PULLING THE PLUG:

A PARADIGM FOR LIFE-ENDING DECISIONS


SYNOPSIS:

    When a patient is being maintained by life-supports,
we are often faced with the decision about when to end such supports.
And it is now becoming more common to 'pull the plug'
before the patient dies despite the 'tubes and machines'.

    We do have informal and behind-the-scenes methods
for making such withdrawal decisions.
If we were to regularize and formalize these life-ending decisions,
perhaps some of the same safeguards
could be applied to other decisions about drawing life to a close,
even for patients who are not dependent on life-supports.

OUTLINE:

1.  ENDING LIFE-SUPPORTS—A WELL-ESTABLISHED MEDICAL PROCEDURE.

2.  SOME FORMS OF 'PULLING THE PLUG' ARE MORE CONTROVERSIAL.

3.  SAFEGUARDS TO PREVENT PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.

4.  SINCE WE CAN BE REASONABLE ABOUT 'PULLING THE PLUG',
     PERHAPS THE SAME DECISION-MAKING PROCESS
     COULD BE APPLIED TO OTHER LIFE-ENDING DECISIONS.




PULLING THE PLUG:
A PARADIGM FOR LIFE-ENDING DECISIONS

by James Leonard Park

    As the 21st century advances,
more of us will be supported by machinery and drugs
in the last few days or weeks of our lives.
If we die from some disease or condition
that normally takes months or years to bring death,
then our dependence on life-support systems might be even longer.

    If we are being kept alive by some form of medical technology,
then any decisions we make about the best time to die
and about the best means to allow our deaths
will have to include questions about what to do
with the life-support systems in place
keeping us alive.




1.  ENDING LIFE-SUPPORTS—A WELL-ESTABLISHED MEDICAL PROCEDURE.

    Medical ethics in the 21st century includes discontinuing life-supports.
And some end-of-life decisions include never starting life-supports
when it is clear in advance that putting us on a ventilator, for example,
will only prolong the process of dying.
If there are no particular reasons to keep us alive for a few more days,
then everyone involved in this end-of-life decision
will probably agree not to extend the dying process.
And even when there is no clear decline into death
because further deterioration is being prevented by the life-supports,
reasonable people can agree that if there will be no recovery,
there is no point in keeping us in a coma on life-supports indefinitely.

    On the other hand, when we are drawing our lives to a close,
we might have some very meaningful things we want to achieve
before the end of our lives.
And usually these will be quite independent
of any objective facts found in our medical charts.

    For example, we might have some religious practices or good-byes
that we want to complete before we 'allow nature to take its course'.
We might want to have our sins forgiven before we 'meet our Maker'.
We might want to make amends with estranged family members.
We might want to see a grandchild or great-grandchild before we die.

    If we imagine our lives as a movie or play,
we know what scenes we would like to have before the end of the show.
And if we are realistic about the amount of time left,
we will know which projects we can complete within that time-span
and what new projects would be unrealistic.




2.  SOME FORMS OF 'PULLING THE PLUG' ARE MORE CONTROVERSIAL.


    'Pulling the plug' on our life-support systems carries no stigma,
as might be the case with taking a lethal chemical to bring death.
Perhaps this is because we can see clearly (and sometimes dramatically)
that 'life' in the intensive care unit
has almost no similarities to the life we lived
in all the years leading up to this final scene.
When we are being supported by a heart-lung machine
that is keeping our blood circulating and oxygenated,
we know that this situation cannot continue indefinitely.

    Our feelings about 'pulling the plug' are somewhat different
when the life-supports seem more like daily living.
For example, our lives might be sustained
by medication to control our blood-pressure
to keep our hearts and blood vessels operating well.
If we go off that medication, we know that we could easily die
from the cardio-vascular condition now controlled by the drugs.

    At least in the advanced parts of the world, if we live long enough,
most of us will be using various medication at the end of our lives.
And we might have so many different prescription drugs
in our bodies that we cannot remember them all.
We might have experienced continual adjustments of our drugs
because of the subtle interactions among them:
One drug causes a particular side-effect,
which needs to be controlled by another drug, etc.

    In such situations, when we are ready for our lives to end,
we can simply refuse to take any of the drugs that are keeping us alive.
Our doctors can tell us how long we can expect to live
without the medications that have been assisting our vital functions.

    A somewhat more controversial situation arises
when the life-support is a feeding-tube
or other means of supplying food and water.
At the end of our lives, if we cannot eat normally,
then we might be attached (either temporarily or permanently)
to a feeding-tube that puts special foods directly into our stomachs.
Or we might have fluid and nutrition put directly into our veins
by-passing our digestive systems completely.

    But even discontinuing artificial feeding
has now become a part of standard medical practice.
It is not a decision that should ever be taken lightly
and without considering all the implications for everyone involved.
But from the perspective of medical practice
discontinuing artificial nutrition and hydration
is a common means by which human life comes to an end.

    When we think of our own lives coming to an end
by means of withdrawing or withholding a feeding-tube,
we know that the utmost caution is needed
in the decision-making process that might lead to this action.
Each of us should consider just how such a life-ending decision
should be reached with respect to our own lives.
And we should put our plans into our Advance Directives for Medical Care.
If we clarify our own medical ethics well in advance of any situation
in which withdrawing a feeding-tube becomes a real option,
then we have faced this means of choosing death on the philosophical level,
probably years before it becomes a real-life choice.




3.  SAFEGUARDS TO PREVENT PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.


    It probably does not happen very often in medical institutions,
but sometimes harmful decisions are made
with inadequate consideration of all the options.
So we as the patients do need protection from mistakes and abuses
of any protocol that allows withdrawal of life-support systems.

    Our doctors will provide the medical facts and recommendations.
And because one doctor might miss something important,
other doctors
perhaps specialists in our disease or condition
might be called upon to examine us and to explore our medical options.

     Our own views on life and death should shape our end-of-life choices
.
Each of us has strong beliefs and values
that we have been using to shape our lives thru-out adulthood.
We have some life-principles that form the basis of our medical ethics.
And here also, it might be useful to ask for input from others.
There might be people we trust who will help us to formulate
our own values concerning life and death.

    And even beyond helping us to clarify our own values,
the views of others who have been close to us
might have to be called into action
if and when we can no longer make our own medical decisions.
This is the role of medical proxies,
whom we should appoint in our Advance Directives for Medical Care.
When we are beyond making our own choices,
our proxies are empowered to make all of the medical decisions
that were automatically given to us while we were still full persons.

    If we find ourselves in difficult dilemmas at the end of our lives,
we might have occasion to call upon a group of ethical consultants.
There might be an institutional ethics committee
in the hospital or nursing home were we are receiving our terminal care.
Because these people have faced several similar situations,
they might be able to offer wise advice to the legal deciders
—ourselves as the patient and/or our appointed proxies
who might be facing life-ending decisions for the very first time.

    Another layer of protection would be the legal system.
We have laws and the means of enforcing them
so that people who cannot always protect themselves
will be saved from others who might have harmful aims.

    The same safeguards that we apply to withdrawing life-supports
could also be applied to other forms of life-ending decisions.
Even if we are not dependent on any forms
of modern medical technology at the end of our lives,
we still do have the right to choose
the best time and the best means for our lives to end.

    We should decide our own lives and deaths,
possibly getting feedback from the people closest to us.
We should appoint proxies who will carry forward our settled values
if and when we can no longer decide for ourselves
or can no longer express our wishes.
And we might consider presenting the pros and cons
of our proposed life-ending decision
to an ethics consultant or an ethics committee.

    Whoever is called upon to offer an opinion or make a decision
should make sure that all of the available alternatives have been considered.
And it might even be wise to put these deliberations into writing,
in case these decisions might need to be reviewed later
by others who were not present at the time the choices had to be made.
Some relatives might be quite distant
and be included in the decision-process only when the end is near.
So, instead of starting the process all over from scratch,
these late-comers can be permitted to read the death-planning record,
which will detail all of the deliberations to that point.

    If our practice of withdrawing life-supports
does indeed become the paradigm for all life-ending decisions,
then we will discover some 'safeguards' that are really not appropriate.
If any proposed safeguards have never been applied
to any situations of giving up life-support systems,
then they should not be applied to other circumstances.

    Here is an extreme example:
Some opponents of the right-to-die hold
that doctors should never cooperate in any death-planning process.
This sometimes takes the form of ethics affirmed by a medical society:
"Doctors must not kill."
But it would be very difficult to apply such a 'hands-off' policy
to life-ending decisions that include withdrawing life-supports.
If doctors can give their professional opinions concerning life-supports,
they should also be permitted to give the medical facts and opinions
that would be relevant to other kinds of life-ending decision.

    Perhaps we need laws to regularize the withdrawal of life-supports.
And any such provisions could be included
in new laws against causing premature death.
Here is a model for such laws:
http://www.tc.umn.edu/~parkx032/PREM-DTH.html.
This draft legislation contains 26 safeguards for life-ending decisions.




4.  SINCE WE CAN BE REASONABLE ABOUT 'PULLING THE PLUG',
     PERHAPS THE SAME DECISION-MAKING PROCESS
     COULD BE APPLIED TO OTHER LIFE-ENDING DECISIONS.


    As more of us gain experience with terminating life-supports,
we will become more familiar with the safeguards that should be used
to make sure that any harm to the patient is less than
the harm already being inflicted by the life-support systems themselves.
Of all deaths that now occur in hospitals,
about 80% involve some important elements of choice.
If no choices are made, the patients will continue to be maintained
on life-support systems until they die despite the 'tubes and machines'.
Standard medical care might sometimes be called being 'treated-to-death'.

    As a culture, we have not given much attention to life-ending decisions.
But if over half of deaths in America now include some choices,
then we are already making over a million life-ending decisions each year.
Implicit safeguards are already being used for these medical decisions.
And as we become more aware of medical decisions that bring death,
we can make the safeguards more explicit
perhaps with an eye on other life-ending decisions
that are not so completely within the control of doctors.

    As we learn to make wise decisions about terminating life-supports,
we are also learning how to articulate the safeguards
that should be applied to all life-ending decisions.
The right-to-die means being able to make wise decisions
so that we can die at the best time and by the best means.

    Pulling the plug is sometimes the wisest end-of-life medical choice.



Created February 2, 2007; revised 9-2-2007; 10-9-2007; 2-2-2008; 12-11-2008; 4-22-2009;
2-14-2010; 4-22-2010; 11-18-2010; 2-24-2011; 3-11-2011;
1-13-2012; 2-3-2012; 2-10-2012; 2-27-2012; 3-21-2012; 7-7-2012; 8-31-2012;
3-30-2013; 5-17-2013; 6-7-2013; 8-1-2014;



Safeguards Website:

    If you would like to explore safeguards for life-ending decisions,
here is an organized catalog of of over 30 such proposed safeguards:
http://www.tc.umn.edu/~parkx032/SG-CAT.html

    And here is the selection of 26 recommended safeguards:
http://www.tc.umn.edu/~parkx032/SG-A-Z.html



AUTHOR:

    James Park is an independent existential philosopher
with deep interest in medical ethics,
especially the many issues that arise at the end of life.  
Medical Ethics and Death are two of the seven doors
to his website called "An Existential Philosopher's Museum":
http://www.tc.umn.edu/~parkx032/




The above exploration of terminating life-support systems
  is also Chapter 43 of How to Die: Safeguards for Life-Ending Decisions:
"Pulling the Plug: A Paradigm for Life-Ending Decisions".

You can help improve this book before publication.
A Facebook Seminar will discuss it one chapter per week.

See the complete description for this seminar:
http://www.tc.umn.edu/~parkx032/ED-HTD.html

Join our Facebook Group called:
Safeguards for Life-Ending Decisions:
http://www.facebook.com/home.php#!/groups/107513822718270/



    Here are a few related chapters and essays by James Park:

A New Way to Secure the Right-to-Die:
Laws against Causing Premature Death
.

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline
.

Advance Directives for Medical Care:
24 Important Questions to Answer
.

Fifteen Safeguards for Life-Ending Decisions .

Will this Death be an "Irrational Suicide" or a "Voluntary Death"? .

Will this Death be a "Mercy-Killing" or a "Merciful Death"? .

Four Legal Methods of Choosing Death .

Methods of Choosing Death in a Right-to-Die Hospice .

VDD:
Why Giving Up Water is Better than other Means of Voluntary Death .

Voluntary Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice
  .

The One-Month-Less Club:
Live Well Now, Omit the Last Month
.

Choosing Your Date of Death:
How to Achieve a Timely Death
Not too Soon, Not too Late .

The Living Cadaver:
Medical Uses of Brain-Dead Bodies .

Depressed?
Don't Kill Yourself! .



Further Reading:

Books on Advance Directives for Medical Care
 

Best Books on Voluntary Death

Best Books on Preparing for Death

Books on Terminal Care


Books on Helping Patients to Die

Books on the Right-to-Die

Books Opposing the Right-to-Die


Go to the Right-to-Die Portal.


Go to the Book Review Index
to discover 350 reviews
organized into 60 bibliographies.


Return to the DEATH page.


Go to the Medical Ethics index page.


Go to other secular sermons by James Park,
organized into 10 subject-areas.


Return to the beginning of this website:
An Existential Philosopher's Museum .



 




The views and opinions expressed in this page are strictly those of the page author.
The contents of this page have not been reviewed or approved by the University of Minnesota.