INDUCED
TERMINAL
COMA:
DYING
IN YOUR SLEEP—GUARANTEED
SYNOPSIS:
Modern medical care has quietly developed a new way
to manage dying:
It is now possible, legal, & ethical to make the patient unconscious
for the duration of the dying process.
This is especially appropriate when the patient has uncontrollable
suffering.
The patient is dying under medical care
—in
a hospital, nursing home, hospice, or even at home.
Everyone involved knows that
this patient is inevitably dying.
All reasonable attempts to cure
the patient have already been tried.
And now, clearly, the patient is on the downward pathway towards
death.
But, instead of forcing the patient to suffer thru
the last few days of life,
everyone agrees that it would be more merciful to induce terminal coma.
Drugs are given to create deep,
permanent
unconsciousness.
And all forms of life-support are also withdrawn or
withheld.
Even food and water provided by any means are discontinued.
Life-supports would only needlessly prolong the dying process.
Inducing terminal coma is a
life-ending decision.
OUTLINE:
1. INDUCING TERMINAL COMA MEANS CREATING PERMANENT SLEEP.
2. USING THE BEST NAME FOR INDUCED TERMINAL COMA.
3.
WHEN TERMINAL SEDATION EMERGED IN MEDICAL PRACTICE.
4. GETTING PATIENT AND FAMILY AGREEMENT FOR INDUCING COMA.
5. THE CAUSE OF DEATH
IS ALWAYS THE
UNDERLYING
MEDICAL CONDITION.
6. SAFEGUARDS FOR CHOOSING TERMINAL COMA.
7. FRANCE AVOIDS THE USUAL RIGHT-TO-DIE CONTROVERSIES
BY OFFICIALLY
AUTHORIZING TERMINAL SEDATION.
8. HOW COMMON IS INDUCED TERMINAL COMA IN THE USA?
RESULT:
For
readers who have never heard of induced terminal coma,
this chapter explains how total unconsciousness can be used
as a medical method of managing dying.
Because the dying patient is completely and permanently asleep,
all suffering has ended forever.
INDUCED
TERMINAL
COMA:
DYING
IN YOUR SLEEP—GUARANTEED
by
James Leonard Park
1. INDUCING TERMINAL COMA
MEANS
CREATING
PERMANENT SLEEP.
One common hope of people when they think about
their own deaths
is that they will "die in their sleep".
This means they will become unconscious one night and never wake up.
And death does come
for a few people while they are asleep:
Some element of their dying process renders their brains unconscious:
In a coma, they never again experience a single thought or feeling.
Thereafter, they are
completely oblivious to the dying process.
Dying on
the operating table
is one
medically-induced way this can happen:
Before the beginning of the operation,
the patient is given sedative drugs that put the patient into sleep so
deep
that even radical cutting into his or her body causes no pain.
Anesthesia creates deep unconsciousness.
The drugs used during surgery make
all forms of suffering impossible.
Surgical anesthesia prevents the
patient from feeling anything
while something is removed or repaired in his or
her body.
Anesthesiology can guarantee
no suffering during surgery.
And if the surgical operation is not successful
—if
the repair does not work,
if the medical condition is much worse than expected—
the doctors might decide
never to allow this patient to awaken.
It would only cause unnecessary and meaningless suffering
for this patient to become conscious again
only to learn that he or she is inevitably dying.
Therefore, to spare everyone concerned,
the drugs are maintained until death is declared.
The operation did not
save this patient
and the patient "never regained consciousness".
This patient died on the operating table or in the 'recovery' room
while under a medically-induced state of deep sleep.
Sometimes heavy
sedation is used to keep the patient asleep
while some recovery process is still being attempted.
This might be called a "medically-induced coma".
The patient would suffer so terribly if awake
that it is obviously best to keep him or her deeply asleep
until the hoped-for healing can take place.
If the patient's body does
recover sufficiently,
then the sedation can be lifted gradually.
The patient will emerge from drug-induced sleep.
Some mechanical supports might still be necessary
until all normal functions of the patient's body are restored.
Such heavy
sedation is completely different from terminal coma.
The sedation used during a surgical operation and the recovery period
is very carefully controlled by the anesthesiologist.
Everyone is hoping and planning for this patient to recover.
Careful attention is paid to keeping
the patient breathing.
Perhaps a heart-lung machine will be used
to keep the patient's blood circulating and oxygenated.
Nutrition and hydration are also
carefully maintained.
All forms of life-support that this patient might need
are carefully kept in place and functioning correctly.
Heavy sedation is a temporary
measure,
intended to help the patient thru a difficult phase of medical
treatment,
which is expected to result in the patient returning to ordinary life.
In contrast, terminal coma is a
declared part of the dying
process.
No one should be under any illusions that this patient will ever
recover.
All forms of medical treatment and support are also withdrawn
since they would only delay the inevitable death.
This patient will never
return to his or her ordinary life.
This coma is called "terminal"
because the
doctor has
ordered
that the drugs be given continuously until death comes.
All efforts at cure
are abandoned.
Besides turning off the ventilator and the feeding tube
—which
are obvious means of life-support—
inducing
terminal coma also includes giving up antibiotics
and any other forms of chemical support for the body.
And because this patient's brain will never have another feeling,
even drugs to control unwanted symptoms are routinely
withdrawn.
Because this patient will be in a deep sleep until death comes,
the drugs to induce
permanent sleep are sufficient
to prevent any and all forms
of possible suffering.
When terminal coma is ordered by the doctor,
this patient will be kept permanently unconscious until death comes.
In other words, this terminal care guarantees
that this patient will die is his or her sleep.
2. USING
THE BEST NAME FOR INDUCED TERMINAL COMA.
This medical practice has been known by some other
names:
"Terminal sedation", "palliative sedation", or "terminal palliative
sedation".
As long as the word "terminal" is included,
there should be less confusion with other uses of anesthesia.
When an induced terminal coma is ordered by the doctor,
the clear intention is to
keep the patient asleep until
death comes.
If the patient shows any signs of suffering, even while unconscious,
the amount of the sedative drug is increased
so that there is not even the slightest hint to any observer
that this patient might be suffering any pain or discomfort.
"Palliative sedation" has been preferred by some
advocates,
because it does not seem so stark an expression.
"Palliative medical care" refers to the medical support at the end of life.
But the expression "palliative sedation" is
redundant.
All sedation is given for the purpose of alleviating symptoms.
And when the patient and/or family agrees to
"palliative sedation",
do they fully understand that
they are making a life-ending decision?
Some might be misled by this expression to believe
that these drugs are being given to prevent suffering for a few
days
—after
which the patient will recover.
But choosing terminal coma is the medical decision
that this patient's life is
completely and permanently over.
Nothing further will be attempted to save this
patient from death.
Rather, the dying process has now been set on a downward path,
with no plan and no chance
ever to reverse the dying process.
Increasing
pain-medication is also a valid end-of-life medical
treatment.
And frequently these medications will also shorten the process of
dying.
But under comfort-care, the patient will be awake
from time to time.
The level of symptom-control will be governed by what the patient
wants.
Even tho this use of drugs takes place near the end of life,
comfort-care should never be called "terminal sedation".
Some doctors blur the difference between
comfort-care and terminal sedation.
The change in medical orders can be very gradual:
More morphine is
given.
The patient has less and less
consciousness
until eventually there is no
consciousness at all.
But if the patient will be kept unconscious until death,
this should be clearly acknowledged as a life-ending decision.
Safeguards
for
life-ending decisions should be used, as noted below.
Let it be clear to everyone: This
life is over. Death
is coming.
Here are a few alternative expressions for
induced terminal coma:
"sedation to unconsciousness",
"continuous sedation to unconsciousness",
"keeping the patient asleep until natural death",
"continuous deep sedation",
"total sedation", &
"continuous palliative sedation".
3. WHEN TERMINAL SEDATION
EMERGED IN MEDICAL PRACTICE.
Modern medicine has used terminal sedation since
before the year 2000.
This can be confirmed by noting the dates of articles about terminal
sedation.
One survey in the United Kingdom found that terminal sedation
was used in 16.5 % of all deaths in the years 2007-2008.
The Royal Dutch Medical Association created its guidelines
for terminal sedation in 2005, which were updated and clarified in
2009.
And in 2008 the American Medical Association
Council on Ethical and Judicial Affairs approved this method of dying.
No major shift in thinking either by doctors or
laypersons
was required to accept using drugs to relieve all suffering at
the end of life.
Because doctors understood the observed suffering in their dying
patients,
they compassionately used the means at their disposal
to limit and then to
eliminate all needless and useless suffering.
No changes of law were required.
Doctors already had all the authority needed
to order more sedatives for their dying patients.
Perhaps it was first referred to as "keeping the patient comfortable".
But later, it was acknowledged as keeping the patient unconscious.
By carefully adjusting the sedative drugs used,
the doctors and nurses could be very confident
that the dying patient would never again experience
even one moment of pain or
discomfort.
And they often considered the psychological stress of dying as well:
The patient and the family know that death is coming.
So then the question can be asked:
"Should the patient be awake or asleep during this process of
dying?"
And if no further purposes could be
achieved by being awake,
the choice was made to keep the patient continuously unconscious
until the natural processes of dying had run their course.
Induced terminal coma
lasts only a few days.
4. GETTING
PATIENT AND FAMILY AGREEMENT
FOR INDUCING
COMA.
Once everyone has acknowledge that this patient is
actively dying,
and that there are no further curative treatments that might be tried,
then it is usually no problem to get agreement from everyone involved
that the patient will be better off sleeping thru the last few days
rather than having to awaken occasionally only to suffer more.
Frequently the problem arises earlier in the process,
when the patient and some family members are not ready to 'give up'
on trying yet one more medical treatment
that has some remote possibility of saving the patient.
Because the doctor has seen similar cases before,
he or she might be more ready to accept death than the patient and
family.
So the doctor might be the first person to suggest terminal sedation
as a way of saving the patient from further meaningless suffering.
How does the patient and the family want to handle
this death?
It might take them a few days to accept that death is coming.
But having observed the suffering of the dying patient,
and having been convinced that further attempts at cure are useless,
they might agree that terminal coma is the best way to meet
death.
When terminal coma is the planned pathway
towards death,
then everyone should say good-bye before terminal sedation
begins.
This patient will never have another moment of consciousness.
And from some perspectives, the last moment of consciousness
might be remembered as the last day of this patient's life.
5. THE
CAUSE OF DEATH
IS ALWAYS THE
UNDERLYING MEDICAL CONDITION.
After the death has occurred and been officially
declared,
the doctor in charge will complete the death-certificate,
which will always name the major
cause of death
—perhaps
with some other notes about contributing factors,
such as other diseases or conditions that the patient had.
But almost never will
the certificate of death say anything
about the specific drugs and their amounts used at the end of life.
Such facts of terminal care will be duly recorded in the medical
record,
but there little reason to include such data on the death-certificate.
Everyone who was present for the last few days
will know whether the patient was awake or asleep.
And the decision-makers will know whether induced terminal coma
was ever ordered and perhaps begun.
Statistics collected about the causes of death
will not be changed by the fact of terminal sedation.
Each death was caused by cancer, heart disease,
breathing problems, degenerative conditions, etc.
And the fact that the patient was kept unconscious at the end
is not relevant for keeping statistics of the causes of death.
However, if and when the medical methods of managing
dying
are added
to certificates of death,
then induced terminal coma
might be put on that additional line
for life-ending decisions
or medical methods of
managing dying.
6. SAFEGUARDS FOR CHOOSING
TERMINAL COMA.
Usually the overwhelming reason for inducing
terminal coma
is the fact that this
patient is already actively dying.
And terminal coma is the medical
method of managing dying.
But it will do not harm to list all of the possible safeguards
that might be relevant for any life-ending decisions.
These safeguards can be used as a check-list
by any group of people considering inducing terminal coma
for a particular patient at a particular time.
Which safeguards are most relevant for this dying-process?
Which planning-procedures have already been completed?
Each of the following safeguards is fully explained
on the Internet.
Following this list of 26 recommended safeguards,
each safeguard is specifically applied to inducing terminal coma.
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. UNBEARABLE
SUFFERING
H.
UNBEARABLE
PSYCHOLOGICAL SUFFERING
I.
PALLIATIVE
CARE
TRIAL
J.
INFORMED
CONSENT FROM THE PATIENT
K. REQUESTS
FOR
DEATH
FROM THE PROXIES
L. ENROLLMENT
IN A
HOSPITAL OR HOSPICE
M.
STATEMENTS
FROM
HOSPITAL OR HOSPICE STAFF MEMBERS
N.
STATEMENTS
FROM FAMILY
MEMBERS
AFFIRMING
OR
QUESTIONING CHOOSING DEATH
O.
A
MEMBER
OF THE
CLERGY
APPROVES
OR
QUESTIONS CHOOSING DEATH
P.
RELIGIOUS
OR OTHER MORAL PRINCIPLES
APPLIED
TO THIS
LIFE-ENDING DECISION
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
T. CIVIL
AND
CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH
U. WAITING
PERIODS FOR REFLECTION
V.
OPPORTUNITIES
FOR THE PATIENT TO RESCIND OR POSTPONE
ANY
LIFE-ENDING
DECISIONS
W. PHYSICIANS
REVIEW THE COMPLETE DEATH-PLANNING RECORDS
X. COMPLETE
RECORDING AND SHARING
OF
ALL MATERIAL
FACTS AND OPINIONS
Y. THE
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
Z. THE
DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS
A. ADVANCE
DIRECTIVE
FOR MEDICAL CARE
Did this patient have the foresight to create an
Advance Directive?
If so, does it support the use of terminal sedation?
Is inducing terminal coma explicitly mentioned?
Are there any conditions or limitations that might be relevant?
B.
REQUESTS
FOR
DEATH FROM THE
PATIENT
How deeply is this patient able to participate in
planning death?
Has this patient explicitly asked for death?
Would terminal coma be a reasonable method of managing dying?
C.
PSYCHOLOGICAL
CONSULTANT EVALUATES
THE
PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS
Did this patient
consult a psychological professional?
If so, did the psychologist or psychiatrist agree with the plans for
death?
Will this professional testify that the life-ending decision was
reasonable,
given all of the medical facts and professional recommendations?
D.
PHYSICIAN'S
STATEMENT
OF CONDITION AND PROGNOSIS
The physician's written statement of the patient's
medical situation
will be the most important document created
for the process of authorizing terminal coma.
Does the physician agree that the patient is actively dying?
Is the patient suffering physically and/or psychologically?
Would terminal coma be a wise end-of-life choice?
E.
INDEPENDENT
PHYSICIAN
REVIEWS
THE
CONDITION AND PROGNOSIS
Because choosing death is so final and irrevocable,
a second professional opinion should be sought from another doctor.
Does a specialist agree that this death cannot be avoided?
Does this second doctor endorse terminal coma
as a good medical
method of managing dying?
F.
CERTIFICATION
OF TERMINAL ILLNESS OR INCURABLE CONDITION
Probably separate from the full medical record,
have the doctors issued an official statement
declaring that this patient is likely to die within six months?
G.
UNBEARABLE
SUFFERING
The basic reason for inducing terminal coma
is that the patient will suffer unnecessarily without these drugs.
Does everyone agree it is better to keep the patient unconscious?
H.
UNBEARABLE
PSYCHOLOGICAL SUFFERING
Sometimes the fear of death is worse
than the actual process of dying.
Thus, if this patient would otherwise endure terrible psychological
trauma,
it might be best to give drugs to keep the patient unconscious
until death.
I.
PALLIATIVE
CARE
TRIAL
In almost all cases of inducing terminal coma,
there has been some period of using other drugs
to see if that will alleviate the symptoms sufficiently
to make this a meaningful
process of dying.
But if such efforts do not yield an acceptable level of
existence,
then permanent, continuous, terminal coma might be better.
J.
INFORMED
CONSENT FROM THE PATIENT
Before terminal coma begins,
it is sometimes possible to ask the patient himself or herself
whether he or she wants to be kept
asleep until death.
Has the patient taken sufficient time to consider this alternative?
If so, has the patient given fully-informed agreement
to following this pathway towards death?
K.
REQUESTS
FOR
DEATH
FROM THE PROXIES
And if the patient is already too far gone to give
informed consent,
do the proxies now agree that terminal coma is the best
option?
Do the proxies want the patient kept unconscious until death comes?
L. ENROLLMENT
IN A
HOSPITAL OR HOSPICE
This safeguard has probably already been fulfilled:
When terminal coma becomes a reasonable end-of-life choice,
the patient is already actively dying
under some forms of professional medical care.
Does this hospital or hospice-program have any reasons
to question the choice of terminal coma for this patient?
M.
STATEMENTS
FROM
HOSPITAL OR HOSPICE STAFF MEMBERS
Do the doctors and nurses connected with this
terminal-care setting
have any views about inducing terminal coma for this patient?
Since they have some experience with this method of dying,
do they regard terminal coma as a wise choice for this
patient?
N.
STATEMENTS
FROM FAMILY
MEMBERS
AFFIRMING
OR
QUESTIONING CHOOSING DEATH
Also, family members might be asked for their
written opinions.
Second only to the dying patient,
these are the people who will be most deeply affected
by whatever pathway toward death is chosen—or not chosen.
Do family members understand the full implications of terminal coma?
And do they prefer this method of managing dying
rather than the patient being awake from time to time?
O.
A
MEMBER
OF THE
CLERGY
APPROVES
OR
QUESTIONS CHOOSING DEATH
If the patient and/or family has any connections
with organized religion,
they might ask for a professional opinion from their preferred
religious leader.
Has this clergy-person been brought 'up to speed'
with respect to all the medical facts and professional recommendations?
Once fully-informed, does this minister, priest, rabbi, or other
religious leader
agree that induced terminal coma would be a good pathway towards death?
P.
RELIGIOUS
OR OTHER MORAL PRINCIPLES
APPLIED
TO THIS
LIFE-ENDING DECISION
And if terminal coma seems a new
option for this religious tradition,
has anyone written a statement of principles covering this method of
dying?
Terminal coma will become an ever-more-common end-of-life choice.
Thus, organized religious group might discuss this pathway towards
death
and issue official statements about how to handle terminal coma.
Q.
AN
INSTITUTIONAL
ETHICS COMMITTEE
REVIEWS
THE PLANS FOR DEATH
Each medical institution that takes care of patients
who are dying
will also face the pros and cons of choosing death by terminal coma.
If there is an official medical ethics committee,
have they been consulted about this particular proposed death?
And do they endorse keeping the patient unconscious until
death?
R.
STATEMENTS
FROM
ADVOCATES FOR
DISADVANTAGED GROUPS
IF
INVITED BY
THE PATIENT AND/OR THE PROXIES
If this patient belongs to any group
sometimes disfavored by society,
would it be reasonable to ask some representative of that group
to review the plans for terminal coma at the end of this
patient's life?
If this advocate selected especially to protect a vulnerable patient
also agrees that death under continuous, deep sedation would be wise,
then other members of the same minority group
should be assured that no lower level of medical care was provided
because of the group-identity of this particular dying patient.
S. REVIEW
BY THE
PROSECUTOR (OR OTHER LAWYER)
BEFORE
THE DEATH
TAKES PLACE
If most of the other safeguards have already been
fulfilled,
then it might not be necessary to do an additional legal review.
But if the case is especially complicated
and if there are differences of opinion about inducing terminal coma,
then the full record can be presented to someone well-versed in the
law.
Does this public prosecutor or private attorney agree
that inducing terminal coma is completely reasonable
given all of the medical facts and family opinions?
Such a legal review should assure everyone involved
that there will be no legal complications after this death
occurs.
T. CIVIL
AND
CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH
However, if someone has manipulated the data or
concealed some facts,
then the justice system in that location
should still have the authority to investigate this death by terminal
coma.
If some patient was put to death before it would have been reasonable,
then a crime or a civil violation has
occurred.
And the most appropriate system of justice can then be applied
with the possibility of imposing severe penalties
on anyone who has done anything to harm the dying patient.
U.
WAITING
PERIODS FOR REFLECTION
Because of the many days and months already devoted
to terminal care,
it might not be reasonable to require any additional waiting periods.
But, if it will not make much difference to anyone involved
—for instance, if
the patient has already been in PVS for a few months—
then it will
do no harm to declare a 'time-out for reconsideration'.
Inducing terminal coma will be the last decision made for this
patient.
Has everyone concerned taken enough time to review this
choice?
V.
OPPORTUNITIES
FOR THE PATIENT TO RESCIND OR POSTPONE
ANY
LIFE-ENDING
DECISIONS
When the patient has become a candidate for terminal
coma,
then no one is likely to rescind or overturn this whole process.
But are there reasons to postpone
the
beginning of terminal coma?
Both the patient and others involved in this life-ending decision
can consider what would be the very best time to say 'good
night'.
Or the drugs for inducing terminal coma can be held close at hand,
to be given only if and when some medical catastrophe occurs.
W. PHYSICIANS
REVIEW THE COMPLETE DEATH-PLANNING RECORDS
As a final review before starting terminal coma,
the physician most in charge of this patient's terminal care
could read thru all of the safeguard-documents already created.
Should any aspect of this plan for death be reconsidered?
If all plans point in the same direction,
this physician can issue the
official order to induce terminal coma.
X.
COMPLETE
RECORDING AND SHARING
OF
ALL MATERIAL
FACTS AND OPINIONS
Because ordering terminal coma is a final
life-ending decision,
have all the relevant facts and recommendations been
gathered?
Perhaps one person has taken responsibility
to make certain that everyone who has a right to know
about this process of planning death
has been informed of each step towards death.
If everything has been completely shared beforehand,
there will be no second-guessing after this patient's death.
Y.
THE
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
Philosophically, it is correct to make certain that
the patient
understands the full implications of inducing terminal coma.
But, obviously, if the patient is asleep for the last week of life,
he or she cannot authorize or act to achieve death at the end.
And this safeguard should never prevent
proxies from authorizing
terminal coma
if the patient has already passed the point
of making wise end-of-life
medical choices.
Probably the patient has endorsed this plan for death beforehand.
And now the duly-authorized proxies are responsible
for carrying forward the settled wishes of the patient.
Z.
THE
DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS
Once terminal coma has been selected for this
patient,
then the record-keeping person should complete the process
of gathering all of the records
concerning this life-ending process into
one permanent place
just in case there might ever be (at some future time)
a need to review the decisions that led to this patient's death.
7. FRANCE AVOIDS THE
USUAL RIGHT-TO-DIE CONTROVERSIES
BY
OFFICIALLY AUTHORIZING TERMINAL SEDATION.
France has achieved by a simple new law (2016)
what other countries have struggled with for decades.
With remarkably little public controversy,
the right-to-die might have been achieved for France
simply by endorsing medical
practices already well
established.
French doctors have long been helping their dying
patients
to avoid the last few days of meaningless suffering
by ordering (with the permission of the patient and/or the proxies)
that the dying patient by kept completely unconscious until death
comes.
French law now officially authorizes
"deep, continuous sedation until death".
Probably no new law was actually required,
but it will be reassuring to everyone to know
that French doctors are now officially and legally authorized
to prevent suffering at the end of life by ordering terminal
sedation.
90% of the French people favor this method of
choosing death.
These are the provisions of the new law authorizing terminal sedation:
1. Normal pain-relief has been found not sufficient. (palliative
care
trial)
2. The patient must be terminally
ill
to be granted terminal sedation.
3. The patient must request
terminal sedation.
4. If the patient can no longer request terminal sedation,
it can still be ordered by the physician.
5. If the patient is no longer able to request terminal sedation,
a prior authorization
(such as in an Advance Directive) can be honored.
6. Other provisions of an Advance Directive are enforceable.
7. The physician can also withdraw all medical treatments
and life-support measures.
8. Artifically-provided food and water are defined as medical
treatments.
These can be stopped (or never started)
at the request of the patient and/or the proxies.
The opposition came mainly in the form of
re-labeling:
Those who do not approve of terminal sedation
want to call it "slow euthanasia".
This condemnation depends on the negative connotations of
"euthanasia".
But terminal
coma differs from euthanasia
is these four ways:
(1) Euthanasia causes death immediately.
Induced terminal coma continues for a few days.
(2) Choosing euthanasia means taking the gentle poison only once.
Terminal coma means the flow of anesthetic continues for days.
(3) In euthanasia, the method of dying is the lethal injection or
death pill.
In terminal coma, the underlying cause of death is the medical condition.
(4) The stated purpose of euthanasia is to bring the patient's life to
an end.
Terminal coma is induced to save the patient from further
suffering.
Several near-by European countries already do have
right-to-die laws
that authorize 'euthanasia' and 'physician-assisted suicide'.
But even where these methods of choosing death are legal,
doctors are increasingly turning to terminal sedation
because keeping the patient asleep until death
does not require any
application to a government agency
nor does it require as much paperwork
after the death has taken place.
And terminal coma is sometimes easier for the family than
euthanasia,
because it gives them a few days in which to adjust to the coming death.
Dutch doctors say that terminal sedation is a normal part
of medical care.
Therefore, there are no special requirements for reporting such deaths.
The death-certificate always says that the patient died of natural
causes.
Sedatives used at the end of life are not mentioned on the
death-certificate.
France now has legal authority for
their doctors to do likewise:
As a normal part of medical practice,
they can order whatever levels
of sedation
they find appropriate for each particular dying patient.
The percentage of French deaths using terminal
sedation
was probably about 10% of
all deaths before this new legislation.
And it could easily jump to 20% of all deaths—or
even higher—
now that terminal sedation has become the law of France.
And
some part of any such increase will result from more honest
reporting.
French doctors have been quietly helping to ease the dying process
by giving their dying patients all of the sedatives found necessary.
And now they can extend the practice of inducing terminal coma
to more patients and
acknowledge this method of dying more openly.
See more information about France's right-to-die law:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/RTD-FR.html
8. HOW COMMON IS INDUCED
TERMINAL COMA IN THE USA?
Because terminal sedation is seldom mentioned on
death-certificates,
there is no easy way to gather statistics about the number of deaths
that take place while the patient was kept unconscious by drugs.
The most reasonable way to gather such numbers
would be to ask the people
who were at the bedside
—both
the doctors who were in charge of the dying process
and the laypersons who observed everything.
Another chapter of this book
—Four
Medical
Methods of Managing Dying—
estimates that only 5-10% of all deaths in the USA used terminal coma.
But as the decades unfold, such numbers are certain to rise.
As noted earlier, in the UK in 2007-2008, one study found
that terminal sedation was used in 16.5% of all deaths.
As laypersons learn more about this method of
managing dying,
they will more readily accept this recommendation from their
doctors.
And sometimes the patient and/or the family will ask for terminal coma.
If everyone already agrees that this death cannot be avoided,
then the only remaining question is:
"How shall we manage this
process of dying?"
There is no logical or medical reason why
terminal coma
could not be used in all
managed deaths
—in
hospitals, nursing homes, and even at home.
Terminal coma, probably combined with giving up food and water,
is one of the most obvious choices for avoiding further suffering.
Dying is already a terrible prospect for everyone.
But inducing terminal coma
can
make dying easier.
Created
March 21, 2015; Revised; 3-26-2015; 4-1-2015; 4-2-2015; 4-3-2015;
4-18-2015; 4-23-2015;
5-1-2015; 7-10-2015; 10-8-2015; 10-27-2015; 12-8-2015; 12-23-2015;
9-15-2016;
11-27-2017; 2-20-2018; 7-2-2018; 8-29-2018;
10-12-2018 (change to
induced terminal coma); 3-28-2019; 5-15-2020;
AUTHOR:
James Leonard Park is an advocate of
the right-to-die with very careful safeguards.
His 26 recommended safeguards are applied
to this medical method of managing dying in this chapter.
(See Section 6 above.)
This whole essays is also a chapter of:
How
to Die:
Safeguards for Life-Ending Decisions
And inducing
terminal coma is also included in:
Right-to-Die
Hospice
Could permanent sleep become a good method of dying?
Did you originally think that being drugged-to-death
was intolerable?
Would you now approve sleeping-into-death as a good method of dying?
Did you previously believe that giving drugs to aid in dying was not
legal?
When the most relevant safeguards are fulfilled,
is continuous sedation an appropriate pathway towards death?
Would you approve terminal coma for someone you love who is dying?
Would you choose terminal coma for yourself at the end of your
life?
TERMINAL
SEDATION LINKS
"Responding to Intractable Terminal Suffering:
The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids"
by Timothy E. Quill, MD & Ira R. Byock, MD
Annals of Internal Medicine, Volume 132, Number 5, 7 March 2000, p.
408-414. https://www.acponline.org/system/files/documents/clinical_information/resources/end_of_life_care/intractable_suffering.pdf
"Four Differences between 'Euthanasia' and Induced Terminal Coma"
https://www.facebook.com/permalink.php?story_fbid=2178596112170797&id=105267556170340
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/COMA&EU.html
"Putting
the Right-to-Die into Health-Care
Laws and Regulations:
Authorized
Methods of Dying,
Safeguards for
Life-Ending Decisions"
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-HCLAWS.html
This
essay includes terminal coma
as one of five possible methods of dying.
"Suicide-Model Right-to-Die vs. Medical Model End-of-Life
Care"
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-SM-MM.html
Inducing terminal coma is one
of the medical methods of managing dying
when the choosing death is affirmed as a normal part of medical
practice.
Future books and articles will be published.
The Library of Congress subject heading is: TERMINAL SEDATION.
This is also a good search-term for the Internet.
Closely
related
chapters and on-line essays:
Four
Medical
Methods of Managing Dying
Methods
of
Choosing Death in a Right-to-Die Hospice
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
The
One-Month-Less Club:
Live Well Now, Omit the Last Month
Choosing
Your Date of Death:
How to Achieve a Timely Death
—Not
too Soon,
Not too Late
Losing the Marks of Personhood:
Discussing Degrees of Mental Decline
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"?
Further
Reading:
Best
Books on Terminal Care (from the Doctor's Point of View)
Books
on
Hospice Care
Terminal
Medical Care from the Consumer's Point of View
Books
on Advance
Directives for Medical Care
Best
Books on Voluntary Death
Best
Books on Preparing for Death
Books
on Terminal Care
Medical
Methods
of Managing Dying
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.
Go to the Book
Review Index
to discover 350 reviews
organized into 60 bibliographies.
Return to the DEATH
page.
Go to the Medical
Ethics
index page.
Read other free
books
on the Internet.
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