Our Advance Directives will outline our plans for the end of our lives.
And when we begin what will probably be the last year of our lives,
we should expand our Advance Directives to explain
how our medical ethics apply to the new situation created
when we know what disease or condition is likely to cause death.  
This updated explanation of our plans for death  
should refer to the doctors' statements of our condition and prognosis
and restate in our own words what we are expecting.
If we have misunderstood our physical condition and its likely outcome,
then any request for death might be premature.  
Such possible misunderstandings will be uncovered
when we explain our reasons for requesting death.
All reasonable requests for death must take the medical facts into account.

     Our reasons for deciding to end our lives under certain conditions
instead of waiting for a natural death
might have many factors that are not medical.
We can ask ourselves:  
Are we ready to die—emotionally, socially, spiritually, philosophically?
What last few things must be accomplished
to make us ready to draw our lives to a close?
In many cases, our personal reasons for choosing death  
will be more important than the medical facts.  
And it will help those who care about us to understand our decision
if we explain these personal factors explicitly in writing.

     Our requests for death express in the fullest possible way
our personal autonomy and self-determination—our right-to-die.
In order to make sure that our requests for death are serious
they must be made formally and in front of witnesses.

    If we have lost the power to speak, our in-person requests
can be made by some other reliable means of communication.
We can mark "yes" or "no" answers to a series of written questions.
Or we can blink our answers to a set of questions
that require consistent answers to the same questions in different forms.
If we can still write, the witnesses will observe us writing with our own hands
or using some electronic means of expressing our views
that make certain that the requests are coming from our free choices.
Such methods are intended to show that we are still functioning as persons
who are capable of making medical decisions.
These in-person requests for death must be witnessed by neutral observers
who can swear that we were of sound mind when we answered
—and that we did unambiguously request death.

    Our requests for death should state at least an approximate time-frame.
When would be the best time for us to die?
Do we wish to specify some milestone or tipping-point
after which death would probably be better than continuing to live?
Are we granting permission for some specific method of dying? 
Have we already designated proxies who will carry forward our plans
even if we ourselves become unable to express any further wishes?

    Besides requests made verbally (or by some other in-person process),
there should be written requests for death that are signed and dated.
We are usually more serious about requests we put into writing
and to which we attach our signatures.
All our written requests for death should have the names and signatures
of the people who witnessed us creating and signing these requests.
Witnesses to such formal, written requests for death
are also affirming that they believe we were freely expressing
our well-informed decision to choose a particular pathway towards death.

    And there might be specific regulations about who can be witnesses.
The general idea is to make sure that the requests for death
are really coming from the patient and were not influenced by undue pressure
from anyone who might have personal reasons for wanting the patient dead.
Thus, usually employees of the health-care institution may not be witnesses.
And any people who might benefit financially
from the patient's death are also not good witnesses.

    The requests for death must also be separated in time
in order to eliminate impulsive responses to a sudden new situation.
This is the reason for waiting periods between requests,
which are discussed as a separate safeguard.

    The patient's requests for death should be formal and explicit,
explaining in the patient's own words the basic reasons for choosing death.
Do these requests for death qualify as informed consent?
And were these separate requests for death
repeated over a sufficiently long period of time
to show that the decision for death is not temporary but persistent?


    When the patient formally requests death both verbally and in writing,
then these requests are taken very seriously by all who are aware of them.
When a patient is in despair or in pain,
such factors undermine the validity of any request for death.
And persons who sometimes have suicidal urges
should be protected from self-destruction
until the irrational urge to kill themselves has passed.
Making sure that any requests for death are formal and serious
will help prevent irrational suicides,
which are often impulsive and capricious rather than well-planned,
which are based on a poor grasp of reality,
which will harm the patient rather than benefit him or her,
and which others will regard as tragic and regrettable
rather than admirable and commendable.

    When a patient writes a suicide note,
this is not a qualified request for death.
And all who are aware of such self-destructive plans
should attempt to prevent irrational suicide.
Thus, those who receive the requests for death from the patient
are expected to evaluate the rationality of the choices expressed.

    Other kinds of mistakes and abuses of the right-to-die
will also be discouraged when the requests for death are put into writing.
For example, when the patient feels pressure from family members
to choose a premature death,
the neutral witnesses to the requests for death
will question the wisdom of that 'choice'.
The witnesses should ask the patient to explain in his or her own words
why death at this time is better than death at some later time.

    The purpose of this safeguard is not merely to get signatures on paper
but to facilitate a thoro discussion of the pros and cons
of any particular pathway towards death.
It is sometimes too easy to get people of questionable capacity
to put their signatures on any paper that is put in front of them.
If the 'choice' would lead to a premature death
as perceived by any of the neutral observers and witnesses,
then they should not agree to witness that 'request for death'.
If the request for death is not rational, not based in well-proven facts,
then this is an opportunity for any observer to prevent a premature death.

    Whenever doubts are raised anywhere in the process
of creating and witnessing requests for death from the patient,
these doubts must be resolved by deeper investigation
before any plans for death are carried forward.

Created January 2007, revised 2-13-2007; 1-26-2008;
2-5-2010; 5-9-2010; 9-9-2010; 5-27-2011; 12-14-2011;
1-29-2012; 2-3-2012; 2-22-2012 ;3-22-2012; 8-1-2012; 8-19-2012; 10-18-2012;
5-22-2013; 6-26-2013; 7-24-2014; 5-16-2015; 12-28-2015;
11-22-2017; 5-31-2018;

The above explanation of the best ways for a patient to request death
has become Safeguard B in How to Die: Safeguards for Life-Ending Decisions:
"Requests for Death from the Patient".

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