would be especially important for people
who are making life-ending
decisions for the very first time.
V. PUBLIC AWARENESS OF THE
PRINCIPAL SAFEGUARDS.
If and when safeguards are routinely referred to
when life-ending decisions are being considered,
then the general public will become more familiar with them.
Safeguards will cease to be the private possessions
of the medical and legal professions.
And when public
safeguards are explicitly applied,
everyone involved can be more assured that this death was wisely chosen,
rather than having recurring doubts
that some additional medical treatments could have been tried.
When some cases of the right-to-die are made public
by
the media,
then everyone can discuss the most
appropriate safeguards.
This did not occur in
the case of Terri Schiavo.
There was no public discussion of safeguards.
The members of the public just lined up on one side of the case or the
other.
Discussing safeguards would have made the right-to-die debate
more rational and principled.
And public discussion of safeguards for life-ending decisions
would have helped everyone involved
to consider just how such safeguards
might apply to their own terminal care.
Applying public safeguards does not mean
that individual medical decisions for every patient is a matter of
public information.
On the contrary, medical
decisions should be kept private
among the deciders except in the unusual situation
where there is some question of a harm being visited upon the
patient,
when law-enforcement authorities will have the right to examine all
medical records.
[For
further exploration of this principle, read:
"Open Safeguards Kept Private":
http://www.tc.umn.edu/~parkx032/SG-OPEN.html.]
VI. RIGHT-TO-DIE LAWS THAT PERMIT
THE USE OF LIFE-ENDING CHEMICALS
BRING THEIR SAFEGUARDS TO BEAR ON
ONLY A TINY PROPORTION OF ALL
DEATHS.
In the first 10 years of operation of the Oregon
Death with Dignity Act,
only about 1 death in 1,000 in Oregon took advantage of this law.
This means that the safeguards embodied in the Oregon DDA
are being applied to much less than one percent of all deaths on Oregon.
New laws that prohibit causing premature death
would apply to all deaths
with a meaningful element of
choice.
And it was estimated above that this would be about half of all deaths.
Until such laws come into effect, we have no way to
knowing
how many of the chosen deaths were premature.
Opponents of the right-to-die might better spend
their efforts
examining routine deaths in
hospitals and nursing homes
rather than trying to prevent the passages of laws allowing life-ending
chemicals,
which are going to apply to much less than 1% of all deaths anyway.
VII. USING PUBLIC SAFEGUARDS FOR
LIFE-ENDING DECISIONS
FOR ONE MILLION DEATHS EACH YEAR.
Perhaps the best way to acknowledge that we already
have the right-to-die
is to bring the process of making life-ending decisions more into the
open.
If we are already using implicit safeguards for routine deaths,
what adverse consequences would follow
if we were to make these implicit
safeguards explicit?
When no clear medical decision emerges easily from
the facts,
then more safeguards can be employed to help reach a wise decision.
If we already have a set of public safeguards ready to be used,
then all who must decide will know where to turn for more clarity.
And the sometimes-ambiguous legal situation would
also be resolved:
If all appropriate safeguards were fulfilled,
then there would be no adverse legal fall-out
for anyone who participated in the process
of making this wise life-ending decision.
Here is a list of 26 recommended
safeguards
which might be named in any new laws against causing premature death:
When the most appropriate safeguards have been fulfilled,
all can be assured that the
chosen death was not premature.
Such safeguards could be used in the one million deaths each year in
the USA
that involve some meaningful
element of choice.
And eventually the best of these safeguards could be used world-wide.
Created
2-3-2008; Revised 2-7-2008; 2-13-2008; 2-14-2008; 2-23-2008; 3-3-2008