When the patient can no longer make reliable medical
decisions,
the power to make medical choices—including
life-ending choices—
passes to those persons designated by the patient
to act on behalf of the patient in just such circumstances.
The proxies might have to take over the medical
decisions
after the patient has already made one or more requests for death.
If so, the reasons for choosing death now rather than death later
should be clear from the patient's requests for death.
The proxies will also be guided by the advance directive
for medical
care
created by the patient while he or she was clearly able to make medical
decisions.
The proxies will strive to carry forward the medical
ethics of the patient,
especially as they are articulated in the advance directive.
And the proxies probably have some further insights into the views of
the patient
because of their long association with the now-incapable person or
former person.
The proxies will probably be called upon to make
medical choices
after the patient has declined towards death
to such a degree that the patient can no longer be expected to make
wise decisions.
And the proxies will know more about the likely causes of death
than the patient knew before he or she lost decision-making capacity.
The proxies will review all of the medical record
and the others statements already created in the death-planning process.
They will pay special attention to the doctors'
statements
about the current condition and prognosis of the patient.
When the proxies consider making a request for death,
they should re-state in their own words
exactly how they understand the condition and prognosis of the patient.
Then if there is any misunderstanding (or incomplete understanding),
the doctors can explain all of the facts and opinions
until the proxies are satisfied that they do indeed understand
what is going to happen to the patient
under each option worth
considering.
To make certain that these requests for death
are
serious and carefully-considered,
they should be in writing
as well as verbally stated
to the doctors and
others involved.
Also waiting
periods for patients asking for voluntary death
should also apply to requests for merciful death from the proxies.
Waiting periods allow everyone to review their thinking.
And when considering a life-ending decision,
everyone involved wants to be sure that all options have been explored
and that death now is
better than any of the other possibilities.
All written requests for death from the proxies should be signed and
dated.
This will make absolutely clear just who is authorizing the
life-ending
decision.
In some cases, it will be appropriate for the
proxies to state explicitly
their reasons for choosing death at this time for the patient.
The proxies might know something about the patient
that is not contained in the medical record
and that might not be known to the strangers involved in the
death-planning process.
HOW FORMAL REQUESTS FOR DEATH FROM THE PROXIES
DISCOURAGE IRRATIONAL SUICIDE
AND OTHER FORMS OF PREMATURE DEATH
Once the decision-making power has passed from the
patient to the proxies,
all talk of irrational suicide is no longer relevant
because the patient has lost the ability to decide
and carry forward any
plans for death—whether
rational or irrational.
But the proxies need to be aware of the possibility
of causing a premature death.
A death that comes too soon
for the patient
is a death that is harmful
to the patient,
usually somewhat out of
touch with the real medical situation,
sometimes taken because of a sudden decline in the patient's condition,
which might precipitate a
rash decision before all options have been considered.
And any such premature death will be regretted later.
Once the proxies have considered all of these ways
in which they might err on the side of death rather than life,
then they can be more confident that they have really weighed the
options
and they have chosen a merciful
death for the patient,
based on the patient's own settled values,
which were expressed when the patient was fully in control of his or
her own destiny.
If the proxies must now decide for the patient,
they will ask themselves whether they are carrying forward the decision
that would have been
made by the patient
if the patient still had enough mental capacity to make the needed
decision.
Another way to make the proxies' request for death
more formal and official
is to have their written request witnessed by others
who have no vested interest in any particular course of action.
The purpose of this safeguard is not merely to get
more
signatures on paper
but to facilitate a thoro
discussion of the pros and cons
of any particular pathway towards death.
And if the choice would lead to a premature death
as perceived by any of the neutral observers and witnesses,
then they should not agree to witness that request for death.
If the request for death is not rational, not based in well-proven
facts,
then this is an opportunity for any observer to prevent a premature
death.
Created January 24,
2007; revised 4-13-2007; 3-15-2008; 4-23-2008;