of Choosing Death
in a Right-to-Die Hospice
A right-to-die hospice affirms all legal methods of
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.
1. SEPARATING CAUSES
OF DEATH FROM METHODS
2. INCREASING PAIN-MEDICATION TO PREVENT ALL
3. TERMINAL SEDATION
4. ENDING ALL CURATIVE TREATMENTS AND LIFE-SUPPORTS
5. TERMINAL DEHYDRATION
6. GENTLE POISON
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.
Right-to-die hospices affirm the medical-model for choosing
Methods of Choosing Death
in a Right-to-Die Hospice
by James Leonard Park
end-of-life decisions fall within licensed medical
where these life-ending decisions are
1. SEPARATING CAUSES
OF DEATH FROM METHODS
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
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
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
In the first right-to-die hospices established
anywhere on Earth
this clear separation of the causes
of death from the methods
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
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
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
Another example: The patient is dying from
The cancer is causing so much pain
that the patient requests being kept unconscious until death comes.
The cause of death is
The method of dying
is terminal sedation.
Once the doctors have agreed on the cause of death,
then everyone is free to choose whatever combination
of methods of dying
seems best for this particular patient.
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
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
And these methods of easing the distress of the patient
will be adjusted from time to time,
as the disease or degenerating condition progresses.
is the outcome expected by everyone involved,
no one should worry about the patient becoming dependent on
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
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
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
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.
The patient's condition might deteriorate to such a
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
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
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
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
by the fact that terminal sedation was chosen as the method of dying.
The death-certificate will say "cancer", "kidney failure", or
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
feeding-tubes and intravenous tubes.
Terminal sedation is clearly a life-ending decision.
And life-sustaining medical treatments would not be
because all should acknowledge that this life is coming to an end.
Because the patient is being kept continuously unconscious,
all forms of suffering are prevented.
ENDING ALL CURATIVE TREATMENTS AND LIFE-SUPPORTS
But sometimes, discontinuing medical treatments is a
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
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
will happen when leaving an
and beginning some form of hospice care.
These decisions taken together constitute our set of life-ending
When we know that we will die from our progressive
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
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
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
no matter what combination of life-ending decisions
were the immediate methods
of choosing death.
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
that this patient is coming to the end of his or her life—
then there is no need to continue providing food
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
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
But sometimes terminal dehydration will be quite
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
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
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
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—
us to choose this particular pathway towards death.
The fact that we chose a
does not change the fact that
we died of cancer and heart failure.
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
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
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
And even if we decide to follow this pathway towards
we should be able to get our doctors to sign death-certificates
that show the basic cause of
death to be the underlying disease or
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
Because every hospice is part of the health-care
it need not follow the suicide-model
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
then that chosen death will be correctly classified as an irrational
The death-certificate will say "suicide" or even "irrational suicide".
And there will be (non-hospice) 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
MAKE THESE METHODS OF DYING
MORE WIDELY KNOWN AND ACCEPTED.
Even when the first right-to-die hospices are
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
If patients in right-to-die hospices can forgo all
what prevents other patients from also ending
If these dying patients can choose to give up all food and water,
can other patients choose the same pathway towards
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
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
will help everyone to consider their own best pathways towards
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
then such individuals and institutions should refer their dying
to providers of terminal care who offer the full range of end-of-life
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
And his other interests are fully explored on his
This essay explaining the four basic methods of
has become Chapter 40 in How to Die:
Safeguards for Life-Ending Decisions:
"Methods of Choosing Death in a Right-to-Die Hospice"
you like to join a world-wide cyber-seminar
is discussing this book-in-progress?
the complete description for this seminar:
our Facebook Group called:
for Life-Ending Decisions:
November 11, 2012; Revised 11-13-2012; 11-28-2012; 12-7-2012; 1-2-2013;
Good Death Hospice
basic proposal for creating right-to-die
policy statement that might be used by a full-service
Hospice Cooperation Project
Encouraging better coordination between
the traditional hospice movement and the right-to-die movement.
How to Die:
Safeguards for Life-Ending Decisions
on-line book explores all 26 recommended safeguards.
Safeguards for Making Life-Ending Decisions
in a Right-to-Die Hospice Program
the 26 recommended safeguards for life-ending decisions
might be applied in a right-to-die hospice
Portal for the Right-to-Die
leading in other new directions