TERMINAL CARE--DECISION MAKING---How many people will review the proposed death?

THE NUMBER OF PEOPLE
REVIEWING A LIFE-ENDING DECISION
USING THE 26 RECOMMENDED SAFEGUARDS

SYNOPSIS:

Medical decisions that will bring one human life to an end
are among the most difficult choices ever faced by human beings.
Therefore, 26 safeguards are recommended below.
And each of these safeguard-procedures involves
the personal and/or professional opinions of a number of people.

This summary attempts to estimate the number of different people
who might participate in the life-ending decisions for a particular patient.

THE NUMBER OF PEOPLE
REVIEWING A LIFE-ENDING DECISION
USING THE 26 RECOMMENDED SAFEGUARDS

by James Leonard Park

    This chapter reviews the 26 best safeguards for life-ending decisions.
Other ways of reviewing the end-of-life plan are also possible.
And some of the following safeguards might seem unnecessary
or irrelevant to a specific end-of-life situation.

    Because the same people will be involved
in fulfilling many of the recommended safeguards,
they will be counted only once for the whole death-planning process.
How many different people would be involved in a chosen death
using the 26 recommended safeguards?

    Each safeguard is linked to its complete explanation on the Internet.

A. ADVANCE DIRECTIVE FOR MEDICAL CARE

An Advance Directive for Medical Care
involves at least the patient and one proxy.
If the patient decides to create a Medical Care Decisions Committee,
this could include all of the closest relatives,
which could be five or more people.

And especially if these other people are selected as proxies,
they might be invited to write their own statements
indicating their willingness to carry forward
the settled values of the patient as explained in the Advance Directive.

2-7 people

B. REQUESTS FOR DEATH FROM THE PATIENT

Of course, the patient (while still able to make medical decisions)
is best qualified to make any requests for death.
Others will be involved in witnessing, recording, & certifying
all requests for death made by the patient.

0 new people

C. THE PATIENT IS MENTALLY CAPABLE OF MAKING A LIFE-ENDING DECISION

If the mental powers of the patient
or the 'reasons' for choosing death are questionable,
then a psychological professional should evaluate the patient's wish to die.

0-1 professional

D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

The physician most comprehensively in charge of the end-of-life care
will issue a written statement explaining the specific condition of this patient
and estimating the prognosis under various medical options.
In complicated situations, several doctors might issue statements
or they might decide to create a joint statement
summarizing the patient's medical condition and outlook.

1-3 professionals

E. INDEPENDENT PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS

Because even physicians can be mistaken,
a second option is very important, especially for life-ending decisions.
This professional opinion must be genuinely independent,
not just a re-affirmation of the reputation
and/or diagnosis of the first physician.

1 new professional

F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

Sometimes a separate statement of terminal illness should be created.
And it would be best if the hopeless nature of this case
were affirmed by another independent physician.

1 new professional

G. UNBEARABLE SUFFERING

The specific nature of the suffering must be expressed by the patient.
But medical professionals in pain-control might be consulted.

1 new professional

H. UNBEARABLE PSYCHOLOGICAL SUFFERING

When one of the main reasons for choosing a voluntary death
is social, interpersonal, mental, or emotional,
then the suffering patient is the main person to explain what is going on.
But a professional in a relevant medical specialty
might be called upon to evaluate the suffering
and to project the possibilities for relief.

1 new professional

I. PALLIATIVE CARE TRIAL

The patient should actually receive comfort care
in a medical setting by professionals in symptom-relief.
Only when the patient still wants to die
even tho he or she is receiving the best possible palliative care
would a life-ending decision be recommended.
At least three medically-trained individuals
would be involved in this end-of-life comfort care.

3 new professionals

J. INFORMED CONSENT FROM THE PATIENT

The patient should agree in writing to the life-ending decision.
The person who keeps medical records
is the only new person to mention in this context.

1 new medical-records person

K. REQUESTS FOR DEATH FROM THE PROXIES

The duly-authorized proxies appointed by the patient
might be called upon to make an official request for death
if the patient himself or herself has already passed the point
of being able to make wise medical decisions.

0 new people

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

If the patient is being cared for in some medical institution,
then there will be several additional people involved in the terminal care.
When all care-givers acknowledge that they are giving end-of-life care,
their awareness of the situation improves the safety of the patient.

4-10 new people, both lay and professional

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

When people besides immediate family and friends are involved,
then some additional people know about the terminal care.
And their statements will support or question
the life-ending options being considered.

3-7 new people, both lay and professional

N. STATEMENTS FROM FAMILY MEMBERS
AFFIRMING OR QUESTIONING CHOOSING DEATH

When the planning proceeds towards choosing death,
family members should be invited to express their opinions.
All relevant opinions should be taken into account
before any further steps towards death are taken.

0-3 new people

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

Sometimes it will be relevant to invite a member of the clergy
to express an opinion about the end-of-life care and decisions.
Since this is an optional safeguard,
only one additional person will be estimated,
even tho there might be a whole committee of clergy involved.
The clergy-person most deeply involved
might ask for the opinions of other religious leaders.

1 new professional

P. RELIGIOUS OR OTHER MORAL PRINCIPLES
APPLIED TO THIS LIFE-ENDING DECISION

Likewise, it is optional for those close to the dying person
to ask for a written statement of how religious or moral principles
might apply to the end-of-life situation being considered.

1 new professional

Q. AN INSTITUTIONAL ETHICS COMMITTEE
REVIEWS THE PLANS FOR DEATH

Whenever the patient is being cared for in a medical institution,
there will probably be some individual or committee
responsible for reviewing difficult end-of-life situations.

3-5 new persons, some laypersons, some professionals

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

Since most of us will not suffer discrimination,
there will probably be no new people involved here.
But when a special advocate issues a written opinion,
it could be quite reassuring
to more-distant members for the specific identity-group
that no lower level of care was provided
because the patient belongs to a group less favored by society.

1 new person

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

    The office of the public prosecutor or a private lawyer
might review the plans for death from a legal perspective.

1-5 legal professionals

T. CIVIL AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH

Keeping penalties in place will largely deter misbehavior.
This would not result in any new documents before death.
And there would be no new minds engaged beforehand.
But dozens of new people will become involved
if this death must be investigated after the fact.

0 new people

U. WAITING PERIODS FOR REFLECTION

The fact that proper periods for reflection have been observed
might be recorded as part of the death-planning record.

0 new people

V. OPPORTUNITIES FOR THE PATIENT TO RESCIND OR POSTPONE
ANY LIFE-ENDING DECISIONS

And the fact that the patient was given
ample opportunities to change his or her mind
should also be a part of the death-planning record.

1 new person

W. PHYSICIANS REVIEW THE COMPLETE DEATH-PLANNING RECORDS

The terminal-care physician
reviews all of the documents created in planning for this death.

0 new people

X. COMPLETE RECORDING AND SHARING
OF ALL MATERIAL FACTS AND OPINIONS

Keeping and sharing the facts and opinions
might include new people in the process,
but most likely the person in charge of the documents
has already been counted in one of the other safeguards.

0 new people

Y. THE PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH

Under some regulations, the patient himself or herself
must be capable of taking the final act that brings death.

0 new people

Z. THE DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS

The individual who organizes the records
has probably already been counted earlier in this summary
of all the people involved in the end-of-life decision-making.

0 new people

    According to these estimates,
at least 26 people would be involved in any life-ending decisions
using all of these safeguards.

    At the other extreme, 54 people might be involved.

    There is no attempt to set a standard number of people
who should be aware of or involved in any chosen death.
But if most of these 26 recommended safeguards are used,
lots of people besides those most closely involved
will be aware of what is happening at the end of this patient's life.
With so many people involved,
there is much less chance of this planned death
being a mistake or an abuse of the right-to-die.
It will be a timely death—not too soon and not too late.

AUTHOR:

James Leonard Park
is a strong advocate of safeguards for all life-ending decisions.
He is the founder of a portal called
Safeguards for Life-Ending Decisions:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG.html
Much more about him will be found on his website
---the last link below.

The analysis above has also become Chapter 25 of
How to Die: Safeguards for Live-Ending Decisions.

Created 10-14-2009; Revised 1-21-2010; 2-4-2010; 3-2-2011; 12-1-2011;
1-12-2012; 2-1-2012; 2-23-2012; 3-16-2012; 3-24-2012; 7-14-2012; 8-3-2012; 8-23-2012;
3-6-2013; 5-5-2013; 6-28-2013; 7-25-2014; 2-4-2015; 2-18-2015; 7-10-2015;
5-5-2016; 12-2-2017; 12-27-2018; 1-13-2020;