LIFE SUPPORT SYSTEMS (Critical Care)---withdrawing life-supports as a paradigm for life-ending decisions

PULLING THE PLUG:
A PARADIGM FOR LIFE-ENDING DECISIONS

SYNOPSIS:

    When a patient is being maintained by life-supports,
we are often faced with the decision about when to end such supports.
And it is now becoming more common to 'pull the plug'
before the patient dies despite the 'tubes and machines'.

    We do have informal and behind-the-scenes methods
for making such withdrawal decisions.
If we were to regularize and formalize these life-ending decisions,
perhaps some of the same safeguards for 'pulling the plug'
could be applied to other decisions to draw life to a close,
even for patients who are not dependent on life-supports.

OUTLINE:

1. ENDING LIFE-SUPPORTS
            —A WELL-ESTABLISHED MEDICAL PROCEDURE.

2. SOME FORMS OF 'PULLING THE PLUG'
            ARE MORE CONTROVERSIAL.

3. SAFEGUARDS TO PREVENT
            PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.

4. SINCE WE CAN BE REASONABLE ABOUT 'PULLING THE PLUG',
            PERHAPS THE SAME DECISION-MAKING PROCESS
            COULD BE APPLIED TO OTHER LIFE-ENDING DECISIONS.

RESULT:

    If we become more comfortable with turning off the machines
and removing the tubes keeping patients alive,
perhaps this will enable us to think more deeply
about the process of making medical decisions
in other situations in which medical technology
is not a major factor.

PULLING THE PLUG:
A PARADIGM FOR LIFE-ENDING DECISIONS

by James Leonard Park

As the 21st century advances,
more of us might be supported by machinery and drugs
in the last few days or weeks of our lives.
If we die from some disease or condition
that normally takes months or years to bring death,
then our dependence on life-support systems might be even longer.

If we are being kept alive by some form of medical technology,
then any decisions we make about the best time to die
and about the best means to allow our deaths
will have to include questions about what to do
with the life-support systems in place—keeping us alive.

1. ENDING LIFE-SUPPORTS
            —A WELL-ESTABLISHED MEDICAL PROCEDURE.

    Medical ethics in the 21st century includes discontinuing life-supports.
And some end-of-life decisions include never starting life-supports
when it is clear in advance that putting us on a ventilator, for example,
will only prolong the process of dying.
If there are no particular reasons to keep us alive for a few more days,
then everyone involved in this end-of-life decision
will probably agree not to extend the process of dying.
And even when there is no clear decline into death
because further deterioration is being prevented by the life-supports,
reasonable people can agree that if there will be no recovery,
there is no point in keeping us in a coma on life-supports indefinitely.

    On the other hand, when we are drawing our lives to a close,
we might have some very meaningful things we want to achieve
before the end of our lives.
And usually these will be quite independent
of any objective facts found in our medical charts.

    For example, we might have some religious practices or good-byes
that we want to complete before we 'allow nature to take its course'.
We might want to have our sins forgiven before we 'meet our Maker'.
We might want to make amends with estranged family members.
We might want to see a grandchild or great-grandchild before we die.

    If we imagine our lives as a movie or play,
we know what scenes we would like to have before the end of the show.
And if we are realistic about the amount of time left,
we will know which projects we can complete within that time-span
and what new projects would be unrealistic.

2. SOME FORMS OF 'PULLING THE PLUG'
            ARE MORE CONTROVERSIAL.

    'Pulling the plug' on our life-support systems carries no stigma,
as might be the case with taking a lethal chemical to bring death.
Perhaps this is because we can see clearly (and sometimes dramatically)
that 'life' in the intensive care unit (ICU)
has almost no similarities to the life we lived
in all the years leading up to this final scene.
When we are being supported by a heart-lung machine
that is keeping our blood circulating and oxygenated,
we know that this situation cannot continue indefinitely.

    Our feelings about 'pulling the plug' are somewhat different
when the life-supports seem more like daily living.
For example, our lives might be sustained
by medication to control our blood-pressure
to keep our hearts and blood vessels operating well.
If we go off that medication, we know that we could easily die
from the cardio-vascular problem now controlled by the drugs.

    At least in the advanced parts of the world, if we live long enough,
most of us will be using various medications at the end of our lives.
And we might have so many different prescription drugs
in our bodies that we cannot remember them all.
We might have experienced continual adjustments of our drugs
because of the subtle interactions among them:
One drug causes a particular side-effect,
which needs to be controlled by another drug, etc.

    In such situations, when we are ready for our lives to end,
we can simply refuse to take any of the drugs keeping us alive.
Our doctors can tell us how long we can expect to live
without the medications that have been assisting our vital functions.

    A somewhat more controversial situation arises
when the life-support is a feeding-tube
or other means of supplying food and water.
At the end of our lives, if we cannot eat normally,
then we might be attached (either temporarily or permanently)
to a feeding-tube that puts special foods directly into our stomachs.
Or we might have fluid and nutrition put directly into our veins
—by-passing our digestive systems completely.

    But even discontinuing artificial feeding
has now become a part of standard medical practice.
Such decisions should not be taken lightly
and without considering all the implications for everyone involved.
But from the perspective of medical practice
discontinuing artificial nutrition and hydration
is a common method of managing dying.

    When we think of our own lives coming to an end
by means of withdrawing or withholding a feeding-tube,
we know that the utmost caution is needed
in the decision-making process that might lead to this action.
Each of us should consider just how such a life-ending decision
should be reached with respect to our own lives.
And we should explain our plans in our Advance Directives for Medical Care.
If we clarify our own medical ethics well in advance of any situation
in which withdrawing a feeding-tube becomes a real option,
then we have considered this method of managing dying,
probably years before it becomes a real-life choice.

3. SAFEGUARDS TO PREVENT
            PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.

    It probably does not happen very often in medical institutions,
but sometimes harmful decisions are made
with inadequate consideration of all the options.
We should be protected from possible mistakes and abuses
of any protocol that allows withdrawal of life-support systems.

    Our doctors will provide the medical facts and recommendations.
And because one doctor might miss something important,
other doctors—perhaps specialists in our disease or condition—
might be called upon to examine us and to explore our medical options.

     Our own views on life and death should shape our end-of-life choices.
Each of us has strong beliefs and values
we have been using to shape our lives thru-out adulthood.
We have some life-principles that form the basis of our medical ethics.
And here also, it might be useful to ask for input from others.
There might be people we trust who will help us to formulate
our own values concerning life and death.

    And even beyond helping us to clarify our own values,
the views of others who have been close to us
might have to be called into action
if and when we can no longer make our own medical decisions.
This is the role of medical proxies,
whom we should appoint in our Advance Directives for Medical Care.
When we are beyond making our own choices,
our proxies are empowered to make all of the medical decisions
that were automatically given to us while we were still full persons.

    If we find ourselves in difficult dilemmas at the end of our lives,
we might have occasion to call upon a group of ethical consultants.
There might be an institutional ethics committee
in the hospital or nursing home that is providing our terminal care.
Because these people have faced similar situations,
they might be able to offer wise advice to the official deciders
—ourselves as the patient and/or our appointed proxies—
who might be facing life-ending decisions for the very first time.

    Another layer of protection would be the legal system.
We have laws and ways enforce them
so that people who cannot always protect themselves
will be saved from others who might have harmful aims.

    The same safeguards that we apply to withdrawing life-supports
could also be applied to other forms of life-ending decisions.
Even if we are not connected to tubes and machines at the end,
we still do have the right to choose
the best time and the best means for our lives to end.

    We should decide our own lives and deaths,
possibly getting feedback from the people closest to us.
We should appoint proxies who will carry forward our settled values
if and when we can no longer decide for ourselves
or can no longer express our wishes.

    Whoever is called upon to offer an opinion or make a decision
should be sure to consider all the available alternatives.
And it might even be wise to put these deliberations into writing,
in case these decisions might need to be reviewed later
by others who were not present when the choices had to be made.
Some relatives might be quite distant
and be included in the decision-process only when the end is near.
So, instead of starting the process all over from scratch,
these late-comers can be permitted to read the death-planning record,
which details all of the deliberations to that point.

    If the practice of withdrawing life-supports
does indeed become the paradigm for all life-ending decisions,
then we will discover some 'safeguards' that are really not appropriate.
If any proposed safeguards have never been applied
to any situations of giving up life-support systems,
then they should not be applied to other circumstances.

    Here is an extreme example:
Some opponents of the right-to-die hold
that doctors should never cooperate in any death-planning process.
This sometimes takes the form of ethics affirmed by a medical society:
"Doctors must not kill."
But it would be very difficult to apply such a 'hands-off' policy
to life-ending decisions that include withdrawing life-supports.
If doctors can give their professional opinions concerning life-supports,
they should also be permitted to give the medical facts and opinions
that would be relevant to other kinds of life-ending decisions.

    Perhaps we need laws to regularize the withdrawal of life-supports.
And any such provisions could be included
in new laws against causing premature death.
Here is a model for such laws:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/PREM-DTH.html
This draft legislation contains 26 safeguards for life-ending decisions.

4. SINCE WE CAN BE REASONABLE ABOUT 'PULLING THE PLUG',
            PERHAPS THE SAME DECISION-MAKING PROCESS
            COULD BE APPLIED TO OTHER LIFE-ENDING DECISIONS.

    As more of us gain experience with terminating life-supports,
we will become more familiar with the safeguards that should be used
to make sure that any harm to the patient is less than
the harm already being inflicted by the life-support systems themselves.
Of all deaths that now occur in hospitals,
about 80% involve some important elements of choice.
If no choices are made, the patients will continue to be maintained
on life-support systems until they die despite the 'tubes and machines'.
How often are patients 'treated-to-death'?

    As a culture, we have not given much attention to life-ending decisions.
But if over half of deaths in America now include some choices,
then we are already making over a million life-ending decisions each year.
Implicit safeguards are already being used for these medical decisions.
And as we become more aware of medical decisions that bring death,
we can make the safeguard-procedures more explicit
—perhaps with an eye on other life-ending decisions
that are not so completely within the control of doctors.

    As we learn to make wise decisions about terminating life-supports,
we are also learning how to articulate the safeguards
that should be applied to all life-ending decisions.
The right-to-die means being able to make wise choices
so that we can die at the best time and by the best means.

    Pulling the plug is sometimes the wisest end-of-life medical choice.

Created February 2, 2007; revised 9-2-2007; 10-9-2007; 2-2-2008; 12-11-2008; 4-22-2009;
2-14-2010; 4-22-2010; 11-18-2010; 2-24-2011; 3-11-2011;
1-13-2012; 2-3-2012; 2-10-2012; 2-27-2012; 3-21-2012; 7-7-2012; 8-31-2012;
3-30-2013; 5-17-2013; 6-7-2013;
2-11-2015; 4-18-2015; 7-11-2015; 10-8-2015; 12-23-2015;
1-24-2016; 2-9-2016; 11-7-2017; 9-4-2018; 11-13-2019; 10-2-2020;

How has this chapter changed your mind?

Did you once think that 'pulling the plug' was not permitted?
Did you think that once life-supports were started,
it would be wrong to discontinue them?
If someone you love is ever on life-supports,
how would you decide to disconnect the tubes and machines?
If you yourself are ever kept alive by life-supports,
do you now think you could authorize your death by withdrawing them?

Safeguards Website:

If you would like to explore safeguards for life-ending decisions,
here is an organized catalog of over 30 such proposed safeguards:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-CAT.html

And here is the selection of 26 recommended safeguards:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html

AUTHOR:

James Park is an independent thinker
with deep interest in medical ethics,
especially the many issues that arise at the end of life.
Medical Ethics and Death are two of the ten sections of his website:
James Leonard Park—Free Library

This essay about withdrawing life-supports
as a medical method of managing dying
has become a chapter in a small book entitled:
Right-to-Die Hospice

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

If you agree with disconnecting life-supports as a valid method of managing dying,
consider joining a Facebook Group and Seminar called Right-to-Die Hospice.
This discussion group is completely free of charge.
And members are welcome to join from anywhere.

The above discussion of disconnecting life-support systems
has become Chapter 7 of 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/

The above exploration of ending life-support systems
is also Chapter 48 of How to Die: Safeguards for Life-Ending Decisions:
"Pulling the Plug: A Paradigm for Life-Ending Decisions".