SAFEGUARD
J FOR LIFE-ENDING DECISIONS
INFORMED CONSENT FROM THE PATIENT
All
decisions about medical care require
that the patient have full information
and give free and voluntary approval for each proposed procedure.
The patient must understand all the medical facts and
options.
This is the meaning of "informed consent",
which has now become a well-established principle of medical practice.
In earlier times, when patients were not expected to
know much,
doctors were the ones
who made decisions,
sometimes asking for perfunctory approval from the patient
or (if the patient was no longer able to decide) from the family.
And some doctors still operate according to their own belief
that the doctor knows best.
One way to make sure that the doctor's recommendation is followed
is to offer only one medical
alternative
or to present the case for one alternative so strongly
that the patient and/or the proxies would feel foolish
even to consider any other course of treatment.
But now doctors are taught in medical school
that
they should welcome a second professional opinion,
even if it seems unnecessary to them.
Any human being can be wrong—including
doctors.
And such 'second opinions' must be truly independent,
not merely reaffirming the recommendations of the first doctor
because of the first doctor's expertise or reputation.
Informed consent could never be more important
than when the outcome being considered is death.
If the patient and/or the proxies are to give informed consent to death,
they must have a complete grasp of all the relevant medical information.
And because the medical facts might be difficult for some deciders to
grasp,
sufficient time must
be allowed for all concerned
to become educated to whatever extent is possible for them.
If the patient and/or the proxies do not feel up to
the task
of making life-ending decisions for the patient,
they should not hesitate to ask for additional input,
either from other friends and relatives
or from other professionals who have experience
with the situation the patient and/or the proxies
might be facing for the first time.
All such deeper investigations will require a few more days,
but when the decisions are about life and death,
then the additional days are always well spent.
If it happens that the patient dies of natural causes
while these further deliberations are being undertaken,
at least all concerned will know that the process was not rushed.
Informed consent requires time to think over the
options still available.
Doctors should not expect to present the facts and options
and get an answer in one single meeting.
That would only be appropriate for emergency situations,
where an immediate decision is required to prevent death.
Even when the final decision goes as expected by the doctor,
the patient and the family will need time to adjust
to the decision they are now being asked to make.
And if the patient and/or the proxies want a second
professional opinion,
this will also take time—time
to find other specialists
and time for additional doctors to examine the patient
and to do any further research that might be needed
before issuing their independent judgments.
Especially when the patient and/or the proxies
are confronted with making a life-ending
decision,
the greatest care must be taken to make sure that all concerned
understand the medical facts and the remaining options.
The truth of what is being decided must not be
hidden
behind words and phrases intended to soften the facts.
For example, when the patient is considering taking a
lethal chemical,
the only purpose of which is to cause death,
it should never be called a "medication".
Likewise, when the proposal is to stop using a drug
that has been keeping the patient alive,
this should be understood by all to be a life-ending decision,
not just a minor adjustment
of medication.
Giving informed consent for death
means being clearly able to articulate the outcome of this decision:
If we follow this course of action
—for
instance disconnecting life-support machines—
the
result will be death for the patient.
Can a patient ever give informed consent for death?
If the patient seems to be tending toward choosing a voluntary death,
how do we know that this is not really some urge toward irrational
suicide?
The patient will explain as fully as possible all the reasons for
choosing death.
Then others will be called upon to evaluate these reasons.
In some cases, it will be wise to have the whole situation reviewed
by a
psychological professional such as a psychologist or psychiatrist.
Of course, this psychological consultant must be
open to the possibility
that sometimes choosing death is the best option.
After examining all the facts and professional opinions,
the psychological professional can issue a written statement
re-stating the complete situation and his or her professional opinion
that the patient is giving
reasonable informed consent for death.
HOW REQUIRING INFORMED CONSENT
DISCOURAGES IRRATIONAL SUICIDE
AND OTHER FORMS OF PREMATURE DEATH
When people are thinking of killing themselves
irrationally,
they are not likely to request any medical opinions.
But if they are hoping for an 'indirect suicide',
such as hoping to die on the operating table,
then any such self-harming impulses should come to light
in the process of exploring the medical options.
Irrational suicide is self-harming, not based in reality,
often capricious, and
always regrettable.
Any of these features
of
suicidal decisions
might be uncovered in the process of seeking informed
consent.
And when anyone
involved in making
this life-ending decision
detects any element of
irrational thinking,
that person should call a halt to the process
until the impulse toward irrational suicide has been addressed.
Proving that the patient really wants to die
is not sufficient.
Informed consent should mean that any urges toward irrational suicide
have been ruled out
by a thoro examination of the reasons
for choosing
death.
How many independent people (both laypersons and professionals) agree
that it would be best for
this patient to die now rather than later?
Several other safeguards gather the considered
opinions of other people.
If two dozen
other people agree with the plans for death,
their support will bolster the informed consent of the patient.
The purpose of giving informed consent is to prevent
medical decisions
that in retrospect turn out to have been wrong.
In cases involving life-ending choices,
the wrong medical decision results in a premature death.
When properly followed, this process of informed
consent
will result in a timely death—not
too soon and not too
late.
When exploring all of the medical options, keep asking:
What would be the best time
and the best means
for this life to end?
Created February 13, 2007; revised
2-17-2007; 3-15-2008; 4-16-2008; 2-6-2010; 5-20-2010; 5-27-2011;
12-15-2011;
1-29-2012; 2-11-2012; 3-23-2012; 8-1-2012; 8-22-2012; 5-22-2013
Especially
when considering medical choices that will result in the patient's
death,
it
is very important to get informed consent from the patient.
This
is Safeguard J in How
to Die: Safeguards Life-Ending Decisions:
"Informed
Consent from the Patient".