LIFE-ENDING DECISIONS
FOR ALZHEIMER'S PATIENTS

SYNOPSIS:

    There are about 5 million Alzheimer's patients in the USA.
And other countries have similar numbers.
These patients are at different stages of mental decline.
This brain disease often causes several years of dementia before death.

    In the past, the standard medical practice in the United States has been
to keep Alzheimer's patients alive as long as technically possible.
Such standard medical treatment has often included a feeding-tube
because patients with advance dementia forget how to eat
and it becomes too difficult and dangerous to feed them by hand.

    This population of patients with various degrees of mental decline
will only increase in coming years
—as more people enter the age when Alzheimer's is more likely.
After age 85, about half of us will have some level of Alzheimer's.

    Even in advanced societies, we have not boldly faced
this problem created by advances in medical technology.
Because people with advanced dementia can be kept alive for years,
we just assumed that they should be kept alive.
Our nursing homes have millions of patients
with Alzheimer's disease or other forms of mental decline.
They need constant care because they cannot take care of themselves.
As they decline into deeper mental disability,
more care and support are needed from the staff of the nursing home.
Consider the costs in human efforts and public and private money.

    If we get Alzheimer's disease, how long should we be kept alive?

OUTLINE:

1.  WHO SHOULD MAKE THE LIFE-ENDING DECISIONS?

2.  WHEN SHOULD DECISION-MAKING POWER
            SHIFT TO THE PROXIES?

3.  FIFTEEN SAFEGUARDS FOR MAKING
            LIFE-ENDING DECISIONS FOR ALZHEIMER'S PATIENTS
A. ADVANCE DIRECTIVE FOR MEDICAL CARE

B. REQUESTS FOR DEATH FROM THE PATIENT

C. PSYCHOLOGICAL CONSULTANT EVALUATES
            THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS

D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

E. INDEPENDENT PHYSICIAN
            REVIEWS THE CONDITION AND PROGNOSIS

F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

G. PALLIATIVE CARE TRIAL

K. REQUESTS FOR DEATH FROM THE PROXIES

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

O. A MEMBER OF THE CLERGY
            APPROVES OR QUESTIONS CHOOSING DEATH

Q. AN INSTITUTIONAL ETHICS COMMITTEE
            REVIEWS THE PLANS FOR DEATH

R. STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

S. REVIEW BY THE PROSECUTOR (OR OTHER LAWYER)
            BEFORE THE DEATH TAKES PLACE

U. WAITING PERIODS FOR REFLECTION

4.  WHICH METHODS ARE BEST FOR DRAWING LIFE TO A CLOSE? 

5.  MEDICAL METHODS OF MANAGING DYING
            FOR FAMILIES WHO REJECT POISON

RESULTS:

    Readers who originally thought that Alzheimer's patients
should be kept alive as long as possible
might have their minds changed in the direction
of allowing some wise end-of-life choices to be made for patients
with very serious brain diseases and other forms of dementia.

    15 specific methods for considering the best course of action
show how several concerned persons might take part
in making even life-ending choices
when the patient has lost most capacity to make medical decisions.

    Life-ending decisions are already being made
for patient's whose meaningful lives are over.
Now we might organize and regularize the process
for choosing the best pathway towards death
for patients who can no longer make their own medical decisions
or enforce their settled values.


LIFE-ENDING DECISIONS
FOR ALZHEIMER'S PATIENTS

by James Leonard Park

1.  WHO SHOULD MAKE THE LIFE-ENDING DECISIONS?

    Terminal care decisions for Alzheimer's patients
become especially difficult because of this brain disease itself.
Once a patient has this progressive brain disease,
all future decisions by that patient will be questionable.

    Sometimes the patient becomes child-like.
Some thought-processes are still taking place,
but the conclusions need to be monitored by other adults
who are still thinking clearly.

    In most cases, there is a long period of several years,
during which the patient is able to make some routine decisions,
such as what clothes to wear and what to watch on television.
But as the disease progresses,
even such simple decisions must be taken over by others.

    The highest and most complex mental processes disappear first.
This might be noticed in the patient's financial affairs:
Has the patient made foolish decisions concerning money?

    Also, does the patient have enough power of concentration
to understand medical information and to reach reasonable conclusions?
Eventually, others take responsibility for making medical decisions.

    And, of course, the most comprehensive medical decision will be
making those choices that will lead to the death of the patient.
Because decisions that result in death are so important and complicated,
a patient with Alzheimer's cannot be trusted to reach a wise conclusion.

    Then someone else must make medical decisions for this patient.

    The most common way this shift of decision-maker takes place
is for the doctor to turn to a close relative
when a medical procedure must be approved.
Without any formal legal process, the next of kin
becomes the actual person to decide for this patient:
The doctor hands the consent-form to the most reasonable relative.

    A better process would be to establish a formal proxy
for the patient who can no longer make wise medical decisions.
This can be done with a special document appointing the proxy.
Or it can be included in an Advance Directive for Medical Care.
One of the most important elements of any Advance Directive
is naming a proxy who will make decisions for this patient
when and if the patient can no longer make meaningful medical choices.

    A formal proxy could also be a committee of relatives and friends,
such as a Medical Care Decisions Committee,
which will be legally empowered to make
at least the most important medical decisions for this patient.
Routine and non-controversial authorizations
could be handled by the chairperson of the MCDC.

    During those months or years in which the patient
is still able to express meaningful opinions about medical care,
then the proxies should consult with the patient as much as possible.
Such consultation will be good both for the patient and the proxies.
And important decisions can be postponed
until a time when the patient is best able to make an informed choice.

    But when the patient has questionable mental capacities,
then the legal, official decision-making power
should rest with the duly-authorized proxies.
They might be able to say with some confidence
that they are making the same medical decision
that the patient would have made
when he or she was still able to make wise medical choices.

    This situation of declining mental capacities
should have been explicitly addressed in the written Advance Directive.
When the patient was still able to make wise medical decisions,
that person wrote what he or she would choose under various conditions.

    Such plans for the end of life cannot cover every possible problem,
but the Advance Directive can set forth the medical ethics of the patient
so that the duly-authorized proxies will be able to choose the best pathway
when the patient can no longer make meaningful decisions.

2.  WHEN SHOULD DECISION-MAKING POWER
            SHIFT TO THE PROXIES?

    The proxies themselves might have daily contact with the patient,
which will allow them to evaluate for themselves
the degree of mental decline in their friend or relative.

    And medical professionals might evaluate the patient's thinking-power.
Such formal and informal observations might lead to the same conclusion:
This patient can no longer make reasonable medical decisions.

    The proxies and the patient should cooperate as fully as possible
when making future medical decisions for this patient.
But the legal power to decide has now shifted to the proxies.

    It would be best to record this official shift in the medical record.
The proxies and the doctors could create a document recording the date
when the decision-making power shifted from the patient to the proxies.

    If the patient ever recovers all of his or her former mental powers,
then another document can be created,
stating the date and time when the power to make medical decisions
was formally and officially returned to the patient himself or herself. 

    Here are links to about 200 questions that proxies can ask,
which will probe the changes they have observed in the patient
in the following areas: consciousness, memory, language, & autonomy:
Discussing Degrees of Mental Decline.

3.  FIFTEEN SAFEGUARDS FOR MAKING
            LIFE-ENDING DECISIONS FOR ALZHEIMER'S PATIENTS

    The patient, the proxies, & the doctors
are the most important people to make end-of-life choices for the patient.
But some additional people might be consulted
to see if they agree with any decision to draw this patient's life to a close.

    Here is a list of the most relevant safeguards for this situation.
Each safeguard is explained briefly, but a more complete discussion
of how to apply that safeguard is linked from its name.
These 15 guidelines or procedures are listed in the order of importance,
beginning with the most relevant and powerful:

A. ADVANCE DIRECTIVE FOR MEDICAL CARE

    When the patient was still unquestionably able to make medical decisions,
that person created a written and signed document
explaining how he or she wanted to be treated at the end of life.
If this was a comprehensive Advance Directive,
it includes provisions that explicitly address the situation of mental decline.
The patient has written (while still able to make meaningful decisions)
just what he or she wants and does not want
when certain medical conditions arise.
What did the patient write about possible mental decline?

    To see one example of such writing,
read James Park's Advance Directive:
Scroll down to Answer 6:
"If I Get Alzheimer's Disease
or a Similar Condition that Limits My Mental Capacities"     page 211

B. REQUESTS FOR DEATH FROM THE PATIENT

    When the patient was already beginning the decline towards death,
he or she might have created an additional written statement
requesting death when his or her health has deteriorated
to the stage described in this document.
This request for death under specified circumstances
should be considered valid if the patient was still able to decide.
The witnesses to any such requests for death will state
that they believed the patient was still able to make meaningful choices
when this more explicit statement requesting death was created. 
This written, signed, & witnessed document
becomes a permanent part of the medical record.
Copies are kept by others involved---especially the proxies.

C. PSYCHOLOGICAL CONSULTANT EVALUATES
            THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS

    The mental capacities of the patient should be evaluated professionally.
An official statement can be created by a psychologist or psychiatrist. 
If the conclusion is that the patient can no longer make medical decisions,
then the proxies take over the decision-making powers.

D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

    Even tho it might be implicit in all of the current discussions,
the primary-care physician should issue a formal, written statement
summarizing the present condition of the patient and the future prognosis.
Sometimes people need to see such professional opinions in writing
before they will take them seriously.
And sometimes everyone has been operating on some implicit belief.
Putting the known medical facts and professional opinions into writing
will make certain that everyone concerned knows the full situation.

E. INDEPENDENT PHYSICIAN
            REVIEWS THE CONDITION AND PROGNOSIS

    And especially when the proxies are making end-of-life decisions,
they should get a second professional opinion about the patient's condition
and likely future course under various treatment options.

    Sometimes, even more professional medical opinions might be relevant.
Has a specialist in the patient's specific condition been consulted?
For example, has the patient been evaluated by an Alzheimer's specialist?
All statements from doctors should be in terms laypersons can understand.

F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

    Sometimes doctors create a separate document stating their judgment
that this patient has an illness or condition inevitably leading to death.

I. PALLIATIVE CARE TRIAL

    It might be useful to have a summary of the medical treatments
already tried as a means of controlling the symptoms of mental decline.
Were these treatments effective for a specific period of time?
Has the patient continued to deteriorate despite the best palliative care?
The medical professionals involved in any such palliative care
might also be asked to write their observations and recommendations.

K. REQUESTS FOR DEATH FROM THE PROXIES

    When the patient can no longer request death for himself or herself,
the proxies are empowered to make any medical decisions
that could have been taken by the patient
while the patient was still mentally able to make such requests.
Let the official authorization for life-ending decisions be put into writing,
signed, dated, & witnessed.
In creating their own written request for death,
the proxies take responsibility for the life-ending decision they are making.

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

    When the patient is receiving care from health-care professionals,
a number of additional people know about the end-of-life situation.
And such observers (even including volunteers for a hospice program)
should express their doubts if they do not believe
that death at this time would be the wisest course of action.
Any and all such questions should be resolved
before the proxies make their final decision for death.

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

    And the case for choosing death for this patient
will be strengthened by any written statements from health-care staff
who help to care for the patient who is at some stage of mental decline.

O. A MEMBER OF THE CLERGY
            APPROVES OR QUESTIONS CHOOSING DEATH
   
    If invited by the patient and/or the proxies, a professional religious leader
might be asked to review the end-of-life plans now being formulated.
This minister, priest, rabbi, etc. would not have any veto power
over the end-of-life decisions being make by the duly-authorized proxies.
But their religious opinions might affect the plans for death.

    And it will be reassuring to more distant skeptics if they are informed
that the life-ending decision was approved by a member of the clergy.

Q. AN INSTITUTIONAL ETHICS COMMITTEE
            REVIEWS THE PLANS FOR DEATH

    Somewhere in planning for death it might be relevant
to seek the professional opinion of an ethics committee or consultant.
Such professionals face end-of-life situations on a regular basis.
And while they should actually visit the patient and talk with the proxies,
they are not emotionally involved with the patient.
They can make more objective recommendations,
based only on the known medical facts and professional opinions
and the recorded wishes of the patient and the proxies.

    If an ethics committee or consultant reviewed the choices,
then most people who know less about the situation should not object
based on their own preconceptions or philosophical views.

R. STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

    Have doubts been raised about the quality of the medical care?
Might the patient be suffering discrimination because of group-identity?
Perhaps a representative of that sometimes-disadvantaged group
might be asked to review the complete death-planning record.
Such an advocate would have no veto power.
But if the representative of an identity-group finds real problems,
such issues can be brought to the attention of the decision-makers. 

    And if no discrimination is found by such an advocate,
then all critics who know less about the situation should remain silent.
The possibility of inferior care has been examined.
And this advocate agrees that the medical decisions are wise and proper.

S. REVIEW BY THE PROSECUTOR (OR OTHER LAWYER)
            BEFORE THE DEATH TAKES PLACE

    The public prosecutor would rarely become involved.
Only when there is valid suspicion that a crime might be committed
under the color of withdrawing life-supports and discontinuing feeding
should the local prosecutor be informed about the end-of-life choices.
If the prosecutor might have reason to open a case-file after the death,
then such doubts can be resolved before the death takes place.
The public prosecutor could grant immunity to everyone involved
if the plans for death proceed as explained in the prepared documents.

U. WAITING PERIODS FOR REFLECTION

    Probably there will be no need for any additional waiting periods
because of the lengthy deliberations already completed.
But if anyone legitimately involved wants to review the facts and opinions,
some delay in the proposed date of death should be allowed.

    There might be other reasons to propose a later date of death.
Perhaps some distant family members want to be present at the end.
And when the approximate date of death is known in advance,
the funeral or memorial service can be scheduled accordingly. 

    Each of the above selected safeguards has a letter of the alphabet.
This is because they were chosen from a larger set
of recommended safeguards for all life-ending decisions.
The safeguards above are the most relevant and powerful
for any situation in which the patient has already lost mental capacity.
But if additional safeguards are wanted, here is the complete list:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html

4.  WHICH METHODS ARE BEST FOR DRAWING LIFE TO A CLOSE? 

    The proxies have a variety of measures they can select
to ensure that their patient has a meaningful, peaceful, & pain-free death. 

    If any organs are going to be donated after death,
then such evaluations should take place before the process of dying begins.

    Usually all life-support systems will simply be discontinued.
This includes all machines attached to the patient.
Food and water provided by any means will be discontinued.
All medications (except those needed for comfort) will be withdrawn.

    Some forms of sedation might be relevant,
especially if the patient is suffering pain for any reason.
And terminal sedation might be appropriate if it seems best
to keep the patient completely unconscious until death occurs.

    In Alzheimer's patients who have no other major medical problems,
the cause of death should be recorded as progressive Alzheimer's disease
and the medical methods of managing dying should be named:
withdrawing a feeding-tube, ending all life-prolonging medical treatments,
increasing symptom-controling drugs, beginning terminal sedation, etc.
The complete medical record will describe the mental decline of the patient
because of Alzheimer's disease or some other cause of dementia.

    A few other medical facts might be relevant for the death-certificate.

    If the safeguards introduced above have been fulfilled,
then the specific last steps towards death will not be as important
as the process of making a set of wise, end-of-life medical choices.

    Often the choice is not between life and death
but between dying now and dying later.
If we suffer advanced dementia, when is the best time to die?

5.  MEDICAL METHODS OF MANAGING DYING
            FOR FAMILIES WHO REJECT POISON

    Even in those locations where gentle poison is a legal option,
many families want to avoid any thought to killing their loved ones.
Thus, the vast majority of deaths chosen for Alzheimer's patients
must use other medical method of managing this process of dying.

    A. Avoid All Future Life-Saving Medical Treatments.

    Especially when the family believes only in completely passive dying,
they might choose a studied course of non-action.
In cooperation with the physician in charge,
they might have medical orders written to reject in advance
any medical efforts that might be used to save this patient from death.

    The best-known of these medical order is Do-Not-Resuscitate (DNR):
If and when this patient begins to die from any cause,
no medical interventions will be used to prevent death from occurring.
If the patient catches pneumonia, no antibiotics will be ordered.
If the patient catches the flu, it will be allowed to run its course.
If the patient has a stroke, he or she will not be hospitalized.
If the patient has a heart-attack, no efforts will be started to prevent death.
If the patient begins to die from cancer, that disease will not be treated.
If the patient develops breathing problems, there will be no interventions.

    It might seem uncaring to choose this course of non-intervention,
but when the patient is already near the end of his or her life,
then this is a valid and legal choice to avoid all future life-saving care.
If any family members have doubts about ordering no intervention,
this might be an occasion to review the documents
proving that the 15 safeguards (that take up 4 pages of this chapter)
have been carefully fulfilled:
This patient's meaningful life is over.
And taking the next available exit is fully justified.

    B.  Adjust Medications Already in Use.

    Once the proxies have decided to draw their patient's life to a close,
they might consult with the physician in charge of the patient's care
to determine how best to make changes in medicines
to allow their patient to decline into a peaceful death.

    Some of the drugs already in use might be for the purpose
of preventing some form of physical problem
such as high blood-pressure, diabetes, blood-clotting, etc.
As part of the collective decision to draw this life to a close,
all medications intended to save the patient from death
can be discontinued on a chosen date.
Or they might be withdrawn one-by-one
in some sequence that makes sense for this patient.

    If the patient is receiving any pain-medication for known problems,
then the doctor can order a steady increase in these drugs
with full acknowledgment to everyone legitimately concerned
that this gradual increase in the pain-killers
will probably shorten the life of the patient.
And with full knowledge of all of the other physical problems,
the doctor might be able to predict with some accuracy
how long this process of increasing the pain-medications will last.

    To prevent any suffering that might result from the other changes,
the doctor in charge might also order some additional medications
for the purpose of preventing the unwanted side-effects.
New drugs might be ordered to make the patient more comfortable.

    Care should be taken in making any such changes of drugs
to make certain that these adjustments are fully within medical ethics.
If there are any doubts by anyone,
a second professional opinion can be obtained
to either affirm the original plan or to suggest some changes.
A specialist in Alzheimer's patients nearing death
might recommend a good plan for end-of-life drugs.

    And because the patient's death will come within a predictable period,
everyone in the family should be informed that the end is near.

    C.  Induce Terminal Coma.

    Once everyone agrees that this patient's life is ending,
it might be merciful to keep the patient asleep 
for whatever remains of the process of dying.
This would be especially appropriate if the Alzheimer's patient
is having terrible psychological symptoms of the disease.
The doctor in charge can order a continuous flow of drugs
to keep the patient completely unconscious for the rest of his or her life.

    Once again, this order for permanent sleep until death
would only be appropriate when using the safeguards above
has convinced everyone that this patient is at the end of his or her life.

    The exact duration of this induced terminal coma
will depend on all other factors about this patient's condition.
But normally, the family should expect death within a week or ten days.

    D. Withdraw all forms of Life-Support, including Food and Water.

    Many Alzheimer's patients have forgotten how to eat and drink.
And feeding them by hand has become too dangerous
because they do not swallow well either.
Food often goes down 'the wrong way'
and the patient dies from food in the lungs.

    In America, a feeding-tube is often used to prevent such problems.
And a feeding-tube can also be the method of choosing death.
If most of the safeguards have already been fulfilled,
it become a legal choice for the proxies to authorize
withdrawing the feeding-tube,
with full knowledge that without food and water,
this patient will soon die of dehydration.

    If there were any other forms of life-supports besides a feeding-tube,
then these can also be discontinued and disconnected at the same time.
Withdrawing a respirator will usually allow death to come immediately.

    Appropriate forms of comfort-care should be provided
so that the Alzheimer's patient does not suffer unnecessarily
as the result of withdrawing any and all forms of life-support.

    Giving up life-supports is a fully legal option wherever they are used.
The process of discussion that results from applying the safeguards
might conclude that death now is better than death later.

    E.  Combine the Best Methods of Managing this Death.

    After the family has examined their own feelings
about each of these medical methods of managing dying,
they might settle on some meaningful combination
of actions and non-actions.

    Perhaps providing food and water has already been ended
because it was too difficult for everyone concerned.
And this could also be a convenient time to cancel all medications
that were intended to prevent various medical problems.

    If and when these changes create problems
either for the patient as the dying individual
or for the family who must observe the dying process,
then terminal coma might be held in readiness:
If being awake and aware creates too many problems,
then it might be best for all concerned
for this dying patient be kept deeply asleep
while the process of dying unfolds as expected. 

    Given that this Alzheimer's patient is dying,
what is the best pathway?

   

RESULTS:

    Readers who have relatives with Alzheimer's disease
might now see a reasonable pathway towards death
for the patient who has lost the mental powers
to make any medical decisions,
including choices about the best time to die.

    When the best safeguards have been fulfilled,
the proxies have in hand the written statements
of several other people who have considered this patient's situation.
And the proxies can choose the best possible methods of dying.
   

Created August 25, 2011; Revised 8-26-2011; 8-31-2011; 9-22-2011; 10-21-2011;
1-14-2012; 2-10-2012; 2-28-2012; 3-21-2012; 7-7-2012; 8-31-2012; 9-7-2012; 12-13-2012;
3-31-2013; 4-21-2013; 5-7-2013; 8-2-2014;
3-5-2015; 3-11-2015; 7-11-2015; 10-9-2015; 12-23-2015;
5-1-2016; 5-5-2016; 10-23-2017; r 12-19-2017; 10-5-2018; 12-21-2018; 1-11-2020; 

AUTHOR:

    James Leonard Park is an advocate of safeguards for all end-of-life decisions.
He is the founder of a website called
Safeguards for Life-Ending Decisions.

Much more about him will be found on his personal website:
James Leonard Park—Free Library

    The above discussion of merciful death for Alzheimer's patients
is also Chapter 52 of How to Die: Safeguards for Life-Ending Decisions:
"Life-Ending Decisions for Alzheimer's Patients".

    Would you like to see such ideas more widely available?
Feel free to share this chapter with any other interested readers.


    For a more conservative approach to Alzheimer's disease,
read this brochure from the Alzheimer's Association:
https://www.alz.org/national/documents/brochure_endoflifedecisions.pdf
Disconnecting life-supports such as a feeding-tube or respirator
are common ways managing the dying process for Alzheimer's patients.


    Because this discussion of end-of-life decisions for Alzheimer's patients
was originally the last chapter in PART FIVE of
How to Die: Safeguards for Life-Ending Decisions,
the following summary is attached here.
If you would like to read any of the other chapters summarized below,
just click the chapter number on the right.

    In 2014, a new chapter on the deaths of children was added to PART FIVE.
So that is the actual place where this summary will appear in the printed book.
Summary of Part Five

Helping Others to Choose Death Wisely


    Patient autonomy means that the primary decider is the patient.
But the very process of dying often causes decline in mental capacities,
including all abilities to make wise medical choices.
In such situations, the proxies (formal or informal) must decide for the patient.

    Historically speaking, the hospice movement and the right-to-die movement
have been far apart, even tho both take care of the dying.
But hospice care will probably allow patients and their families
to use more liberal methods of managing dying.                                     Chapter 46

    A right-to-die hospice would allow patients and their proxies
to choose any combination of the following methods of dying:
1. providing comfort-care to prevent all suffering;  2. inducing terminal coma;
3. ending all curative treatments and life-supports;  4. voluntary dehydration;
& 5. (where permitted by law) gentle poison.                                                 Chapter 47

    When hospice programs openly acknowledge
that they allow patients to exercise such choices at the end of life,
safeguards for life-ending decisions become more relevant than ever.
Using 26 safeguards for life-ending decisions in hospice care.               Chapter 48

    When will the first right-to-die hospice be created?
Some opposition might arise because of negative media coverage,
but even adverse publicity can be turned positive
if the first right-to-die hospice program is prepared to explain
how all of the end-of-life choices it offers are completely legal and ethical.
Such discussion of end-of-life options will advance the right-to-die.      Chapter 49

    The public already accepts 'pulling the plug' as a valid life-ending decision.
Ending life-supports when they are no longer helpful
could become a paradigm for all life-ending decisions.                              Chapter 50

    When the patient has become a 'former person',
the family members who have been closest will discuss such mental decline.
Which dimensions of personhood have disappeared?                             Chapter 51

    And if the patient has Alzheimer's disease or some other dementia,
all further decisions must be made by the duly authorized proxies.
Good safeguards can help the proxies to make life-ending decisions.   Chapter 52

    Sometimes newborns, infants, & children also die.
Their parents can use the safeguards discussed here
to make wise life-ending decisions for their dying children.                       Chapter 53

    Here are a few related chapters and essays:

Comfort Care Only:
Easing the Passage into Death

Induced Terminal Coma:
Dying in Your Sleep---Guaranteed

Pulling the Plug:
A Paradigm for Life-Ending Decisions

VDD:
Why Giving Up Water is Better than other Means of Voluntary Death

Voluntary Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline
 
The One-Month-Less Club:
Live Well Now, Omit the Last Month

Taking Death in Stride: Practical Planning

Choosing Your Date of Death:
How to Achieve a Timely Death
—Not too Soon, Not too Late

Death Certificates:
Adding Medical Methods of Managing Dying

A New Way to Secure the Right-to-Die:
Laws Against Causing Premature Death

Two Approaches to Right-to-Die Laws:
Granting Permission and Banning Harms

Advance Directives for Medical Care:
24 Important Questions to Answer

Fifteen Safeguards for Life-Ending Decisions

Will this Death be an "Irrational Suicide" or a "Voluntary Death"?

Will this Death be a "Mercy-Killing" or a "Merciful Death"?

Four Medical Methods of Managing Dying

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

The Living Cadaver:
Medical Uses of Brain-Dead Bodies

Depressed?
Don't Kill Yourself!


    Further Reading:

Best Books on Voluntary Death


Best Books on Preparing for Death


Books on Terminal Care


Books on Helping Patients to Die


Books Supporting the Right-to-Die

Books Opposing the Right-to-Die


Go to the Right-to-Die Portal.

This chapter about closing the lives of Alzheimer's patients
also appears in these shorter books:
Medical Ethics at the End of Life
and
Right-to-Die Hospice.


WOULD YOU LIKE TO MEET OTHER SUPPORTERS
OF RIGHT-TO-DIE HOSPICE?

If you agree with these suggested safeguards
for making life-ending decisions for Alzheimer's patients,
consider joining a Facebook Group and Seminar called Right-to-Die Hospice.

 Here is a complete description of this on-line gathering of advocates of the right-to-die:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/ED-RTDH.html

And here is the direct link to our Facebook Group:
Right-to-Die Hospice:
https://www.facebook.com/groups/145796889119091/

Return to the DEATH page.

Go to the Medical Ethics index page.

Go to other on-line essays by James Park,
organized into 10 subject-areas.

Go to the beginning of this website
James Leonard Park—Free Library