DEATH--PLANNING---4 legal methods of choosing death

Four Medical Methods of Managing Dying

Original Title: FOUR LEGAL METHODS OF CHOOSING DEATH

{alternate title: Legal Ways to End Our Lives}

1. Increasing Pain Medication: Comfort-Care Only.

2. Inducing Terminal Coma.

3. Withdrawing Curative Treatments and Life-Supports.

4. Voluntary Dehydration.

A. SUMMARY OF THESE FOUR METHODS OF MANAGING DYING

B. HOW MANY DEATHS ARE ACHIEVED BY EACH METHOD?

C. STATISTICAL PROBLEMS:
WHAT WAS THE PRIMARY PATHWAY TOWARDS DEATH?

D. METHODS OF DYING AND CAUSES OF DEATH

E. LAWS THAT EXPLICITLY AUTHORIZE
THESE METHODS OF MANAGING DYING

    As we approach the end of our lives,
we will probably be receiving various forms of medical care.
Our specific medical problems and the care selected to treat them
will help to decide which pathways towards death would be best for us.
Are we already receiving medication for pain?
Are we already lying in a hospital bed?
What treatments and life-supports are keeping us alive?
Would it be easy to give up food and water?

    Once we know we are dying, we can cooperate with our doctors
to select specific actions that will bring death as gently as possible.

    The following four methods of managing dying
can help to bring a peaceful death at the best time.
These four kinds of medical behavior are all completely legal
everywhere in the United States of America
and also in most other advanced countries of the world.
And even where the status of these end-of-life choices is uncertain,
moral thinking is moving toward affirming these options.

1. Increasing Pain Medication: Comfort Care Only.

   If we are under the care of doctors as we approach death
and if we are already receiving some kind of medication for our pain,
it is entirely within the law and good medical practice everywhere
for our doctors to increase our pain-medication
even if this higher dose will shorten the process of dying.

   When considering the amount of medication to administer,
the patient, proxies, & doctor should be clear about
the purposes for which the medication is being increased.

   If there is still some realistic hope of recovery,
then caution is appropriate when deciding the dose of pain-reliever.
Too much of any medication could be harmful.
And if we—the patients—are hoping to return to ordinary life,
or just hoping to have at least a few more days of meaningful living,
then we do not want the additional problems
of having our bodies or brains damaged by too much of any drug.

   However, if we are not expected to recover and return to ordinary life,
and/or if the burden of the pain
is greater than the benefit of the additional time,
then the possible side-effects of pain-relievers need not concern anyone.
One side-effect of pain-relievers is dependence on the drug,
which could also be called 'addiction'.
But why worry about drug-dependence if we will never recover?
Limiting medication because of the side-effect of drug-dependence
is not relevant in terminal care.
And standard protocols limiting such drugs should not be applied.

   When we have entered the last phase of our lives
—namely the downward pathway towards death—
then the only relevant considerations
are the effects of the drugs on our bodies and minds
between now and the hour of our death.

     In other words, decisions that are part of terminal care
differ sharply from medical decisions aimed at recovery.
We could even say that some of the decisions
taken as part of terminal care are life-ending decisions.
And if we are making decisions that will bring our lives to an end,
then we should be explicit about this new purpose for medical care.

   This is the sense in which we might consider
the consequence of shortening the process of dying.
Medications intended to control pain also suppress vital functions,
such as heart-beat and breathing.
When large doses of morphine (for instance) are prescribed,
the doctor knows that one of the side-effects of this drug
is that our lives might be shortened by a few days.

     Should we say that increasing pain-medication
is a life-shortening decision rather than a life-ending decision?
The higher dose of pain-relievers will not immediately end our lives.
Rather, one predictable result will be fewer days of terminal suffering.
And the pain-medication itself will reduce the severity of that suffering.
We might spend much of our last few days sleeping.

   This decision to increase pain-killing drugs
does not require any new decision-makers.
The same people who first authorized, ordered, & gave the drugs
will simply increase the dose to some reasonable level
that will achieve the wished-for result of less suffering
while the natural processes of dying proceed.

   Increased pain-medication can assure a more peaceful death,
even if that death comes a few days sooner than it would have
if we had made no decision to increase the pain-killers.
And our doctors can predict how many days we will survive
if we choose comfort-care-only.

    One traditional way of examining the details
of the decision to increase pain-medication
was called the principle of double-effect:
There is one action—a reasonable increase in pain-medication.
But there are two effects—less pain and a shorter process of dying.
Traditional ethics and law approve the action
if it is taken primarily to achieve a good result
—here the reduction of terminal pain—
even if the second effect—here the shortening of life—
is an easily-foreseen result.

    Modern thinking has moved away from the principle of double-effect
because it is so problematic to discover real intentions.
How can we know how much the doctor intended death?

    But a reasonable increase in pain-relievers
—within the parameters of standard terminal care—
should not create any legal problems for anyone involved.

    If there is any question about the amounts of pain-medication to use,
we could ask other physicians specializing in terminal care
and have them record their professional recommendations.
Moving from cure to comfort is a common end-of-life medical decision.

    Read more about increasing pain-medication here:
Comfort-Care Only: Easing the Passage into Death
A link at the end gives details about what drugs are used.

2. Inducing Terminal Coma.

     Another way to use drugs is to choose medication
to keep the patient completely unconscious until death occurs.
This method would be appropriate when the burdens of the dying process
exceed the benefits of being awake.
In the most extreme situations, every moment of conscious life
might be meaningless suffering and torment.

     If there is no hope of recovery from the medical problem
that will ultimately cause our deaths,
and if every conscious moment between now and death would be agony,
then the truly compassionate practice would be
to keep us asleep until the natural process of dying is over.

     And as noted in the first option—comfort-care-only—
the drugs themselves might shorten the process of dying.

     Inducing a terminal coma is clearly a decision
that acknowledges that death is coming within a few days at most.
And the proxies for the dying person have decided
that it is better to keep the patient unconscious
than for the patient to have even a few more moments of suffering.
Also, a timely death might mean earlier
rather than later under these circumstances.

     Once terminal coma has been chosen as the means of dying,
then other medical decisions also follow logically:
Unconscious patients can no longer eat or drink normally.
And there is no point in continuing to give nutrition and fluids by tubes
because that would only prolong the process of dying.
Also, if any other life-support systems are being used,
they can be discontinued when terminal sedation begins.
Or the terminal coma might begin
before the life-supports are disconnected,
especially if there might be suffering and distress
as a result of removing the life-supports.

     The family and friends can even begin their process of grieving,
since it is known with absolute certainty that death is coming.
They can even begin the orderly process
of arranging the funeral or memorial service
since the approximate day of death will be known in advance.

     Terminal coma might seem an unnecessary step in some cases.
Occasionally the family will ask why the process must take so long,
since everyone knows that death is coming in a week or less.
And if and when new laws allow merciful death
—defined as purposely ending the life of another
when proper safeguards have been fulfilled—
then a lethal injection could bring death immediately
---instead of inducing a terminal coma and waiting for the natural end.
How soon will such means of merciful death be permitted?
Each legal jurisdiction on the Earth must change its laws
to make such forms of chosen death legal options.

    Another chapter of this book explores terminal sedation more completely:
Induced Terminal Coma: Dying in Your Sleep—Guaranteed

3. Withdrawing Curative Treatments and Life-Supports.

     Modern science has created an ever-increasing array
of technical means to support life:
heart-lung machines, mechanical respirators,
drugs to control every natural process of the body,
means of providing fluids and nutrition,
ways of clearing toxins from the blood, etc.
And we can expect further advances in medical technology.

     In fact, if we end our days in a hospital,
it is very likely that we will have some form of life-support.
And in the developed world, most deaths now occur in hospitals.
Thus, one legal way to end our lives
is to turn off the machines and disconnect the tubes.

     Such a life-ending decision should not be taken easily or lightly.
Very careful consideration of all possible means of recovery
should be explored before we give up hope for a cure
and decide to end medical treatments and disconnect the life-supports.

    Because receiving medical care and being connected to life-supports
usually means that we are in a hospital,
there are already good safeguards in place to make sure
that withdrawal does not take place accidentally or casually.
A series of medical cures will already have been attempted.
And new treatments can always be proposed.
But will they really save us from death?
Eventually in almost every case, there comes a time to consider
ending all medical treatment and turning off the machines.

     Doctors will be the main technical advisors for such decisions.
But according to law as practiced in the Western world,
the decision to end treatments and life-supports belongs to the patient.
If the patient is no longer able to make medical decisions,
then the duly-authorized proxies for the patient
must decide to withdraw curative treatments and life-supports.

     When one of the life-supports was a respirator,
death will follow almost immediately
when the breathing-machine is disconnected.
The same is true if machines were performing the functions of the heart.
Without blood circulating, death will come immediately.

     When the main form of life-support was a feeding-tube,
then it might take a few days for the body to shut down.
And if there is any possibility of suffering
due to disconnecting any machines, tubes, or other life-supports,
such suffering can be prevented by appropriate drugs.
If necessary, the patient can be kept completely unconscious
during what remains of the dying process.
This might be called "an induced terminal coma"
if it is going to take any significant time for death to occur.

     Disconnecting life-support systems used to be controversial
because it was too active a means of allowing death to occur.
But modern thinking about life-support systems
allows the decision to discontinue (or never start) any life-supports.

     Another worry that has mostly passed from medical practice
regards the question of beginning life-supports:
Once a patient has been attached to life-supports,
is it morally wrong to disconnect the machines?
The universal answer in medical ethics now is that
beginning to use any system of life-supports
does not require that they remain in place until death.

     Thus, if we are asked to authorize some form of life-support,
we should not worry that we will be prevented
from disconnecting the tubes and machines later if they do no good.
In many cases, it is wise to use life-support systems
as a temporary measure while specific cures are attempted.
But when all means of saving us from death have been tried,
then it might be appropriate to disconnect the life-support systems
and "let nature take its course".

     Life-support systems were originally invented to sustain life
while the body of an accident victim, for instance,
was given medical care so that he or she could return to normal life.
Also life-support systems maintain vital functions during surgery.
But life-supports have become the standard equipment of dying.
Dying patients are routinely put into the Intensive Care Unit (ICU),
where they are connected to several different machines at once.
But when it becomes clear that recovery is not going to happen,
and/or if the patient finds the burdens of life-supports intolerable,
then the machines are turned off and death takes place.

     In fact, disconnecting life-support systems has become so routine
that this action is seldom mentioned on death-certificates.
The death is recorded as caused by the underlying disease or condition
that put the patient into the hospital in the first place.
Disconnecting the life-supports was simply the last step in medical care.

    More discussion of terminating life-supports appears here:
Pulling the Plug: A Paradigm for Life-Ending Decisions

4. Voluntary Dehydration.

     The first three medical methods of managing dying
—increasing pain-medication, inducing terminal coma,
& ending medical treatments and life-supports—
all include actions by physicians, usually in hospitals.
But giving up eating and drinking is a legal method of dying
anyone can use anywhere.

     When we have carefully determined that death is the best option,
we can achieve a peaceful death simply by giving up fluids and food.

    Good palliative care can limit the various kinds of distress
associated with dying by dehydration.

     The advantages of this pathway towards death are explored in
VDD:
Why Giving Up Water is Better than Other Means of Voluntary Death

    Another chapter explores 26 suggested safeguards:
VOLUNTARY DEATH BY DEHYDRATION:
Safeguards to Make Sure it is a Wise Choice

   And a website has been established called:
Voluntary Death by Dehydration—Questions & Answers

A. SUMMARY OF THESE FOUR METHODS OF MANAGING DYING

     These four legal methods of drawing our lives to a close
could be expanded to include other permitted means
of making life-ending decisions.
But these four methods can be recommended
because they are not likely to be misused to bring death too soon.
When considering the various ways we might end our lives,
we should consider the possible misuse of any such methods
to commit irrational suicide or to commit a mercy-killing.
Assisting an irrational suicide or committing a mercy-killing
should both remain outlawed, punishable, criminal acts
when they definitely harm the victims.

    Here is a proposed law that would permit wise medical decisions
while at the same time prohibiting causing premature death.

    Increasing pain-medication, inducing terminal coma,
withdrawing all curative treatments and life-supports,
& choosing terminal dehydration are all reasonable and wise ways
to draw a human life to a peaceful and painless close.
Medical ethics already recognizes the validity of these methods.
Legal authorities know that each of these actions
—when taken with careful safeguards—
is a fully permitted choice at the end of life.

    The reason for selecting these four legal methods of choosing death
—while thousands of other means of bringing death were omitted—
is that each of these includes implicit safeguards
to prevent abuses and mistakes.
The first three methods
—increasing pain-medication, inducing terminal coma,
& withdrawing curative treatments and life-supports—
all take place within medical institutions,
where good record-keeping and professional standards of care
should prevent abuses of these methods of choosing death.
The fourth method—voluntary death by dehydration—
contains within the very process of giving up water (and food)
many safeguards that will discourage irrational suicide
and other forms of premature death.

    When other methods of managing dying are discussed,
safeguards to prevent abuses and mistakes should be included.
Here is a catalog of several possible dangers, perils, & worries,
each of which is warded off by a specific set of careful safeguards:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-ABUSE.html

B. HOW MANY DEATHS ARE ACHIEVED BY EACH METHOD?

    About half of all deaths in countries with advanced medical systems
probably use some combination of these methods of managing dying.

    If we back up to view ourselves from the distance of the moon,
we notice that all human beings die—100%.
So, how many deaths follow the pathways described above?
No matter how we classify the pathways towards death,
all pathways taken together must total 100%.

    In those places on Earth that have advanced medical systems,
most deaths take place under some kind of medical care
—in a hospital, nursing home, hospice, etc.

    Unexpected, accidental, or violent deaths take place elsewhere.
Of all deaths, such sudden deaths probably amount to 20%.

    Thus, about 80% of all deaths take place under medical care.

0. Deaths with Maximum Medical Care: 25-30% of all deaths.

Many deaths take place under medical treatment.
These patients are 'treated-to-death'.
All of their medical care is based on the hope that they will recover.
Even when that hope of recovery is disappearlingly small,
medical treatments are intended to save the patient from death.
But the patient dies no matter what methods are used.
In the surgical suite or the intensive care unit,
the doctors are still working to save their patient
when the patient dies despite their best efforts.

    1. Comfort-Care-Only: 20-25% of all deaths.

    The purpose of pain-medication is always to reduce suffering.
But there comes a point in the downward journey towards death
when the pain-management turns from recovery towards comfort.
The doctors stop worrying about the side-effects of the pain-killers.
If the patient will not return to ordinary life,
why worry about drug-dependence or 'addiction'
---or even about suppressing vital functions
such as heart-beat and breathing?

    Careful doctors will discuss this change of purpose for the drugs
with the patient if the patient can still deal with such medical matters.
If the patient is unconscious, the proxies decide.
Here the decision to increase pain-killers is a life-ending decision.
The purpose of medical care shifts from cure to comfort.

    Under comfort-care, the patient will be awake part of the time.
And the patient might be able to eat and drink normally.

    Ordinary standards for amounts of drugs no longer apply.
Higher doses might shorten the process of dying.
But to protect the professional status of the doctors and nurses,
the new dose will not cause immediate death.
An earlier death might be expected but not intended.

    Of course, such subtle lines are difficult to draw.
In retrospect, will it be correct to say that the timing of this death
was affected by the amounts of pain-killing drugs that were used?
Where such medical choices are acknowledged,
the recorded cause of death will be the underlying disease or condition.
And the process of dying was shortened by the pain-killing drugs.

    2. Induced Terminal Coma: 5-10% of all deaths.

    The doctor recommends keeping the patient unconscious
for the rest of the patient's natural life—until death comes.

    When terminal coma is decided by the doctors and the proxies,
there is no point in continuing food and fluids,
since these will only prolong the process of dying.
Inducing terminal coma is clearly a life-ending decision.
When this process begins, there is no uncertainly about the outcome:
The patient will be dead within a few days.
The doctor can predict how long dying will take,
which depends on the condition of the patient's body
when terminal coma begins and life-supports are withdrawn.

    3. Ending Treatments and Life-Supports: 10-15% of all deaths.

    Many deaths in hospitals take place when it becomes clear
that medical treatment is not going to prevent death.
The life-supports in place are only going to prolong the dying-process.

    With the permission of the proxies (perhaps even the patient),
all of the medical means of curing are discontinued.
There will be no more curative medical procedures.
When life-supports are in use, including drugs to maintain vital functions,
they are all discontinued at the same time.
However, any means of comfort-care can be continued
if the patient might have even a moment of conscious suffering.

    The life-supports withdrawn might be providing oxygen or nutrition.
If the patient was supported by a respirator, death will follow immediately.
If the patient was maintained by tubes providing food and water,
dying might take a week or ten days.
The doctor should explain how long it will take for the patient to die
after withdrawal of all medical treatments and life-supports.

    The family can begin planning for a funeral or memorial service
as well as all other after-death events
because the likely date of death will be known.
Withdrawing all medical treatments and life-supports
is definitely a life-ending decision.

4. Other Chosen Deaths: 5% of all deaths.

When the patient is not being supported by any kind of life-supports
that can be disconnected or turned off,
then the patient, the proxies, & the doctors can all agree
(if the patient is not going to recover),
that the best pathway towards death is to give up all fluids.
This death by dehydration when used alone
probably accounts for 1% of all deaths.

    In the terminology used here, "other chosen deaths"
includes all voluntary deaths and merciful deaths.

     In Holland 5% of all deaths are achieved by what they still call
"euthanasia" and "physician-assisted suicide".
But terminal dehydration is not included in this category.
Deaths by planned dehydration are recorded as "natural deaths".

    In other locations, voluntary deaths using right-to-die laws
usually account for less than 1% of all deaths.

    These totals should add up to 100%.
But some additional methods of dying could be added.

    Irrational suicides should be counted in the 20% of unexpected deaths.

C. STATISTICAL PROBLEMS:
            WHAT WAS THE PRIMARY PATHWAY TOWARDS DEATH?

    20% unexpected, accidental, or violent death

    25-30% treated-to-death in a hospital

    20-25% increasing pain-medication, comfort-care-only

    5-10% induced terminal coma

    10-15% withdrawing curative treatments and life-supports

     5% other chosen deaths

    These estimates for countries with advanced medical care
are based on similar numbers collected in Holland,
which might have some of the best records available.
More data is needed to get the picture for other countries.

    The statistical categories for summarizing all deaths
will have to be defined very carefully
in order to decide just where to include a particular death.
Many deaths that take place under medical care
include more than one of the four methods of managing dying.
For example, when life-supports are withdrawn,
drugs are often given to alleviate the suffering that results.
Also, when terminal coma is ordered by the doctor,
this usually also includes ending all food and water,
since the unconscious patient cannot eat or drink.
And supplying nutrition and hydration artificially
will only unnecessarily prolong the process of dying.
If the patient is receiving any other forms of life-support,
these will normally be ended
when the induced terminal coma begins.

    Such statistical questions will be settled by asking:
Which method of drawing life to a close was the primary action?

    And while we are talking statistics,
none of the specific methods of managing dying
will create any changes in the statistics of the causes of death.
Those causes will still be listed on the death-certificates
as cancer, heart disease, multi-organ failure, etc.
These four legal methods of managing dying were the pathways.

D. METHODS OF DYING AND CAUSES OF DEATH

    Before the advent of modern medical care,
there was no concept of the methods of dying—just the causes of death.
But now that about half of all deaths in the advanced parts of the world
are achieved using some meaningful elements of choice,
some distinctions between methods and causes are needed.

    The 'causes of death' will still be recorded on our death-certificates
as the underlying diseases, organ-deterioration, accidents, etc.
which are the medical explanation of why our lives came to an end.

    But in addition to the medical reasons we could no longer survive
we might have chosen methods by which our lives were drawn to a close.

    The most common causes of death are:
heart and circulation failure, cancer, multi-organ failure, breathing disorders.

    The most common chosen medical methods of managing dying are:
ending curative treatments and life-supports (including food and water),
increasing pain-medication, terminal coma, & voluntary dehydration.

     Among the possible methods of managing dying,
most are first suggested by the terminal-care physician.
When it becomes clear to the doctor that we cannot be saved from death,
the physician who is most responsible for our care at the end of life
will suggest or recommend some combination of changes of medical care
that clearly acknowledge that we are dying.

    Especially if we are already receiving some drugs
to control our pain and other distressing symptoms at the end of life,
the doctor might increase the medications already in use
—now without worry about the side-effects,
since we will never return to normal life.

    The doctor might even recommend inducing a terminal coma,
which means using drugs to keep us unconscious until natural death.

    If terminal coma is selected as our method of managing dying,
then food and water are usually also discontinued,
since such means of support will only prolong the process of dying.
If other means of life-support are in use,
these will usually also be terminated at the same time.
Medical procedures and drugs intended to prevent death are ended.

    And even if there are no other forms of life-support in use,
we might all agree to stop providing food and water by any means.
If the doctor is the one who recommends this change of care,
it might be called "medical dehydration".
If the choice comes primarily from the patient and/or the proxies,
it might be called "voluntary dehydration".

    Even if we do not have any disease or condition
that would likely cause our deaths within a few days,
we can choose voluntary death by dehydration
if no other change in medical support would lead to death.

    If we choose voluntary death by dehydration,
our cause of death and method of dying would be the same:
Our death-certificates will say that we died by voluntary dehydration.
And if there were good reasons for us to die at the time
---perhaps proven by the safeguards we fulfilled---
then our deaths might be recorded as voluntary deaths
rather than irrational suicides.
Foolish self-killing will continue to be a regular cause of death.

    If there were any relevant medical conditions
behind our decision to choose a voluntary death
(or for our proxies to choose a merciful death for us),
these should also be explained on our certificates of death.

    For example, if we died from incurable cancer,
then cancer should be listed as the cause of death,
even if we decided to shorten the process of dying
by any combination of the available methods of dying.

    If, on the other hand, we had no terminal disease or condition,
we still had the right to end our own lives at the best time.
The agreement and cooperation of other people
might have been proven in the process of fulfilling safeguards.
Our reasons for wanting to choose death now rather than later
might not be facts recorded in our medical records.
But our death-planning records should give ample explanation.

    As the right-to-die is more widely acknowledged everywhere,
most deaths will be achieved with some cooperation from doctors.
At least our doctors will provide the medical facts
about our current situation and our likely future
under various methods of treatment that might be tried.

    But if we still have our wits about us as we approach death,
we have the right to choose our own best methods of dying.
The underlying causes of death are beyond our control.
But we need not be merely passive victims
of whatever medical conditions will claim our lives.
We can choose our own best pathways towards death.

    Here is a recommendation for adding a line to certificates of death:
Just below the cause of death (the underlying medical condition)
the doctor might add any life-ending decisions
or medical methods of managing dying:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/DC-LED.html

E. LAWS THAT EXPLICITLY AUTHORIZE
THESE METHODS OF MANAGING DYING

Sometimes these long-acknowledged principles of medical care
are explicitly embodied in the laws of the various states of the USA
and in the national laws of other countries.
The modifications of some laws
might help other jurisdictions to make wise revisions,
acknowledging these four medical methods of managing dying
are completely legal and moral.

    In Minnesota, the changes are embodied
in the revised law against assisted suicide:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/MN-SUIC.html
Minnesota doctors have official authorization to
(1) increase pain-medication and/or
(3) end all life-sustaining medical treatments.
(Using the numbering system of this chapter.)

    Quebec authorizes three medical methods of managing dying:
(3) ending all life-sustaining medical care,
(2) continuous palliative sedation, &
(5) medical aid-in-dying:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-QUEB2.html

    The national law of Canada authorizes
(5) medical assistance in dying:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/RTD-CAN.html

    France authorizes all four legal methods of managing dying:
(1) increasing pain-medication,
(2) inducing terminal coma,
(3) withdrawing all medical treatments and life-supports, &
(4) giving up food and water:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/RTD-FR.html

drafted 10-13-2005; revised 10-24-2005; 11-25-2005; 8-10-2006;
2-19-2008; 3-3-2008; 3-4-2008; 7-31-2008; 11-21-2008; 6-5-2009; 8-17-2009;
3-27-2010; 3-11-2011; 11-11-2011;
1-6-2012; 2-1-2012; 2-24-2012; 3-3-2012; 3-8-2012; 3-10-2012; 3-18-2012; 4-12-2012;
7-28-2012; 8-25-2012; 11-6-2012;
1-3-2013; 5-30-2013; 6-9-2013; 7-16-2013; 10-19-2013;
3-19-2014; 7-31-2014;12-23-2014; 4-2-2015; 7-1-2015; 7-10-2015;
2-11-2016; 5-6-2016; 9-16-2016; 6-14-2017; 8-3-2017; 3-23-2018; 11-17-2018; 1-17-2020;

AUTHOR:

James Park is an advocate of the right-to-die with careful safeguards.
Much more information about him will be found on his website,
which is the last link below.

The above presentation of four pathways towards death
has become Chapter 32 of
How to Die: Safeguards for Life-Ending Decisions:
"Four Medical Methods of Managing Dying".

And Chapter 42 of How to Die discusses
how these methods of managing the process of dying
might be used in a right-to-die hospice:
"Safeguards for Making Life-Ending Decisions
in a Right-to-Die Hospice Program".

Another approach—by Norman L. Cantor—
to the question of shortening the process of dying is entitled:
"On Hastening Death Without Violating Legal and Moral Prohibitions"
This links to the Loyola University Chicago Law Journal,
Volume 37, number 2, 2006, pages 101-125.
The article is also available at other locations on the Internet.
Law professor Cantor summarizes the law with respect to
the following 4 legal and moral methods of managing dying:
1. ending life-sustaining medical treatment (LSMT);
2. voluntary stopping eating and drinking (VSED);
3. terminal sedation (TERSE),
often with ending life-supports and/or voluntary dehydration;
4. pain-relief that probably shortens the process of dying.