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


SYNOPSIS:

    A right-to-die hospice affirms all legal medical methods of choosing death.
The official cause of death will be the underlying disease or condition
that led to admission into this hospice program.
Once the medical causes of death have been established,
the patient and/or the proxies for the patient
may select any combination of the following methods of choosing death.

OUTLINE:


1.  SEPARATING CAUSES OF DEATH FROM METHODS OF DYING


2.  INCREASING PAIN-MEDICATION TO PREVENT ALL SUFFERING

3.  TERMINAL SEDATION

4.  ENDING ALL CURATIVE TREATMENTS AND LIFE-SUPPORTS

5.  TERMINAL DEHYDRATION

6.  GENTLE POISON

7.  HOWEVER, A RIGHT-TO-DIE HOSPICE NEED NOT SUPPORT IRRATIONAL SUICIDES.

8.  PUBLIC CONTROVERSY ABOUT THE FIRST RIGHT-TO-DIE HOSPICES
     WILL MAKE THESE METHODS OF DYING MORE WIDELY KNOWN AND ACCEPTED.




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


by James Leonard Park


    Right-to-die hospices affirm the medical-model for choosing death:
All end-of-life decisions fall within licensed medical practice
where these life-ending decisions are being made.




1.  SEPARATING CAUSES OF DEATH FROM METHODS OF DYING


    Thru-out most of the history of medical practice,
the causes of death have not been distinguished from the methods of dying.
Doctors were devoted to fighting against all causes of death.
But now that medical science prevails in many parts of the world,
what will be recorded as the official causes of death
might be separated from the actual last acts leading to death.

    Probably the best example of this separation
is shown in the practice of disconnecting life-supports.
Modern hospitals have elaborate systems
for supporting (or replacing) many of the functions of the human body.
Even vital functions such as pumping blood and providing oxygen
can be (temporarily) taken over by machines.
But when the patient is going to die despite such life-support measures,
the cause of death is always recorded as the disease or condition,
not the fact that the life-support systems were disconnected at the end.

    In the first right-to-die hospices established anywhere on Earth
this clear separation of the causes of death from the methods of dying
will become more important than ever before.
In order not to distort the statistics concerning the causes of death,
the fatal condition of the patient will be established upon admission.

    The patient's primary-care physician will describe
all of the medical facts about the patient
in preparation for admission to the right-to-die hospice.
The medical director of the right-to-die hospice
will agree with the diagnosis and prognosis of the other doctors.
And they will agree in advance just which doctor
will prepare the death-certificate
and what the official, legal cause of death will be.

    For example, if the patient is dying from heart disease,
that will be recorded as the official cause of death.
Or perhaps the patient is dying from advanced cancer.
Quite possibly the patient is dying from a combination of physical causes.
All of these can be included on the certificate of death.
And for statistical purposes, it might be expected
that the doctors will specify the primary cause of death,
followed by the other contributing factors.

    For example, the major medical problem might be Alzheimer's disease,
which prevented the patient from receiving sufficient food and water.
In this case, the cause of death is progressive Alzheimer's disease,
even if the immediate method of dying was removal of a feeding tube.
It would not be accurate or complete to record this death as "dehydration".

    Another example: The patient is dying from wide-spread cancer. 
The cancer is causing so much pain
that the patient requests being kept unconscious until death comes.
The cause of death is terminal cancer.
The method of dying is terminal sedation.

    Once the doctors have agreed on the causes of death,
then everyone is free to choose whatever combination
of methods of dying seems best for this particular patient.




2.  INCREASING PAIN-MEDICATION TO PREVENT ALL SUFFERING

    All forms of hospice care include drugs to relieve symptoms.
Normally, the drugs will be supplied to the dying patient
in whatever patterns work best for that patient.
For example, normal sleep might not be possible
because of the pain associated with the disease or condition.
So, the hospice staff will provide whatever level of sedation is needed
to allow the patient to have normal patterns of sleeping at night.

    During the daytime, the patient will normally be allowed to awaken,
which will permit the easy administration of other forms of palliative care.

    If and when the distressing symptoms of dying cannot be controlled,
the periods of unconsciousness might be increased
The patient, the family, the nurses, & the doctors will all consult
to help determine the best patterns of pain-relief and symptom-control.
And these methods of easing the distress of the patient
will be adjusted from time to time,
as the disease or degenerating condition progresses.

    Because death is the outcome expected by everyone involved,
no one should worry about the patient becoming dependent on drugs.
Increasing doses of the same medications might be required
in order to achieve the same results of pain-and-symptom control.

    Also, there should be no worry that the pain-medications themselves
will shorten the process of dying.
Everyone has already agreed that this patient will never recover.
So, what is the best pathway towards death?
Should this patient have a long dying?
Or would everyone involved now be satisfied
that a shortened process of dying would be better?

     All hospices provide palliative care,
which usually includes some forms of pain-and-symptom relief.
And honest accounts of the dying process
will usually acknowledge that the palliative care itself
did shorten the time between admission and death.

    A right-to-die hospice might be more open about explaining
this option of using reasonable amounts of palliative-care drugs
to shorten the process of dying.
And no matter what patterns of pain-relief are followed,
none of this end-of-life sedation will change the causes of death.




3.  TERMINAL SEDATION

    The patient's condition might deteriorate to such a degree
that it will be wise to keep the patient unconscious until death.
This could emerge as a gradual decision,
if the patient becomes less able to tolerate being awake.
Relatives and friends should be given meaningful opportunities
to say good-bye to the dying patient
before terminal sedation begins.

    When terminal sedation seems the best method of dying,
let this decision become known to everyone involved. 
The official deciders are first the patient himself or herself,
then the duly-appointed proxies for the patient,
who are authorized to act on behalf of the patient
when the patient no longer has
the necessary mental capacities to make medical decisions.
And it would be best if the decision to begin terminal sedation
were a joint decision of the patient and the proxies.
This would allow the burden of this life-ending decision
to be shared in the most meaningful ways for all involved. 

    Of course, the official medical order for terminal sedation
will come from the doctor in charge of this patient's medical care.
The nurses who are administering the drugs
will be following the medical orders of the doctor,
authorized by the patient and/or the proxies for the patient. 

    Once again, the causes of death will not be altered
by the fact that terminal sedation was chosen as the method of dying.
The death-certificate will say "cancer", "kidney failure", or "heart disease".
And there might be no reason to mention the amount of sedation.
The complete medical records maintained by the hospice program
will, of course, provide all of the details
of what drugs were given and their specific amounts.

    Almost always. ordering terminal sedation
includes withholding or withdrawing all forms of life-support,
including food and water provided by any means
such as feeding-tubes and intravenous tubes.
Terminal sedation is clearly a life-ending decision.
And life-sustaining medical treatments would not be appropriate
because all should acknowledge that this life is coming to an end.
Because the patient is being kept continuously unconscious,
he or she no longer suffers any form of pain or discomfort.




4.  ENDING ALL CURATIVE TREATMENTS AND LIFE-SUPPORTS

    But sometimes, discontinuing medical treatments is a separate decision.
Or disconnecting life-supports might be decided
as the primary method of allowing death to occur.

    If the patient is dependent on a breathing machine,
the life-ending decision to disconnect the respirator will probably occur
in the hospital where such life-support was being provided.
So why mention withdrawing life-supports
in connection with a right-to-die hospice?
Discontinuing some forms of life-support
will not result in immediate death.

    For example, many of us will be maintained at the end of our lives
by a wide variety of drugs intended to control various vital functions.
When we have decided that our lives are ending,
we can decide to discontinue all of the medications
that were intended to save us from death.
But all drugs to ease our process of dying should be continued.

    Often, ending curative treatments and disconnecting life-supports
will happen when leaving an acute-care hospital
and beginning some form of hospice care.
These decisions taken together constitute our set of life-ending choices.

    When we know that we will die from our progressive cancer,
there is no point in continuing the chemotherapy, surgery, or radiation,
which were tried as means of saving us from death.

    Instead of continuing to fight the terminal disease or condition,
we decide that we would prefer to return home
and/or to enter a hospice program.
Curative medical treatments are finally over
and all of the life-support efforts can be discontinued.

    If dying will take a few days, we can be made as comfortable as possible
either at home or in some health-care facility.
If we have chosen a right-to-die hospice program,
we know what we will be supported in whatever pathway we choose
(or is chosen for us by our proxies)
so that we can achieve the most peaceful and meaningful deaths.

    Once everyone has accepted that death is coming,
all forms of medical care that were aimed at cure can be discontinued.
And all forms of life-support can be disconnected.
New forms of comfort-care can be maintained until death comes.

    Depending on the specific medical problems causing our deaths,
we might decide to discontinue all food and water
at the same time when we are disconnected from other life-supports.
For example, if we are dying of a cancer in our digestive tract,
then putting more food and water into that part of our bodies
will only cause more trauma and distress.

    Sometimes, it will be wise to begin terminal sedation
even before life-supports are disconnected.
For example, if a respirator is the main means of sustaining life,
then we would probably prefer to be deeply unconscious
when the breathing-machine is switched off. 
Then death will come immediately
without any distress to the patient or to any of the observers.

    However, such a very brief period of deep sedation might be so short
that it would not actually be called "terminal sedation".
Exactly what combination of life-ending methods to use
will be chosen by the deciders.
And it will not be necessary to define exactly which method
contributed the most to the ultimate death.
The death-certificate will record the underlying disease or condition
as the official cause of death,
no matter what combination of life-ending decisions
were the immediate methods of choosing death.




5.  TERMINAL DEHYDRATION

    As already mentioned, giving up food and water
will often be combined with other life-ending decisions,
such as terminal sedation or ending curative medical treatments.
When everyone involved is absolutely clear about what is happening
namely that this patient is coming to the end of his or her life
then there is no need to continue providing food and water.

    Usually, food and water will be provided by artificial means:
Tubes will be needed to get nutrition and hydration into our bodies.
In the lingo of medical care, this is "artificial nutrition and hydration"
ANH.
And such life-supports are routinely withdrawn (or withheld)
in deaths that occur in modern hospitals.
When nothing can save the patient from death,
providing food and water by tubes will only prolong the process of dying.

    But sometimes terminal dehydration will be quite separate
from other immediate medical decisions
such as terminal sedation or turning off life-support machinery.

    If we have good reasons to chose death,
which will be proven by fulfilling the specified safeguards,
then we always have the right to discontinue eating and drinking.
These life-ending decisions can be taken anywhere.
But we might decide to use the services of a right-to-die hospice
in order to control the symptoms of dying by dehydration.

    This form of dying will take several days,
but we might prefer voluntary death by dehydration
precisely because it will be a slower process,
which will allow everyone to adjust to the end of our lives.

    For the first week of following this pathway towards death,
we will be conscious during the daylight hours.
This will allow us to complete our interpersonal and financial affairs
before we ultimately meet death.

    And we always have the right to employ
whatever levels of pain-and-symptom relief we choose
when we are following the pathway of voluntary dehydration.
We might even decide to choose terminal sedation,
so that we will be completely unconscious during our last few days.

    As re-affirmed concerning all possible methods of choosing death,
if we decide to follow the pathway of voluntary terminal dehydration,
our death-certificates will nevertheless record our official causes of death
as whatever conditions
such as terminal cancer and heart failure
led us to choose this particular pathway towards death.
The fact that we chose a shorter pathway
does not change the fact that we died of cancer and/or heart failure.




6.  GENTLE POISON

    In a few places on the planet Earth,
it is now possible to choose a new pathway towards death:
We can arrange with our doctors to get a prescription for a deadly chemical.
Each place on Earth that permits this life-ending decision
has a different set of safeguards that must be fulfilled.
But they are all contained within the safeguards recommended
for all right-to-die hospices. 
And before we take lethal chemicals to end of our lives,
we should make certain that this is a wise choice.
Fulfilling the recommended safeguards is an ideal way
of making sure that we are making a wise life-ending decision.

    The purpose of legislation that authorizes this pathway towards death
is to affirm that each and every patient
is really in charge of his or her own life and death.
(Vermont calls its law: The Patient Choice and Control at End of Life Act.)

    And even if we decide to follow this pathway towards death,
we should be able to get our doctors to complete death-certificates
that show the basic cause of death to be the underlying disease or condition
that has led us to this final life-ending decision.

    The fact of using the gentle poison at the end
is not as important as the Alzheimer's disease or terminal cancer
that led us to make this reasonable life-ending decision.




7.  HOWEVER, A RIGHT-TO-DIE HOSPICE NEED NOT SUPPORT IRRATIONAL SUICIDES.

    Because every hospice is part of the health-care system,
it need not follow the suicide-model right-to-die.
Yes, everyone on Earth has a right to commit irrational suicide.
But the health-care system should not assist people
who wish to kill themselves for foolish reasons.

    If the person who wants to die cannot fulfill the specified safeguards,
then that chosen death will be correctly classified as an irrational suicide.
The death-certificate will say "suicide" or even "irrational suicide".

    And there will be right-to-die organizations
that do in fact help people to kill themselves,
depending on the inherent right to give up one's life,
rather than following the medical-model right-to-die
as explained in detail above.




8.  PUBLIC CONTROVERSY ABOUT THE FIRST RIGHT-TO-DIE HOSPICES
     WILL MAKE THESE METHODS OF DYING
     MORE WIDELY KNOWN AND ACCEPTED.


    Even when the first right-to-die hospices are proposed,
this will become an occasion to review all methods of choosing death.

    Patients who are coming to the end of their lives
in conventional hospice programs or ordinary nursing homes and hospitals
will find themselves asking: "Why can't we have the same rights?"

    If patients in a right-to-die hospice can have pain-medication as needed,
what prevents us from also getting adequate pain-relief?
If terminal sedation is an option for patients in extreme distress,
why not use continuous unconsciousness in other medical settings?
If patients in right-to-die hospices can forgo all life-supports,
what prevents other patients from also ending life-sustaining treatments?
If these dying patients can choose to give up all food and water,
can other patients choose the same pathway towards death?

    The answer to all such questions is: "Yes, we can!"
The end-of-life options brought into public awareness
by the establishment of the first right-to-die hospice programs
will help everyone to consider which pathways towards death
they would choose for themselves and for other patients they love.

    The more loudly conservatives object to right-to-die hospices,
the more clarity will emerge in the public mind
about just what choices are legal and ethical at the end of life.
After all the objections have been answered by careful analysis
of the applicable laws and traditions of medical practice,
then even the conservatives will have to agree
that a right-to-die hospice is a completely legal and ethical operation.

    And the disclosure of these 'new' ways of choosing death
will help everyone to consider their own best pathways towards death.
Conventional hospice programs, nursing homes, & hospitals
will all be asked why these options have not been offered.

    If traditional terminal care cannot adjust to the right-to-die,
then such doctors and institutions should refer their dying patients
to providers of terminal care who offer the full range of end-of-life choices.




AUTHOR: 

    James Leonard Park is an independent philosopher.
He advocates the right-to-die when careful safeguards are observed.
Other dimensions of this proposal for right-to-die hospices are linked below.

    And his other interests are fully explored on his personal website:
An Existential Philosopher's Museum.

    This essay explaining the four basic methods of choosing death
has become Chapter 40 in How to Die: Safeguards for Life-Ending Decisions:
"Methods of Choosing Death in a Right-to-Die Hospice"

    Would you like to join a world-wide Facebook Seminar
that is discussing this book-being-revised?
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/



Created November 11, 2012; Revised 11-13-2012; 11-28-2012; 12-7-2012; 1-2-2013; 1-12-2013; 6-1-2013; 4-28-2014; 5-20-2014;


Medical Methods of Choosing Death
Books discussing doctor-approved means of bringing death.
http://www.tc.umn.edu/~parkx032/B-METH.html

Good Death Hospice
The basic proposal for creating right-to-die hospices.
http://www.tc.umn.edu/~parkx032/GDH.html

Full-Spectrum Hospice
A policy statement that might be used by a full-service hospice.
http://www.tc.umn.edu/~parkx032/HOS-PHIL.html


The Hospice Cooperation Project
Encouraging better coordination between
the traditional hospice movement and the right-to-die movement.
http://www.tc.umn.edu/~parkx032/HOSPICE.html


How to Die:
Safeguards for Life-Ending Decisions
This on-line book explores all 26 recommended safeguards.
http://www.tc.umn.edu/~parkx032/HTD.html


Safeguards for Making Life-Ending Decisions
in a Right-to-Die Hospice Program
How the 26 recommended safeguards for life-ending decisions
might be applied in a right-to-die hospice
http://www.tc.umn.edu/%7Eparkx032/HOS-SG.html


Portal for the Right-to-Die
leading in other new directions
http://www.tc.umn.edu/~parkx032/P-RTD.html




Go to the opening page for 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.