ONE
MILLION CHOSEN DEATHS PER YEAR?
OUTLINE:
1. ESTIMATING THE NUMBER OF CHOSEN DEATHS IN THE USA.
2.
WHAT IS A "MEANINGFUL ELEMENT OF CHOICE"?
A. INCREASING
PAIN-MEDICATION.
B. INDUCING TERMINAL COMA.
C. WITHDRAWING OR WITHHOLDING LIFE-SUPPORTS.
3.
WILL WE BE "TREATED-TO-DEATH"?
4.
FULFILLING SAFEGUARDS FOR MAKING LIFE-ENDING DECISIONS.
5.
PUBLIC AWARENESS OF THE PRINCIPAL SAFEGUARDS.
6.
RIGHT-TO-DIE LAWS THAT PERMIT THE USE OF LIFE-ENDING DRUGS
BRING THEIR
SAFEGUARDS TO BEAR ON ONLY A
FEW DEATHS.
7.
USING PUBLIC SAFEGUARDS FOR LIFE-ENDING DECISIONS
FOR ONE
MILLION DEATHS EACH
YEAR.
RESULT:
This
chapter might change any preconceptions of the readers
that making life-ending decisions is quite rare in terminal medical
care.
Perhaps half of all
deaths in the United States
(and other countries where most deaths take place under medical care)
now include making significant
choices about the timing of death.
ONE
MILLION CHOSEN DEATHS PER YEAR?
by
James Leonard Park
How many deaths under medical care in the United States
include some
meaningful element of choice?
75-80% might be a good guess.
In the other 20-25%, the patients receive maximum medical care
until they die despite
everything medical science can offer.
If this is so, then in practice we already have the
right-to-die,
but it has not been very clearly acknowledged by the medical profession
and it has not been fully grasped by the public.
All of these chosen deaths have some informal
process
for making the life-ending decisions.
But the principles used have not been discussed or validated by the
public.
This also means that no
public safeguards are being applied
to these one million chosen deaths each year.
How many of these deaths with some element of choice
were premature?
If reasonable public safeguards were used for every life-ending decision,
probably some premature
deaths would be prevented.
Perhaps one chosen death in 1,000 would be judged 'premature'
if public safeguards were applied to all life-ending decisions.
Also, using safeguards well known to everyone
involved
would assure all who are trying to make medical decisions
that they have
taken all appropriate care
to make wise and compassionate end-of-life choices.
1. ESTIMATING THE NUMBER OF
CHOSEN
DEATHS IN THE USA.
In the United States at the beginning of the 21st
century,
about 80% of all deaths take place in health-care facilities.
These are not the unexpected
deaths reported in the news media.
But these are the routine
deaths
that come at the end of some process
of medical care.
They are reported on the obituary
page of every newspaper.
Most of us will undergo a
death
coordinated with medical care.
Under modern medical care, a high percentage of
deaths
include some meaningful
element of choice.
Some observers estimate as many as 80% of deaths with medical care
come after a medical decision
to give up treatment aimed
at cure
and to provide comfort-care
only.
If these guesses are correct, then 64% of all American deaths
include some meaningful element of choice.
But even if these estimates are not accurate,
if,
say, only 50% of hospital deaths include choice
then 40% of all American deaths might be called "chosen deaths".
But because we cannot easily define what we mean by
a "meaningful element of choice",
we will leave the guess at about half of all deaths in the USA,
which leaves us with a nice round number of 1 millions deaths per year.
(Over two million Americans die each year.)
People with access to more detailed data about
hospital deaths
are welcome to provide more accurate estimates.
And such
data can be linked from here.
2. WHAT IS A
"MEANINGFUL ELEMENT OF CHOICE"?
The most common expression used by laypeople and doctors alike
when acknowledging the turn towards death is: "Nothing more can be
done."
What we actually mean is that our care will now shift from cure to comfort.
There are still many ways to ease
the passage into
death.
And the best terminal care can begin
once we shift away from using medical technology
that was intended to save
the patient from death.
Turning from cure to comfort can take many forms.
A.
INCREASING PAIN-MEDICATION.
As we approach
death from natural causes
(cancer, heart disease, multi-organ
failure, etc.)
we might be receiving medication to
relieve our terminal suffering.
When it becomes clear that we are
dying,
the doctor can increase
our
pain-killers without worry about side-effects.
Increasing our doses will probably
also shorten the process of dying.
When the purpose of medical care
turns from cure to comfort,
a life-ending decision has
been silently confirmed.
B. INDUCING TERMINAL COMA.
If our suffering
is severe and unrelenting,
the doctor might recommend using
enough drugs to keep us asleep
thru all of the remaining days of
our lives.
Just as anesthetic drugs can keep us
unconscious during surgery,
medical science knows the proper
doses of drugs needed
to keep us continuously unconscious until
natural death.
The drugs used to prevent even one
moment of suffering
will also shorten the process of
dying
because those drugs will also
suppress our vital functions
such as heart-beat and breathing.
And since the
decision for death has already been taken,
then all forms of medical treatment
and life-support are also discontinued.
This includes food and water
supplied by any methods.
Inducing a terminal coma is clearly
a life-ending decision.
C. WITHDRAWING
OR WITHHOLDING LIFE-SUPPORTS.
If our bodies
were being kept alive by any form of life-supports,
then the primary action to bring our
lives to an end
might be the simple decision to stop everything.
Or such a life-ending decision might
take the form of never
starting
some form of life-support that would
be necessary for our survival.
From the
perspective of laypersons,
this looks like removing (or never
starting) the tubes and
machines.
One obvious machine might be doing
our breathing for us.
But we might also be receiving drugs
to maintain our vital functions.
Withdrawing life-supports almost
always includes giving up
food and water,
which is discussed more fully below.
If we are on life-supports in the intensive-care
unit, then the options are:
(1)
keep
the machines running or (2) pull the plug.
Laypersons generally favor keeping the life-supports in place.
They do not want to "give up on" the patient.
And the medical profession has generally gone along with this option.
This means that the patient will remain attached to the life-supports
until the patient dies despite
being maintained in those diverse ways.
Such deaths would be counted as taking place without any choices.
Such patients were "treated-to-death".
However, if and when the prognosis for the patient
is
clearly terminal,
someone might ask: Should the life-supports be discontinued?
And increasingly, this is just what happens
—after
considerable discussion among
the doctors, the patient,
and/or the proxies.
Specialists might give independent assessments
of the patient's condition and prospects.
If no recovery seems likely—if
death is inevitable no matter what is
tried—
then everyone might agree to discontinue the life-supports.
Hospice-care generally does not use life-support
measures.
But the choice to enter a
hospice program is already
a choice on the way towards
the death of this patient.
One of the requirements for entering a hospice program
is that the patient has given
up all medical treatments aimed at cure.
The doctor officially declares that the patient has a "terminal
condition"
—meaning
that the patient is expected to die within the next 6 months.
The duration of hospice-care is usually much less—often
only a few days.
Feeding-tubes are a
common example of life-supports we all understand.
At the end of our lives, some of us will be sustained by tubes
providing nutrition either into our stomachs or directly into our veins.
If a feeding-tube is the only way we can receive sustenance,
then disconnecting the
feeding-tube is a life-ending decision,
since we all know that we cannot survive without food and water.
Scientific data probably exists summarizing the
number of patients
who were being sustained by some form
of artificial nutrition and
hydration at the end of their lives.
In how many cases was the feeding-tube removed?
And how many patients sustained by such tubes
died while the tubes
were still in use?
Links to
actual data can be provided here.
There will be some discussion among all
concerned
—including
probably some medical professionals with special expertise
in the disease or condition that is likely to cause the death of the
patient.
And all will explicitly know that removing the tubes
will be the specific method
of choosing death for this patient.
In either of these cases
—life-supports
generally
and feeding-tubes specifically—
the certificate of death will name
the underlying disease or
condition as the cause of death.
And the death-certificate might not mention
the support-measures used
at the end.
(However, the complete hospital record will certainly have details
about the drugs, tubes, & machines used to keep the patient alive.)
Removing
a feeding-tube is obviously a life-ending
choice.
Most life-ending decisions made in the hospital
would fall under this very broad category: ending curative treatments.
When all reasonable efforts have been made to cure us,
when we have received drugs, surgery, radiation,
transplants,
etc.,
and nothing medical science can offer is going to prevent our deaths,
then the life-ending decision comes in the form of
discontinuing the medical
treatments that have not worked.
The patient and/or the proxies consult with the
doctors
to see if there is any reasonable hope in further medical efforts to
cure.
And when they collectively decide that more treatments would be
futile,
they shift to comfort care
for the patient.
The curative drugs and treatments are discontinued.
Only those drugs that will ease the dying process remain in use.
In such routine life-ending decisions,
most of the safeguards become irrelevant.
The medical facts are the compelling reasons for allowing death to
come.
3.
WILL WE BE "TREATED-TO-DEATH"?
The most common scenario for hospital deaths
is maximum application of
medical methods to cure the patient,
followed by the decision to end curative treatments
once it becomes clear that further treatments would be useless.
But some patients will be "treated-to-death", which
means
receiving all possible medical treatments until the last moment of
life.
Would it be correct to say that a minority of
patients in hospitals
will continue to receive curative treatments until the last day of
their lives?
It used to be standard
medical procedure
to apply all possible cures,
all of the time.
If no one makes a move to depart from that traditional protocol,
then the patient would continue to receive
life-supports and curative treatments until everything fails anyway:
The patient dies no matter
what medical care is provided.
Would it be fair to call this being "treated-to-death"?
And would it be correct to say that only 20-25%
of patients who die in hospitals were
"treated-to-death"?
4. FULFILLING
SAFEGUARDS FOR MAKING LIFE-ENDING DECISIONS.
Most life-ending decisions are made
without any
explicit reference to "safeguards".
Implicit safeguards
underlie all medical decisions.
But should we make safeguards
more explicit
so that some hasty deaths can be avoided?
Should we
apply safeguards to all
life-ending decisions?
Applying safeguards need not be a complicated bureaucratic process.
But those who are deciding that this human life is now at an end
should employ the most appropriate safeguards
to assure themselves as deeply as they wish
that the death they are considering will be a wise and timely
death,
not a foolish, rushed, or
premature death.
One way to
apply safeguards to all life-ending
decisions
would be to create a new
law against
causing premature death.
Then everyone would know that fulfilling the stated safeguards
would help to achieve a timely death—not too soon and not too late.
Here are 26 recommended safeguards for
life-ending decisions:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html
These
are conveniently named for the letters of the Roman
alphabet—A-Z.
Thus those who are discussing which safeguards would be most appropriate
can refer to them by their letters in the list above.
Each recommended safeguard is linked to a full explanation.
Careful application of the most appropriate safeguards
would be especially helpful for people
who are making life-ending
decisions for the very first time.
5. PUBLIC AWARENESS OF THE
PRINCIPAL SAFEGUARDS.
When safeguards are routinely
used for making end-of-life choices,
then the general public will become more familiar with them.
Safeguards will cease to be the private possessions
of the medical and legal professions.
And when public
safeguards are explicitly applied,
everyone involved can be more assured that this death was wisely chosen,
rather than having recurring doubts
that some additional medical treatments could have been tried.
When some cases of the right-to-die are made public
by
the media,
then everyone can discuss the most
appropriate safeguards.
This did not occur in
the case of Terri Schiavo.
There was no public discussion of guidelines for making end-of-life
choices.
People just lined up on one side of the case or the
other.
Discussing safeguards would have made the right-to-die debate
more rational and principled.
And public discussion of safeguards for life-ending decisions
would help us all to consider just how such procedures
might apply to our own end-of-life situations.
One example of a safeguard would be consulting
an
ethics committee.
How would we feel if we knew that the medical facts and opinions
would be reviewed by an impartial ethics committee of experts
who routinely discuss proposed end-of-life choices?
Applying such defined safeguards does not mean
that individual medical decisions for every patient is
public information.
On the contrary, medical
decisions should be kept private
among the deciders except in the unusual situation
where there is some question of a harm being visited upon the
patient,
when
law-enforcement authorities can examine all
medical records.
For
further exploration of this principle, read: "Open Safeguards Kept
Private:
End-of-Life Medical Decisions Should Never Become Public Information":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-OPEN.html
6. RIGHT-TO-DIE LAWS
THAT
PERMIT
THE USE OF LIFE-ENDING DRUGS
BRING
THEIR SAFEGUARDS TO BEAR ON ONLY A FEW DEATHS.
In the first 20 years of operation of the Oregon
Death with Dignity Act,
only 1-4 deaths in 1,000 took advantage of this law.
This means that the safeguards embodied in the Oregon DwDA
are being applied to less than one percent of all deaths in Oregon.
New laws that prohibit causing premature death
would cover all deaths that
include a meaningful element of
choice.
And as estimated above, this would be about half of all deaths in the
USA
—more than one million deaths per year.
Until such laws come into effect, we have no way of
knowing
how many of the chosen deaths were premature.
Opponents of the right-to-die might better spend
their efforts
improving routine deaths in
hospitals and nursing homes
rather than working against laws allowing life-ending
chemicals,
which are going to apply to much less than 1% of all deaths anyway.
Might they oppose hasty
decisions in hospitals and nursing homes
that do actually result in premature deaths?
7. USING PUBLIC SAFEGUARDS
FOR
LIFE-ENDING DECISIONS
FOR
ONE MILLION DEATHS EACH YEAR.
Perhaps the best way to acknowledge that we already
have the right-to-die
is to bring the process of making life-ending decisions more into the
open.
If we are already using implicit
safeguards for routine deaths,
why not make these safeguards explicit?
When no clear medical decision emerges easily from
the facts,
then more safeguards
can be employed to help reach a wise decision.
If we already have a set of public safeguards ready to be used,
then all who must decide will know where to turn
in order to achieve more
clarity for the situation at hand.
And the sometimes-ambiguous legal situation would
also be resolved:
If all appropriate safeguards were fulfilled,
then there would be no adverse legal fall-out
for anyone who participated in the process
of making or supporting any wise end-of-life medical decisions.
Here is a list of 26
recommended
safeguards
which might be named in any new laws against causing premature death.
When the most appropriate safeguards have been fulfilled,
all can be assured that the
chosen death was not premature.
Such safeguards could be used in the estimated one million deaths
each year in
the USA that involve some
meaningful
element of choice.
And eventually the best safeguards could be used world-wide.
RESULT:
Has
your mind been changed about how terminal care works?
Do you now believe that about half of all deaths in the USA
are accompanied by significant end-of-life choices?
Do you agree that it would be wise
to make the implicit
safeguards more explicit
and public?
Created
2-3-2008; Revised 2-7-2008; 2-13-2008; 2-14-2008; 2-23-2008; 3-3-2008;
6-16-2009 (when this discussion also became an on-line essay of the
same
name:
CY-1MILL);
1-3-2010; 11-18-2010; 1-3-2011; 4-5-2011; 11-23-2011;
1-6-2012;
2-23-2012; 2-27-2012; 3-3-2012; 3-11-2012; 3-15-2012; 7-10-2012;
8-4-2012; 8-25-2012;
4-18-2013; 6-8-2013; 10-9-2013; 7-30-2014; 4-4-2015; 7-10-2015;
5-27-2016; 11-3-2017; 12-16-2017; 11-17-2018; 12-30-2019; 10-30-2020;
AUTHOR:
James Park is an independent philosopher
with deep interest in end-of-life issues.
Much more about him will be found on his website:
James
Leonard Park—Free
Library