COMFORT-CARE
ONLY:
EASING THE PASSAGE INTO DEATH
SYNOPSIS:
Using drugs to control symptoms
is a
very common medical method of managing dying.
In advanced
countrieswith
modern medical care
20-30%
of all deaths are accompanied by the careful use of drugs.
Sometimes without noting the transition,
medical care at the end
of life shifts
towards comfort-care.
Earlier treatments were intended to cure the patient.
But when it is
no longer possible to return
the patient to ordinary life,
then
the purpose of continuing medical attention
becomes easing
the passage into death.
OUTLINE:
1.
DRUGS FOR ACUTE MEDICAL PROBLEMS
2. DRUGS FOR CHRONIC
MEDICAL PROBLEMS
3. DRUGS AS PART OF TERMINAL MEDICAL
CARE
4. HOSPICE CAREMOVING
FROM CURE TO COMFORT
5. WHEN COMFORT-CARE-ONLY
IS A LIFE-ENDING DECISION
6.
SAFEGUARDS FOR INCREASING PAIN-MEDICATION
AS A METHOD OF
MANAGING DYING
7.
COULD THE PAIN-MEDICATION CAUSE PERMANENT SLEEP?
RESULT:
We might begin reading this
chapter
with a weak grasp of how drugs might be used at the end of life.
Perhaps we believe that health-care laws and medical ethics
prevent doctors from prescribing 'too much' of any drug.
But after reading 26 different safeguards
to prevent any mistakes and possible abuses
related to treating the symptoms of dying,
will we embrace the option called "comfort-care only"?
COMFORT-CARE
ONLY:
EASING THE PASSAGE INTO DEATH
by James Leonard Park
Modern medical care means that most of us will die in hospitals
or
maybe in nursing homes or other long-term care institutions.
Hospitals were created to care for patients with acute medical
problems
broken
bones, gun-shot wounds, heart-attacks, or problems with cancer.
Comfort-care might take place in some other settingeven at home.
1.
DRUGS FOR ACUTE MEDICAL PROBLEMS
The first phase of any acute medical care
almost always includes
some drugs intended to cure the disease or problem.
Antibiotics will ward-off or clear-up any
infections that might be present.
Blood-thinners will dissolve
blood-clots in the heart or brain.
Cancer-fighting drugs will
attempt to kill off the harmful cancer cells.
And alongside all of these chemical means of curing the disease
we
will also be given drugs to help us feel better.
Pain is
nature's way of letting us know that something has gone wrong.
But
once we notice the problem and take corrective action,
pain is no
longer helpful.
Thus, our doctors might evaluate the medical
problem by asking what hurts.
And then they might prescribe
pain-killing drugs to prevent further pain.
"Pain-killing drugs" should be expanded to include all
medications
intended to deal with any symptoms we might
be suffering:
Do we feel short-of-breath?
Is our heart
beating too fast or too slow?
Are we going to throw up?
Are
we anxious about everything that is happening to us?
Do our
symptoms prevent us from getting sufficient sleep?
Has the
fear-of-death become our major emotion?
If
we explain everything we are experiencing,
then
our doctors can provide drugs that will address each problem.
Sometimes the drugs prescribed work to correct the
underlying disease:
If the bacteria can be killed off,
all of
the symptoms of that infection will also be relieved.
If
our coronary arteries can be unclogged, angina will disappear.
And
in the meantime, drugs can relieve most of our symptoms:
The
cough, the sore throat, the headache can all be treated directly.
Who could object to using drugs to cure
our medical problems
and/or to relieve all forms of suffering
related to disease or injury?
2.
DRUGS FOR CHRONIC MEDICAL PROBLEMS
As we age, we will probably develop medical problems
that will
continue for a long timeperhaps
even for the rest of our lives.
We
might develop pains in our joints.
And short of replacing these
joints,
we can receive medications that will both reduce the
inflammation
and control the pain when we move these joints.
If we develop chronic heart-problems,
we
can receive medications that will help our hearts to operate better.
And pain-relievers can reduce the symptoms of heart-problems.
If cancer is our long-term medical
problem,
we will receive medical treatments intended to cure the
cancer.
And if our tumors are causing problems
anywhere in our bodies,
drugs can soften the
troubles caused by those cancers.
3.
DRUGS AS PART OF TERMINAL MEDICAL CARE
When we begin the last year of our lives,
drugs might be needed to control our chronic
symptoms.
In fact, if we have been taking any pain-relievers for a
few months,
we will probably require higher
doses of
the same drugs
to achieve the same pain-reducing results.
This is called drug-tolerance.
And if this is the last year of
our lives,
there should be no worry about 'drug-addiction'.
Yes,
we will be dependent on these drugs for pain-relief.
And if we go
off these drugs for any reasons,
our symptoms will return.
All of the worries associated with coming to the end of our
lives
might also be troubling us unduly.
We will have to deal
with such problems as how to distribute our assets.
But there
might be better times than just this week.
If we are
traumatized
by dying, we can receive drugs to calm
us.
Drugs used as part of terminal medical
care
are not usually intended
to shorten the process of dying.
Rather, we will tell our medical
care-givers what bothers us most.
And they will try various
medications until they find the best match
between the relief
we want
balanced against unwanted
side-effects.
For example, do pain-relievers make us sleepy?
And if we want to be awake
during the daytime,
then our pain-meds might need adjustment to
achieve that result.
However, everyone
should acknowledge
that pain-relieving drugs might
shorten the process of dying.
And if we want our dying to be well-managed,
then shortening the process might be one of our goals.
How long do we want to live under the
current circumstances?
How much pain can we tolerate?
Do we
know for certain that our symptoms will get worse?
If so, when
would it be wise to accept more
drugs
in
order to have fewer
symptoms?
We might come to a turning-point in
our terminal medical care
when we would say: "Give me all the
drugs I want
because I wish to end this process of dying."
"I
am now as ready as I will ever be to meet my death,
so there is no
further point in prolonging the process."
Under standard medical ethics,
we do have full freedom to request
increasing pain-medication
even
with the explicit recognition that these symptom-controls
might shorten the process of dying.
Some palliative care experts
claim that the drugs themselves do
not shorten the patient's life.
But is
longer life necessarily a benefit to the patient?
If each additional day is just more suffering and
torment
perhaps
punctuated with some moments of lucidity
what
is the point of continuing such an existence?
Let the patient
evaluate the benefits
and burdens.
And if the patient can no longer make meaningful decisions,
let
the proxies consider increasing the pain-medication.
4.
HOSPICE CAREMOVING
FROM CURE TO COMFORT
Hospice care is explicitly for patients
known to
be dying.
To be admitted to any hospice program,
we must be officially
declared by our doctors
to be likely to die within the next six
months.
In some places "terminal illness" is defined as
less than 12 months to live.
However, hospice care is frequently
used only at the very end of
life.
In
its earliest formulation, hospice
philosophy
required abandoning
curative medical care.
But in recent years, this has been modified in principle and
in practice.
Now some
curative treatments can be continued under hospice care,
especially when continuing to treat the
cancer, for example,
will also reduce
the suffering experienced in the last few months of
life.
Hospice providers have
hundreds of drugs at their disposal.
The more fully we explain
our specific forms of suffering,
the more accurately the hospice
program can treat our symptoms.
In hospice
care, we---the patients---should decide
just what combination of
drugs works best for us.
And when we are ready for death to come,
we can stop worrying that drugs might bring death sooner.
5.
WHEN COMFORT-CARE-ONLY
IS A LIFE-ENDING DECISION
As we approach the obvious end of our lives,
there is even less
reason to worry about misusing pain-medications.
We know with
absolute certainty that death is coming.
So the only remaining
question is exactly when
will we die?
And how much suffering
will we endure on the way towards death?
Some of us might find some meaning in
living for a few more days,
even if more days will include more
suffering.
But we might
choose fewer
days of suffering at the end.
The same pain-medications that have been effective
in controlling
all of our specific symptoms on the way towards death
can now be
increased as much as we want.
We are no longer trying to
postpone death as long as possible.
A shorter process of dying
might be better for everyone involved.
Knowing full well that we are now beginning to die,
we can
authorize whatever levels of symptom-control we desire
now
with no further worry that the medications themselves
might
contribute to death or shorten the process of dying.
6.
SAFEGUARDS FOR INCREASING PAIN-MEDICATION
AS A METHOD OF MANAGING DYING
If we feel the need to make absolutely certain
that we are
choosing the very best pathway towards death
when we authorize
increasing our pain-medication,
here are several safeguards
appropriate for all
life-ending decisions.
Since the medical situation is already
well-understood,
safeguards to confirm that
we are dying
are
not as useful as those safeguards intended to make sure
that we
and our families are ready
for us to die.
Each of the following 26 safeguard-procedures
is linked to a complete
explanation on the Internet.
When one safeguard seems especially
applicable,
read the more complete explanation.
These safeguards might also be used as a check-list
to assure ourselves that we are making a wise,
life-ending
medical decision.
If we are actively dying in a hospital,
most
of these safeguards might already have been fulfilled.
Which safeguards would be most meaningful to use right now?
SAFEGUARD
A Advance
Directive for Medical Care
When we are
getting ready for our own deaths,
the most important documents we
can create
are called "Advance Directives for Medical Care".
Comprehensive ADs ask for our philosophy
of pain-control.
How do we want our possible pains to be
treated?
Do we approve using drugs to control our end-of-life
symptoms,
even if such drugs might
shorten the process of
dying?
When we make our end-of-life plans explicit in writing
especially
with respect to using drugs to control
symptoms
this makes it much easier for others to make the
decisions required
if and when we lose the power to make our own
medical choices.
SAFEGUARD B Requests
for Death from the Patient
Once we are
receiving terminal medical care,
such as being cared for by some
hospice program,
we might explicitly request pills to ease the passage into
death.
If we are finished
with living,
perhaps especially because continued existence includes
suffering,
we might decide to authorize a new form of medical
care
to ease our terminal suffering
even if the pain-relief
brings death a few days earlier.
With careful planning, there
should be no problems
with creating the best pathway towards death
for ourselves.
Exactly when would be the best
day to die?
SAFEGUARD C Psychological
Consultant Evaluates
the
Patient's Ability to Make Medical Decisions
When we are approaching the end of our lives,
there might be some
doubt about our mental capacities.
Can we be expected to make
reasonable life-ending decisions?
Are we feeling pressured towards
death by family members?
Do we have a realistic grasp of our
end-of-life situation?
If we have expressed any reasons for
dying,
will the psychological professional agree with our
thinking?
SAFEGUARD D Physician's
Statement of Condition and Prognosis
Since we are already receiving medical care,
our physical condition
is well known to the providers.
But it will be helpful for everyone involved
to have the
specific medical conditions
explained in terms that laypersons
can understand.
How many more days will we live
given the
whole constellation of our condition and medical care?
SAFEGUARD
E Independent
Physician Reviews the Condition and Prognosis
And because easing the passage into death is so final and
irrevocable,
it is always wise to get a second professional
medical evaluation.
Does a specialist accept the
diagnosis and prognosis?
Does this additional doctor agree with
the plans for terminal care?
SAFEGUARD F Certification
of Terminal Illness or Incurable Condition
If we are in a hospice program,
terminal illness has already been
certified in writing.
But if anyone might be in doubt (such as
the prosecutor),
then it will be helpful to have an official
document
stating that we are probably in the last months or weeks or our
lives.
How much longer will we live under various treatment-plans?
SAFEGUARD G Unbearable
Suffering
The basic reason we are requesting increased
pain-medication
is that our suffering cannot be alleviated any other way.
We should explain in our own words
the kinds of
suffering we are experiencing.
What is the degree of
this
suffering?
Do we know that it will only get worse?
Is our
suffering so great that we prefer
to have pain-medication
to prevent any further torment,
even if the drugs keep us asleep
most of the time?
SAFEGUARD H Unbearable
Psychological Suffering
Sometimes our
inward suffering is greater
than the medical problems might
suggest.
If we have psychological or spiritual dilemmas
that
cannot easily be grasped by others,
then we should do our best to
explain what is happening to us.
And is this psychological
suffering
sufficient all
by itself
to justify choosing an earlier death?
SAFEGUARD I
Palliative
Care Trial
Because we are already
receiving medical care,
much of this effort might already be
directed toward
relieving all forms of suffering.
Once we have
seriously tried all of the most relevant
methods of healing and
symptom-control,
then the basis for our future decisions that accept death
are well-founded in our history of health-care.
We know the specific effects of various drugs
that have been tried to control our terminal symptoms.
SAFEGUARD J Informed
Consent from the Patient
We prove that
we are giving informed consent
for whatever course of action we
are choosing
when we explain in our own
words
our end-of-life
physical and psychological problems
and what methods of
symptom-control we approve.
We know we are dying.
And these are the drugs we prefer for comfort-care.
SAFEGUARD K Requests
for Improved Comfort-Care from the Proxies
If and when
we slip beyond being able to make our own plans,
then we have
appointed proxies who will carry forward
our plans as decided when
we had all our mental faculties.
Our proxies should have all of
the same powers and authority
to make terminal-care decisions we once had ourselves.
Our proxies will continue (perhaps increase) our terminal medications.
SAFEGUARD L Enrollment
in a Hospital or Hospice
This safeguard
might be already fulfilled for all to observe:
Are we already
living in a hospital?
Are we enrolled in any kind of hospice
program?
Perhaps we are even receiving care from a right-to-die
hospice.
SAFEGUARD M Statements
from Hospital or Hospice Staff Members
The people who are taking care of us at the end of our lives
will
probably have definite views about our plans for terminal care.
If we are
choosing to allow death to come earlier
by the generous use of
pain-killing drugs,
what do these professional staff persons say
about this choice?
SAFEGUARD N Statements
from Family Members
Affirming
or
Questioning Increasing Pain-Medication
We will probably have family members involved in our
terminal
care.
Should they write their own statements of understanding and
support?
Do they also agree that comfort-care-only
is a wise method of managing our process of dying?
SAFEGUARD O
A
Member of
the Clergy
Approves
or
Questions Comfort-Care-Only
If we have any connections with organized religion,
we might ask
our religious leaders to write statements
about our decisions to ease our passage into death
with the
help of palliative-care medications.
SAFEGUARD P
Religious
or other Moral Principles
Applied
to
this Life-Ending Decision
Especially if
our decision seems somewhat novel or controversial,
it might be
valid to seek an
official ruling or statement
from some group of religious experts of our own tradition.
Has
our religious tradition addressed the question
of the most
appropriate amounts of drugs to use at the end of life?
Or, if we
are not religious, perhaps secular thinkers
have explored using drugs to shorten the process of dying.
SAFEGUARD Q An
Institutional Ethics Committee
Reviews
the
Plans for Comfort-Care-Only
The place where we are receiving our terminal care
might have a
formal ethics committee.
If so, they could easily be asked to
review our end-of-life plans.
Do they agree that the medical
situation warrants
choosing a shorter pathway towards
death
using
more drugs than might normally be prescribed?
If the ethics
committee has any doubts,
let these be resolved before the
end-of-life sedation program begins.
SAFEGUARD R
Statements
from Advocates for Disadvantaged Groups
If
Invited by the Patient and/or the Proxies
If we belong to any minority group,
would it be helpful to
have some other member of that identity-group
review our plans to ease the passage into death?
We would not want anyone to worry
that we might be receiving different terminal
care
because of our perceived identity-group.
SAFEGUARD S
Review
by
the Prosecutor (or other Lawyer)
Before
the
Death Takes Place
When we choose as our
preferred method of managing dying
increasing the pain-meds we are already
taking,
then there should be no reason to begin a criminal
investigation.
But if any doubts about the legality of our choice
might be raised,
it might be wise to do a legal
review ahead of time.
Has any doctor ever been charged with a crime
for using the proposed level of medication for comfort-care?
SAFEGUARD T Civil
and Criminal Penalties for Causing Premature Death
And if some crime (harm) might have been committed
in the process
of providing palliative drugs to us,
then the justice system
should have in place
laws and methods of evaluating harms and/or proving crimes
so
that any mistakes can be identified and perhaps punished.
SAFEGUARD U Waiting
Periods For Reflection
The long process
of planning and preparing for death
probably has already included lots of
moments for reflection.
Has everyone involved had
opportunities to express himself or herself?
Have the results of comfort-care already been beneficial?
SAFEGUARD V
Opportunities
for the Patient
to
Rescind
or Postpone the Life-Ending Decision
If we are slowly approaching our deaths
by means of carefully
controlling the drugs we use,
we might decide that our
symptom-control is good enough
for us to decide to live a few more
days than originally planned.
We might find a combination
of drugs
that allows us to have a few more days of meaningful
living
before the comfort-care ends with our deaths.
SAFEGUARD W Physicians
Review the Complete Death-Planning Records
As a final check before the last decisions for pain-control are
taken,
the doctor should review all of the documents already
written
in support of this decision to manage our deaths by using
sedative drugs.
Are there any questionable documents or
poorly-based opinions?
Any problems that arise can be resolved
before the final decisions about levels of drugs for the
last few days.
SAFEGUARD X Complete
Recording and Sharing
of
All Material Facts and Opinions
Thru-out the process of planning for our deaths,
we have always
shared the documents created
with everyone who has a valid right
to know about our plans.
And a final storage-place can be created
for keeping these documents
just
in case a deeper investigation might be needed later.
SAFEGUARD
Y The
Patient Must Be Conscious and Able to Accept Death
Ideally, we could prove that our end-of-life plan is valid
by
staying awake for each time a new dose of drugs is given.
But in
practice, this will probably not happen.
We are more likely
to authorize in advance
certain levels (and increases) of palliative-care drugs.
We might not be fully conscious and in-charge during the last few days,
as the drugs have their expected
effects.
SAFEGUARD Z The
Death-Planning Coordinator Organizes the Safeguards
Someone can collect all of the documents into one written file
or
into one electronic file.
The process of collecting written
statements from two dozen people
will be a way to make
certain that comfort-care-only
as a method of managing dying has taken into consideration
all relevant facts, personal opinions, & professional
recommendations.
7.
COULD THE PAIN-MEDICATION CAUSE PERMANENT SLEEP?
Choosing to manage dying
by increasing pain-medication
is similar in some ways to choosing induced
terminal coma
as the best pathway towards death.
And as the
drugs are gradually increased,
the sedation might actually turn
into permanent
deep sleep.
Inducing terminal coma is also a completely valid, ethical, &
legal
medical method of managing dying.
Thus, there should be
no worry that increasing pain-medication
might render the patient
'too unconscious',
because complete and total sedation until
death
is also a reasonable
end-of-life medical option.
See another chapter, called:
Induced
Terminal Coma: Dying in Your SleepGuaranteed.
That chapter also applies the same 26 safeguards
to the more
radical choice to keep the
patient completely asleep
while the
process of dying proceeds.
AUTHOR:
James Leonard Park is an advocate of the
right-to-die with careful safeguards.
When he approaches his own
death,
he might easily agree to increasing any
symptom-controlling drugs then in use.
And he has given full
powers to his proxies
to make such life-ending decisions on his
behalf.
More of his views will be found in the links below.
How
has this chapter changed your thinking?
What did you know about comfort-care when you began this chapter?
Do
you see how drugs are used in the various phases of medical care?
Did
you think that doctors would not be permitted to increase drugs?
Did you assume that using drugs to facilitate dying was a crime?
Do
the 26 safeguards assure you
that increasing pain-medication could be a moral and legal
choice?
Would you yourself now approve
comfort-care-only as a
method of managing your own dying?
Closely
related chapters and on-line essays:
Induced
Terminal Coma: Dying in Your SleepGuaranteed
Four
Medical
Methods of Managing Dying
Methods
of Managing Dying in a Right-to-Die Hospice
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
Medical
Methods of Managing Dying
Books
on Helping Patients to Die
Books
Supporting the Right-to-Die
Books
Opposing the Right-to-Die
More on controlling
end-of-life symptoms:
"Comfort
Care for Patients Dying in the Hospital"
by Craig D. Blinderman, MD & J. Andrew Billings, MD
This article offers many technical methods
for controlling distressing symptoms at the end of life.
These are the medical details of comfort-care.
And if palliation fails, terminal
sedation is the last resort.
These authors do not endorse shortening the process of dying.
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 ParkFree
Library
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