Legislators creating new health-care laws, rules, & regulations
for anywhere on the planet Earth are invited to adapt
the following provisions for their own jurisdictions.

FIVE MEDICAL METHODS OF MANAGING DYING
            CAN BE OFFICIALLY AUTHORIZED

    When all five methods of managing dying approved by doctors
are explicitly written into the health-care law of any jurisdiction,
then patients and their doctors can choose any combination
that fits any particular patient and family.

    The new end-of-life medical care act
can officially and legally authorize dying patients and their families
to choose the best pathway towards death,
using the most appropriate of these 5 methods of managing dying.
(Each method is linked to more information on the Internet.)

1. PROVIDING COMFORT-CARE ONLY

    When the patient is already receiving pain-meds from the doctor,
the doctor can order an increase in these symptom-controlling methods
with an explicit awareness that giving more drugs
will probably shorten the process of dying. 

    Adjusting the levels of pain-killers
is already within the normal practice of medicine everywhere. 
And professional standards of terminal medical care
establish the reasonable limits for all forms of comfort-care.

    This medical method of managing dying
should not be confused with giving a intentional overdose of drugs
with the purpose of causing immediate death.
Immediate death by gentle poison is approved method 5, below.

2. INDUCING TERMINAL COMA

    If the patient's symptoms cannot be satisfactorily controlled
by increasing the pain-medications already in use,
then the patient (and/or the proxies) and the doctors
can select another medical method of managing this patient's dying
—continuous, deep sedation until death comes from natural causes.

    Drugs will be given (and adjust as needed)
to guarantee that this patient will be kept completely unconscious
while the rest of the process of dying unfolds as expected. 

    As with other methods of managing the process of dying
(such as increasing pain-medication and disconnecting life-supports),
the cause of death will be recorded as the underlying disease or condition.

3. ENDING CURATIVE TREATMENTS AND LIFE-SUPPORTS

    Also completely within the normal practice of medical care,
the patient and/or the proxies can agree with the doctors
to discontinue whatever medical supports are keeping the patient alive.

    As medical technology becomes a common part of terminal care,
it will also become more common for life to end
when the various systems of supporting vital functions
are disconnected or discontinued because they are doing no good.

4. WITHDRAWING WATER

    Often one of the forms of life-support was a feeding-tube,
which was keeping the patient alive by artificial nutrition and hydration.
When other life-supports are switched off,
food and water provided by any method
are usually also discontinued. 
The patient will not benefit from having more food and fluid.

    But this way of managing dying can also be authorized
when there are no other major life-supports in place.
And here, as with any other medical methods of managing dying,
careful safeguards must be fulfilled
to make certain that giving up fluids is a wise way to manage dying.

5. USING GENTLE POISON

    The newest authorized medical method of managing dying
(beyond what was already common in modern medical care)
will allow a physician to prescribe lethal chemicals
with the explicit purpose
of granting the patient a speedy and painless death. 

    When this method of dying is the primary means
by which a patient's life will come to an end,
then the others methods of dying become irrelevant.
But the other methods of getting ready for death
might have been chosen as preparation for this final act.
For example, food and water might have been stopped some days before
because they only caused the patient to suffer more deeply. 
Also, the patient might be unconscious
as the result of drugs already given as part of the terminal care.

    Either the patient himself or herself or the proxies for this patient
can authorize this shortest medical method of dying.

    The specific method of administration of this fatal dose of drugs
will depend on the exact situation of the patient at the end of life.
Such details might (or might not) be specified in any new right-to-die law.
The safeguards should mainly ensure a wise life-ending decision.
Then the particular methods of dying will not be as important
as achieving the desired, planned, & authorized result
—immediate, pain-free death for this patient.

EIGHTEEN BEST SAFEGUARDS FOR LIFE-ENDING DECISIONS

    The core of any new end-of-life medical care act
authorizing the named medical methods of dying
will be a set of careful safeguard-procedures
to be fulfilled by the patient, the family, & the doctors
before the plans for death go forward. 

    All right-to-die laws do have implicit and explicit safeguards,
but a major problem with the earlier laws
is that they always scatter the safeguards thru-out the body of the law.
This means that people attempting to follow the law
must read the whole law (or some organized summary of the law)
in order to discover if they have fulfilled each and every safeguard
intended by the law-makers when they authorized
the specified medical methods of managing dying.

    Because several different people will be consulted
in making this life-ending decision,
we should not expect them all to read and sign
the same statement of fulfilled safeguards.

    The safeguards should all be stated and explained
in one easy-to-find section of the right-to-die law. 
These safeguards should be named and numbered (or lettered)
so that a check-list can be created to make certain
that all these important documents have been completed and recorded. 

    Each jurisdiction on the planet Earth will probably select
a slightly different set of safeguards for life-ending decisions.

    The following list of possible safeguards
is organized beginning with the most important.
Jurisdictions that wish to have a very careful system
for authorizing life-ending choices
will incorporate all of these suggested safeguards
—and they might even create a few additional safeguards. 
Places that feel less need for details
will select from the first few safeguards.

    In your place on the Earth,
which safeguards would be the most useful
for the purpose of preventing irrational suicide
and other forms of premature death?

    Because these safeguards are concerned with health-care
rather than criminal law,
safeguards establishing punishments for outlawed behavior
can be included in new criminal laws.
If and when any criminal laws about 'assisting suicide'
are repealed or replaced by more complete laws
explaining more fully what behavior is prohibited,
other safeguards that look more like prohibiting murder
could be put into that criminal code.
Here is a draft-law to prevent CAUSING PREMATURE DEATH.

    The following safeguards have been selected
from the more complete list of safeguards for life-ending decisions
included in How to Die: Safeguards for Life-Ending Decisions.
And they retain their letters from that list of 26 recommended safeguards.
Each is linked to a complete explanation on the Internet.

    Safeguards for making life-ending decisions
should be written in soft ways
so that patients, their families, & their doctors
will not first think of ways to avoid or ignore the safeguards.
Governments should not close the gate and establish gatekeepers
in order to control end-of-life medical decisions.
This will only make the patients and their doctors angry at government.

    Likewise, safeguards should not give exclusive power to doctors
to say "no" to patients' requests for help in dying.

    Rather, the safeguards should function as creative ways
to empower the decision-makers to separate
premature death from death at the right time. 
End-of-life situations that were unclear or uncertain initially
can achieve consensus among the deciders
by the process of discussing the following safeguards.

---

A. ADVANCE DIRECTIVE FOR MEDICAL CARE

    A written statement explaining the patient's philosophy of life and death
is probably the most basic document for making end-of-life decisions.
Life belongs to each individual patient.
His or her settled values should shape all medical decisions.

    For an overview of what to include in a comprehensive Advance Directive,
see Advance Directives for Medical Care: 24 Important Questions to Answer.

    Once the patient has created an Advance Directive for Medical Care,
he or she will share the Advance Directive with significant others
—especially those chosen as medical proxies.
And they should create brief statements
expressing their agreement with the Advance Directive
and (if they are proxies) their commitment to carry forward
the settled values of the patient.

B. REQUESTS FOR DEATH FROM THE PATIENT

    The patient owns his or her own life and death.
Whenever the patient is still capable of making medical decisions,
any and all serious requests for death should be recorded,
stating the date, time, circumstances, & witnesses.
The patient should also explain why he or she thinks
death at the chosen time would be better than death at some later time.
Such requests for death might lead to creative discussions
among all the people concerned with this patient's life and death.

    If the patient is no longer capable of making medical decisions,
the duly-authorized proxies then have the power and responsibility
to make any reasonable requests for death on behalf of their patient.
See Safeguard K below: Requests for Death from the Proxies.

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

    If there is any doubt about the patient's
mental capacities to make medical choices
—including any decisions that will terminate his or her life—
then the patient's wish for death should be evaluated
by a licensed psychologist or psychiatrist.

D. PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

    The most important document created by a medical professional
will be a summary of the medical facts and future of this patient.
In order to avoid any confusion, ambiguity, or misunderstanding,
this statement should be put into writing
as well as explained to the satisfaction of those who must decide.

E. INDEPENDENT PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS

    Whenever making life-or-death decisions,
it is always wise to seek a second—independent—professional opinion.
This second recommendation might be sought from a specialist
in the disease or condition from which the patient is possibly dying.
If there are differences in these professional evaluations,
any such uncertainties should be resolved by further investigation
before the plans for death proceed.

F. CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE CONDITION

    Even tho the patient need not be in a terminal condition to request death,
if the disease or condition is likely to lead to death,
the same physicians who have written
the full statements of the patient's condition and prognosis
might also create a separate document to certify terminal illness
if the patient is likely to die within the next 6 months.
Or such certification could be included in the doctors' other statements.
Certification of terminal illness should specify
whether the projected period of survival includes life-supports or not.

G. UNBEARABLE SUFFERING

    An important question for any life-ending decision
is whether the patient is suffering in some way that cannot be relieved
and which the patient finds intolerable.
Such physical suffering can be explained and documented
by the doctors who have been treating the suffering.

H. UNBEARABLE PSYCHOLOGICAL SUFFERING

    The patient might also be suffering emotionally.
Only the patient can ultimately decide whether such suffering is intolerable.
But professional efforts to alleviate the mental suffering
should also be documented.
Psychological suffering can be evaluated by both family and doctors.

    And if the psychological suffering is so great
as to make the patient incapable of making wise medical decisions,
then the power to decide passes to the authorized proxies.
The proxies will make any life-ending decisions:
Is death now wiser than death later?

I. PALLIATIVE CARE TRIAL

    The actual application of comfort-care
by medical professionals well trained in the care of the dying
will help to decide which is the wisest course of action.
Sometimes physical and psychological suffering can be so reduced
that the patient and/or proxies no longer believe
that death is the best choice at this time.

    However, in some obvious cases, palliative care would be useless.
But at least the patient and/or proxies should be
fully informed about the benefits of palliative care
and even consult a specialist in controlling suffering at the end of life.

J. INFORMED CONSENT FROM THE PATIENT

    The patient must have full information about his or her condition
and all the possible medical treatments that still remain open.
When the patient has received and understood the medical statements
concerning his or her medical condition and likely future,
the patient is empowered to make wise end-of-life choices.

K. REQUESTS FOR DEATH FROM THE PROXIES

    If the patient can no longer make meaningful medical decisions,
then the decision-making power shifts to the proxies,
who have been carefully selected by the patient
when the patient was still fully able to make all medical choices.

    The proxies shall carefully consider all of the medical facts,
taking into account the opinions of everyone legitimately concerned.
Then the proxies can decide to make requests for death
just as such requests could once be made by the patient.

L. ENROLLMENT IN A HOSPITAL OR HOSPICE

    If the patient is being treated in a hospital
or receiving terminal care in a hospice program,
any such medical institution will keep careful records
of all discussions and decisions regarding the care of the patient
—including all explorations of end-of-life choices.
Terminal-care professionals deal with life-ending decisions frequently.
They will not support a premature death.

M. STATEMENTS FROM HOSPITAL OR HOSPICE STAFF MEMBERS

    The nurses, doctors, & volunteers who know the patient well
can also create statements about their discussions
with the patient about end-of-life choices.
Do those who see the patient daily support the life-ending decision?

N. STATEMENTS FROM FAMILY MEMBERS
            AFFIRMING OR QUESTIONING CHOOSING DEATH

   Other persons who have known the patient for some time
either agree with the life-ending decision
or question the wisdom of ending the patient's life now.
Even tho these significant other persons might not be directly involved
in the process of making any life-ending decisions
and they will not be responsible for carrying out any terminal choices,
they know of the plans for death well in advance.
And they create written statements either affirming the choice of death
or questioning the wisdom of the end-of-life plans.
What are their considered opinions about the proposed death?

Q. AN INSTITUTIONAL ETHICS COMMITTEE
            REVIEWS THE PLANS FOR DEATH

    An ethics committee of the institution providing terminal care
reviews all of the documents created for the death-planning process
and approves or questions any life-ending decisions.
The ethics committee should meet with the patient and/or the proxies.
If there is no ethics committee,
a private ethical consultant can review the plans for death.

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

   If any patient worries about discrimination
because of membership in a disfavored group,
advocates can be selected from that identity-group
to review the death-planning documents
to make sure that no discrimination has taken place
because of the group-identity of the patient.
Adding any such statements to the death-planning record
will assure others who are not as close to the patient
that the life-ending decision was as free as possible from discrimination
and that the patient received terminal care independent of group-identity.

U. WAITING PERIODS FOR REFLECTION

    Appropriate periods for further reflection are needed
between the time when the first life-ending decision is made
and when the final life-ending act is performed:
(a) one week for the withdrawal of life-support systems,
(b) one year for a voluntary death, or
(c) six months for a merciful death.
These waiting periods may be adjusted when adequately explained
by the special circumstances of the specific patient.
Spreading the end-of-life discussions over significant periods of time
encourages all concerned to re-think their previous decisions.

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

    If the patient has already begun the death-planning process,
ample opportunities should be provided
for the patient to change his or her mind.
The people offering these opportunities should document
that the patient had several occasions to change the plans for death.
Does the patient decline each opportunity to change course
and reaffirm his or her determination to choose death?