DO
WE ALREADY HAVE THE RIGHT-TO-DIE?
MEDICAL
METHODS OF MANAGING DYING
SYNOPSIS:
When we know we are dying,
we often want to cut the process short.
Our first impulse might be to seek drugs
that will bring death quickly and easily.
But if we explore the medical options for terminal
care,
we might choose some other pathway.
Perhaps the freedom to choose a good pathway towards death
has been waiting for us all along.
OUTLINE:
FOUR COMMON METHODS OF MANAGING DYING
1. Providing Comfort-Care Only
2. Inducing Terminal Coma
3. Ending all Curative Medical Treatments and Life-Supports
4. Giving Up Water
COMBINING
THESE METHODS OF MANAGING DYING
5. Using Gentle Poison
Why Are the Standard Ways
of Managing
Dying so Little Known?
How
Often is Each of these
Medical
Methods of Managing Dying Used?
The
Complete Picture of Terminal Care
Shows We
Already Have the
Right-to-Die.
RESULT:
If this chapter fulfills its promise,
some advocates of the right-to-die
will discover that we already have the freedom
to choose any combination of four medical methods of managing dying.
This chapter will illustrate how patients with specific terminal
conditions
can achieve a peaceful and pain-free death
with the help of the medical profession.
And even where gentle poison is authorized,
most dying patients still use the standard ways to manage dying.
DO
WE ALREADY HAVE THE RIGHT-TO-DIE?
MEDICAL
METHODS OF MANAGING DYING
by
James Leonard Park
When we learn that we are dying,
we might first wish for an instant death.
We want to "get it over with" as quickly as possible.
We might begin to make plans to go some place
where a quick and painless death is available.
Oregon and Switzerland come to mind.
We might want to take a pill or drink a liquid
that will immediately end our lives.
The so-called "right-to-die" means the freedom
to choose a gentle poison that will bring death today.
However, when we think a bit more clearly,
we might discover that other methods of dying
have even more benefits
and less downside.
The medical profession (especially terminal care)
has not well explained the following methods of managing dying.
When we know the full range of end-of-life medical care,
we might select some other pathway
than instant death by gentle poison.
1. Providing Comfort-Care
Only
It is already fully legal everywhere in the
developed world
for us to choose palliative
care for whatever remains of our lives.
Whatever symptoms we experience as we approach death,
comfort-care can provide drugs to limit our suffering.
Perhaps we have discovered that we are dying of
cancer.
The doctors tell us that we have only a few more weeks to live.
The cancer cells have spread to so many parts of our bodies
that there is zero chance that they can all be eradicated,
even with the most advanced methods of treating cancer.
After trying many methods of cure,
we become convinced that nothing can save us from death.
Then we might want death to come sooner
rather than later.
When we know we are inevitably dying,
the choice is not between dying
or being saved from death
but between dying now
or dying later.
Once we have been certified to be terminally ill,
we can apply for hospice care.
Then medical professionals will handle everything
needed for the last few days or weeks of life.
The "only" part of "Comfort-Care Only"
means that the curative
efforts of medicine have ended.
There will be no more chemotherapy, surgery, or radiation.
Only those forms of medical support that are needed
for our comfort and well-being will continue.
And sometimes just giving up the aggressive curative
treatments
is a relief all by itself.
The medical methods that were being applied to our bodies
in the hope of killing the cancer were making us miserable.
We should ask our doctors how long we are likely to
survive
under this new form of medical care: comfort only.
Depending on the specific form of cancer,
it might be only a few days, a couple of weeks, or much longer.
The remaining time should be used for the best
purposes.
We might even draw up a list
of the things we want to do before death takes us.
This list should set priorities,
just in case we do not live long enough to do all of them.
We can put the most important
things first.
Hospice care can still be a planned process of
dying,
but it will take a few more days than death by gentle poison.
And we as the patient will decide just what forms of medical support
we want in the last days of our lives.
If our symptoms of dying become too terrible,
we can ask that our drugs be increased
so that we spend less and less time awake.
And if every moment awake creates only more suffering,
then we can request terminal
coma,
which will keep us permanently unconscious
for whatever remains of the process of dying.
Hospice care does not mean compulsory suffering.
We choose exactly how much comfort we want,
based on our first experiences with symptom-control.
Are we satisfied with this qualify of life?
Here is a full chapter devoted to exploring
comfort-care
as a good pathway towards death:
1.
Comfort-Care Only:
Easing the Passage into Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-INCRE.html
2. Inducing Terminal
Coma
If we have ever had surgery,
we know that anesthetics can keep us
in such a deep state of unconsciousness
that we do not feel a thing,
even when the deepest cutting is required.
We have never been that deeply asleep since we were born.
A medically-induced coma will be as deep as general
anesthesia,
but it will be maintained until death comes from natural causes.
This medical method of managing dying
will keep the dying patient completely
and permanently unconscious
for the last few days of the patient's life.
This method of dying is also known as "terminal sedation".
Whatever good-byes might still be possible
should be completed before
terminal coma begins.
This patient will never have another conscious thought or feeling.
Interpersonal communication is over.
Heart
failure might be a fatal condition
for which terminal coma would be appropriate.
The doctors conclude that this patient cannot be saved.
The heart-beat is becoming weaker and weaker.
In a few days, this heart will completely stop.
If every conscious moment for this patient
feels like a hopeless gasping for air
unless 100% oxygen is provided,
everyone might agree to end all suffering
by keeping this patient in a
coma until death comes.
And if all forms of life-support are also
discontinued,
the doctors can predict with some accuracy
exactly how long this period of terminal coma will last.
A week or ten days is usually the maximum.
And very often, death comes sooner
rather than later.
When compared with instant death by gentle poison,
inducing terminal coma does take a few more days.
But when we remember the waiting
periods required for gentle poison,
inducing terminal coma might
actually last fewer days.
And those additional days will be spend in absolute peace
rather than in the radical
suffering
that sometimes accompanies waiting for gentle poison.
The same safeguards should be used for either method
of dying.
Everyone must be completely convinced that death is inevitable.
And the particular pathway towards death will establish
at least an approximate date
of death.
Death by
gentle poison can be scheduled some days in
advance.
If there is a 10 or 15-day waiting period
before this form of the right-to-die can be achieved,
everyone concerned can be informed of the exact date of death.
The date and time when the gentle poison will be given
can be shared with everyone concerned
—the
patient, the family, the friends,
& whatever other medical team is providing terminal care.
However, following the pathway of terminal coma,
only an approximate date of
death will be established.
Sometimes having a slightly-delayed death
will have some benefits for the family members
who will have those days to adjust themselves
to the coming death.
And because death is absolutely certain,
they can begin the planning for the funeral or memorial service
and for other changes that will follow this patient's death.
When terminal coma is seriously considered
as a possible pathway towards death,
what factors would make it better
or worse than gentle
poison?
Because there is no required waiting period for beginning the coma,
there might be fewer days of
suffering
than when waiting for death by gentle poison.
Here is a chapter on dying while in an induced
terminal coma:
2. Induced
Terminal Coma:
Dying in Your Sleep—Guaranteed
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-TERMS.html
3. Ending all Curative
Medical Treatments
and
Life-Supports
Probably some methods of curing the patient
have already been tried and discontinued.
But when all methods of cure have proven useless,
then they can be explicitly withdrawn.
The patient-and-family should know
when medical methods of cure have failed.
Maintaining a medical show
of curative treatment
does no good for anyone.
Sometimes both the laypersons and the professionals
know that such efforts are completely futile.
Also, if there are any life-supports still in use,
their purpose should be evaluated:
Is there any reasonable hope that this patient will survive?
If not, should the life-support systems all be ended?
Sometimes ending of life-supports will bring death
immediately.
If a respirator was keeping the patient alive,
then death might come immediately after removing it.
(And deep sedation might be used to prevent any suffering
when the life-supports are withdrawn or turned off.)
In many terminal patients,
several drugs were being used to keep this patient alive.
Some were intended to cure the disease or condition.
But other drugs were needed to support vital functions.
Without these chemical supports, the patient will soon die.
Once again, the doctors who have been using
these methods of cure and support
can explain with some accuracy
just how long the patient will live
after this final change in medical orders
has been implemented.
If the patient is dying from wide-spread infection,
then giving up curative treatments and life-supports
would mean ending the various drugs
that were intended to kill the microbes that are causing death.
And the adverse side-effects of these drugs will also disappear.
Medical science could not save this patient from death.
But, as said before, comfort-drugs can be given
to ease the process of dying from an overwhelming infection.
Here is a chapter about managing dying
by ending curative
treatments and life-supports:
3. Pulling the
Plug:
A Paradigm for Life-Ending Decisions
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-PLUG.html
4. Giving Up Water
Ending hydration is often an automatic part of
terminal coma.
Giving up anything supplied by tubes
might be included when all
life-supports are disconnected.
But in some cases, ending hydration is a separate
life-ending choice.
Giving up water might be used
when there are no other obvious means of life-support.
Perhaps the patient has carefully determined
that his or her life has been completed
even if the collection of medical problems
might not yet constitute 'terminal illness'.
Alzheimer's
disease is a common condition
in which withdrawing all tubes
is the preferred method of managing dying.
When the patient has forgotten how to eat normally,
sometimes a feeding-tube is used to support life.
But there will probably come some point in mental decline
when all forms of life-support have become futile and useless.
Would this patient want to be kept 'alive'
after his or her mind was gone?
As with induced terminal coma,
giving up water will result in death within a few days.
The exact length of the process of dying by dehydration
will depend on the amount of water stored in the patient's body.
If all possible meanings have already been achieved,
if this patient is fully ready to die,
then everyone can cooperate
to make this death as peaceful and painless as possible.
The doctors and nurses will provide effective ways
of dealing with any unpleasant effects of this pathway towards death.
And this method of choosing a pain-free death has
two chapters:
4. VDD:
Why Giving Up Water is Better than
other Means of Voluntary Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-VD-H2.html
Voluntary
Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-VDD-SG.html
COMBINING THESE METHODS OF
MANAGING DYING
These four medical methods of managing dying
can be used in any
combination.
If the cancer was in the digestive tract,
then giving up everything by mouth might have been the first change.
And terminal coma might have been held in reserve
just in case the suffering became too great.
It is not absolutely necessary to specify
which method of managing dying was the most important.
The cause of death will be cancer, heart disease, or other organ failure
not any of the adjustments of medical care at the end.
And because these methods of easing the passage into
death
are now so common in terminal medical care,
no special authorizations or approvals are required.
Occasionally these methods of facilitating dying
have been mentioned in written laws.
But such references have always been positive:
These four methods of helping patients to meet death
are completely within the law
and permitted by medical
ethics.
Doctors already possess all of the powers needed
to authorize these four methods of managing dying
when they have obtained informed consent
from the patient and/or the proxies.
5. Using Gentle Poison
In some places on our planet,
a shortest-possible method of dying has been legalized.
The doctor can prescribe a lethal
substance
that has no other purpose than to cause immediate death.
In some cases, the doctor injects the gentle poison.
In other situations, the patient eats or drinks the deadly poison.
Laws that allow this last method of achieving death
usually establish that the underlying disease or condition
shall be the stated "cause of death" on the death-certificate.
The final life-ending decision was the method of dying,
not the cause of death.
Of course, this would also hold for all other methods of dying:
1. palliative care to keep the patient comfortable on the way to death.
2. terminal coma to keep the patient asleep during the
dying-process.
3. ending curative medical treatments and life-supports.
4. giving up water.
A cause of death where gentle poison might be
appropriate
would be ALS
(Amyotropic Lateral Sclerosis)
or more broadly Motor Neuron Disease (MND).
This is a slow, degeneration of the nervous system,
which will ultimately cause death.
The stages of the slow decline into death are well documented.
And precisely because the process is so slow,
the patient has plenty of time to decide just how far to go
before deciding that death
now would be better than death later.
The same considerations would also apply
to other slow, degenerative diseases, such as Parkinson's disease.
Because the process of dying might become so terrible,
the patient should be permitted a shorter pathway towards
death
---including immediate death by gentle poison on a specific date.
Perhaps some laws about recording the causes of
death
will add a line to the
certificate of death
where (in addition to the underlying cause of death)
the doctor will explain what life-ending decisions were made
and what methods of managing dying were used.
A link at
the end of this chapter explains this new line for the
death-certificate.
Read more about this fastest medical method of
dying:
5. Gentle Poison:
The Demand for Quick Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-GEN-P.html
Why are the Standard Ways
of Managing
Dying So Little Known?
The reason that many people faced with a terminal
diagnosis
think first of going to Switzerland or Oregon to take gentle poison
is that they do not know how
dying is usually handled.
Doctors have not explained the processes of managing dying,
which can achieve the same desired results
—often
without many of the problems, delays, & expenses
associated with death by gentle poison.
In some places, the chemicals frequently used for
the right-to-die
have become very expensive
---occasionally thousands of dollars for the needed dose.
This could become another factor to consider
when choosing the best pathway towards death.
The older medical methods of managing dying
simply do not cost as much
---even given that a few more days of comfort-care will be provided.
If we understand all our end-of-life options,
most of us will have a well-managed process of dying.
And we might find some combination of the standard methods
to be just as beneficial as death-by-gentle-poison.
How Often is Each of these
Medical
Methods of Dying Used?
In order to get a full picture of organized methods
of dying,
we must include two other ways of dying:
accidental death and dying despite medical care.
A. Unmanaged Dying (20% of all deaths in the USA).
This includes all sudden, unexpected, or violent
deaths
that take place outside of medical institutions
—at
home, on the road, at work, during vacations.
Car and plane crashes, fire, irrational suicide, murder,
heart-attack, stroke, sudden bleeding, burst blood vessel, etc.
B. Dying with Medical Care (35-45% of all deaths).
Most hospital deaths would be included in this
category:
during surgery or in the recovery room, in the ICU,
receiving medical care with the honest hope of recovery.
This is the largest single category of deaths in America.
1. Comfort-Care Only (20-30% of all deaths).
When medical care cannot cure the patient,
supportive and palliative care will nevertheless be provided.
Hospice care might be the best example of comfort-care.
The caregivers are no longer trying to prevent death.
Rather they are trying to manage
the symptoms of dying.
2. Induced terminal coma (5-10% of all deaths).
The doctor orders a continuous stream of drugs
to keep the patient completely
and permanently asleep
for whatever remains of the process of dying.
This method of dying is usually combined with other methods,
such as turning off the life-supports.
3. Ending Curative Treatments and Life-Supports (5-10% of all deaths).
When medical care can no longer benefit the patient,
the doctors recommend ending efforts to save the patient from
death.
If there are any life-supporting machines or drugs in use,
these can be disconnected and discontinued.
4. Giving Up Water (?% of all deaths).
Because this method of dying is usually combined
with others,
it is hard to decide which deaths to include here.
Water and other fluids are usually part of comfort-care.
But when death is inevitable,
everyone concerned might agree
that it would be best to give up all fluids
when the other forms of life-support are discontinued.
5. Taking Gentle Poison (1% of all deaths where permitted).
Even tho this quickest method of dying
might be the first thought of many patients
when they newly learn that they are dying,
as a matter of actual terminal care,
only a few people out of a thousand dying patients
choose gentle poison as their method of dying.
The Complete Picture of
Terminal Care
Shows We
Already Have the
Right-to-Die.
Until more precise numbers are collected
using these categories (or some other classification)
we will say that about half
of all deaths were managed.
The other half of all persons who are now
dead
(having died in the last few years in the USA)
died without medical care (A above)
or were receiving active medical care at the end (B).
Managed dying took these forms:
comfort-care (1),
terminal coma (2),
ending medical treatments and life-supports (3),
giving up water (4),
or using gentle poison (5).
Thus, as it turns out,
the first impulse of the newly-diagnosed patient
to ask for quick death by gentle poison
is probably the least used
of all of the methods of managing dying.
With a bit more time to think about their terminal options,
most choose some combination of methods
that does not include
using poison to cause immediate death.
Another chapter discussing end-of-life decisions
also suggests that about half of all deaths in America
now include a meaningful element of choice:
One Million Chosen Deaths Per Year?
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-1MILL.html
If this is what we mean by the "right-to-die",
then in all places where modern medicine is practiced,
the right-to-die has already been realized:
If we do not die in an unexpected accident,
and if we cannot be cured by modern medical science,
then we still have a reasonable
set of options
for receiving terminal medical care.
AUTHOR:
James Leonard Park is an advocate of the right-to-die with
careful safeguards.
The chapter above was one of the last written for his largest book:
How
to Die: Safeguards for Life-Ending Decisions.
This chapter includes the following links
to detailed
explanations of each
medical
method of managing dying
(MMMD).
Here they are again:
1. Comfort-Care Only:
Easing the Passage into Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-INCRE.html
2. Induced Terminal Coma:
Dying in Your Sleep—Guaranteed
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-TERMS.html
3. Pulling the Plug:
A Paradigm for Life-Ending Decisions
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-PLUG.html
4. VDD:
Why Giving Up Water is Better than
other Means of Voluntary Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-VD-H2.html
4.
Voluntary
Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-VDD-SG.html
5. Gentle Poison:
The Demand for Quick Death
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-GEN-P.html
These Medical Methods of Managing Dying (MMMD)
are also discussed
in the context of a hospice service
that embraces all legal,
doctor-approved methods of dying:
Methods of
Managing Dying
in a Right-to-Die Hospice
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/METHODS.html
DEATH-CERTIFICATES
SHOULD INCLUDE
METHODS OF DYING OR LIFE-ENDING DECISIONS
As modern medical care acknowledges more clearly
than ever before
that we are applying these medical methods of managing dying,
certificates of death might be expanded to include a new line for
life-ending decisions
or medical methods of
managing dying:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/DC-LED.html
Further reading:
Five
Medical Methods of Managing Dying
This op-ed article presents the same five methods of dying
—in a much shorter form.
Created
August, 2017; Revised 9-1-2017; 9-19-2017; 10-28-2017; 12-14-2017;
r
3-7-2018; 3-29-2018; 6-21-2018; 10-11-2018; 11-28-2019; 8-14-2020;