Does your country allow a patient to execute an advance directive? An advance directive specifies a specific person to act as the patient's surrogate to make health care decisions if the patient can't make them himself/herself - for example, if the patient is in a coma or otherwise incapacitated.  When a patient has an advance directive, that surrogate makes the decision when to switch off the device, though the physician or other clinician is the one who actually switches it off.

There are some good treatises on American end-of-life law, but I don't know of any that discusses Philippine law.

to be accurate, i should say the question  you've raised, is involuntary euthanasia. there's no treaty, agreement, or regulation in international level, which permits euthanasia in any form of it, or legitimize it. in universal declaration of human rights, covenant of civil and political rights or any other document in this field, there's no article that recognize "right to die". the only cases that brought before European court of human rights, were based on article 8 of European convention of human rights on "right to respect private life."

so, if you wanna know who has the right to switch off life support machine, you may see the internal laws and regulations of countries like Netherlander and Swiss that accepted this concept in their countries. there's a euthanasia center in Swiss, which called Dignitas , and you can study it's  procedure too.

http://www.dignitas.ch/?lang=en

When you ask "who should turn off the life-support machine?", do you mean who will carry out the physical act? 

We have a 1400 page thorough discussion is USA law in Right to Die: The Law of End-of-Life Decisionmaking, Third Edition

http://www.wklawbusiness.com/store/products/right-die-law-end-life-decisionmaking-third-prod-0735546657/looseleaf-item-1-0735546657

Thaddeus' work is extensive and far reaching but... yo're not in the US. You are a physician or lawyer in the Philippines. And you're not asking about whether this is appropriate or legal rather, as I understand it, about the procedures. So, generally, here is my general guideline. The decision to terminate life-saving and life-prolonging care is a difficult one in the best of circumstances. Even when everyone agrees and the patient is persistently unconscious it's hard. It's harder yet if the patient is conscious and needs to be sedated (for example, one requiring ventilation). 

 Assuming this is the case of a patient who is persistently unconscious and the family and physician's agree that this is appropriate: As a medical decision it typically falls to the attending physician to physically turn off the machines that maintain a patient's physical functions. Patients are normally unfamiliar with the machines. I have heard that, in some cases, where the family seeks this ending and physicians agree the family is present. They may ask to participate and be shown what buttons to push to discontinue ventilation or cardiac assistance. 

That said, the action should not be left to a nurse of another who is uninvolved with the patient's normal care. Be aware that some members of the hospital or care home staff may disagree with the decision. If physicans and family are in accord, they might be given the day off or assigned to another ward. But their concerns should be respected, the decision explained, and options for their comfort in an uncomfortable position outlined.

Not knowing any more particulars that's a broad response but the best that might be offered at this point. Obviously, the laws and customs of your culture and society must be respected, first and foremost.

Legally it makes little if any difference who actually physically turns off the machine but I agree with the comment above that it should normally be the treating physician. The original physician may wish to transfer care for this. There are particular faiths that do not believe in turning off life support - I know that some paediatric intensive care units in the UK will continue to ventilate children who are brainstem dead where Orthodox Jewish parents insist on it. There is no legal requirement however. 

I have yet to come across anything that indicates anybody but the physician should be the one to actually turn off the machine (i.e., MD/DO).

I've never seen it stipulated in judgments, and there's no legal reason I can think of why it would need to be a physician.

I am currently studying for a Masters in Bioethics, and this is but one of the topics discussed. In fact, amongst ethicists (philosophers) there remains debate about the accepted definitions of various actions I.e. Which is active/passive/euthanasia/ physician assisted suicide etc. There are a vast number of articles discussing bioethics and the law, so only generalities can be expressed:

1. In most countries the law lags behind around 10 years compared to public opinion.

2. Depending on the form of government, the policies that are made into law are generally those which cause the least offence to the majority.

3. Unfortunately, most societies perceive health care professionals, particularly doctors, as protectors of life, involved in acts of beneficence only. Hence, the philosophical debates are looking to options most empathetic carers particularly doctors find unacceptable.

4. It is morally too demanding to expect the patient, if able or friends or family to pull the plug.

5. Interestingly, there appear to be a significant number of conscientious objectors amongst nurses, coming from a position of the ethics of care compared to doctors.

6. The idea has been mooted of creating non-medically trained thanetricians; trained in pharmacology etc. However, rightly, there is a fear they would become morally bruised while being death technicians alone.

7. Another idea that has been discussed is allowing robots (programmed to question patients empathetically) to administer the drug or disconnect the machine.

8. My personal feeling on the issue is this: though it may not make a difference who pulls the plug, it is the decision-making process that is the morally demanding one. In the West, most such cases occur in the ICU scenario, where, as a bear minimum, two consultant specialists must be involved, both being in agreement regarding the futility of treatment; other advice being sought if different clinicians are involved. As a surgeon, I firmly believe on moral grounds that as this is the most difficult decision we make, we should be the ones making it; if for no other reason, than to keep us grounded. It is easy for people switching machines off frequently to become emotionally numb,maps seen in the high percentage of burn-out in ICU personnel. I.e. In the UK, my anaesthetic colleagues would keep at least one day of elective surgical lists per week, to ensure they didn't spend all their time in ICU, for this same reason. Though senior registrars must learn this delicate combination of art and science, till they are nearly trained, I believe the consultant intensivist is the appropriate one to pull the plug. 

9. Feelings of near and dear vary. The Scandinavian data shows some of them like to be present, and are comforted if the process is not too rapid, whereas others cannot face being present; as constantly asking a doctor if the patient is dead is painful.

10. As a fraternity of doctors where we are constantly judged by our positive results, which are openly available to the public, I believe we should be constantly in touch with the reality of medicine; we do not win all battles; we need to be equally prepared to accept the reality of futility by recognising it, with the support of our colleagues. After all, though there is immense sadness, in medicine, we are not supporting our dying patients with dignity if we have personal regrets. I hope that at least in my life time, this highest yet most difficult of jobs remains the duty of the physician.

Lots of things in your comment above I could address, but I find this sentence in particular interesting: "Unfortunately, most societies perceive health care professionals, particularly doctors, as protectors of life, involved in acts of beneficence only". Is that really unfortunate?

To reframe the sentence, it is unfortunate that we are only seen as protectors. It would be fine if we were considered rounded personalities, who don't have all the answers and despite trying our level best, do not get it right sometimes. This is not to say there is any place for complacency or lack of respect, accountability and responsibility on our part, but, in a number of societies, we demonstrate personas in keeping with society's expectations of us. One cannot deny doctors, particularly those belonging to the interventional specialities of surgery are put on perches by chunks of society and it is unfortunate that this leads to certain doctors becoming arrogant in their achievements. Though a doctor's job is extremely difficult, particularly in relation to end-of-life decisions, we act out of empathetic duty, rather than being different kinds of human beings. 

Though we aspire to do the right thing in all circumstances, and take full responsibility for our thoughts and resultant actions, we are by no means virtuous individuals. It is this perception of moral difference that I find unfortunate.

To be viewed as benefactors alone is unfortunate, as doctors are but persons. Although our driving force is always to do the best for our patients and to keep re-assessing our decisions and results, at the same time it is essential for us and society to remember we are fallible; death does occur even in elective situations, we do not have all the answers and we do get it wrong sometimes. By only focusing on the good, the demarcation between competence and arrogance is often lost. This is the unfortunate truth.

We often forget that medicine is a job, a duty, one of empathy and respect. Being there for our patients at the end, making those most difficult of decisions for them and with them is the pinnacle of our duty. It is natural for us to find these decisions difficult; but of what good is our knowledge and expertise if we do not put it to good use in difficult times? This is not to say that anyone would expect one treating physician to be there 24/7, turning the ventilator off for each patient, but, with the team of clinicians caring for a patient he should be an active contributor to the discussion till the end. Hence, I said that though there is deep sorrow, there should be no regret as to decisions made or not made.

In the UK for instance, though we take relatives' opinion into account, legally, the doctors alone take responsibility of determining the point where futility of treatment has been reached, such that treatment is stopped, withdrawn or not initiated. Advance directives make this easier, but, the quality of such documents is not always such that a patient's wishes are clearly documented in given situations. As society becomes more open to discussing such matter in more detail, we find that in the last couple of years, the documents are becoming more relevant and valid to the patients' conditions. Clear communication, honesty, openness, respect remain key to any process of informed consent. In some processes and procedures, allied health care workers are able to take consent; however, in complex medical and ethical scenarios I believe this vital role does fall upon the treating physicians.

Interesting - after apparently arguing against medical exceptionalism you then argue for it!

Not at all. All I highlighted was the law as it stands and our duty as professionals within that law. Practitioners of all professions abide by the particular ethics and expectations of their role. It just so happens that the decisions we make often involve vital issues; where we support others in making those difficult choices. Am I correct in inferring you are objecting to the requirements of the role of a medic?

Which requirements of the role of the medic? Medics certainly not equipped for tackling complex ethical issues by dint of being medics, I think you'll agree?

Am I to presume you are not a surgeon? Because I have to disagree. We are both equipped and used to making a vaste number of decisions regarding very complex ethical issues on a daily basis; surgery is all about decision- making, and being accountable and responsible for those decisions!

I would presume nothing. Do you think surgeons are a breed apart in the medical profession? Surgeons not really known for complex decision-making generally - physicians the real diagnosticians.

I see - so it is the physicians who are a separate breed and surgeons don't make decisions. Perhaps they are technicians? I stand by my presumption. 

I suggest you acquaint yourself with some of the Ealing comedies to see how well you imitate their portrayal of the stereotypical surgeon. I've dealt with many surgeons and sadly many of them are bombastic and overconfident too.

Dear Rodel

Thank you for being so honest in putting forth a query which affects all doctors. In fact, your answer is in the question. It is right that you find it so difficult; as doctors are healers who, working within the law, remain so emotionally involved especially at the end of life. Yet, we have a responsibility to use our emotions intelligently while remaining in control.

Regarding the legality, you will note that all medical councils realise medicine is contextual and situational; thus, they only provide guidance and not guidelines in the care we provide. Medical councils do not direct us which patients to treat and how to treat them; they only judge our actions and the consequences.

Thus, as long as you have at least another consultant colleague for support, intensivist, physician or surgeon depending on the case, who you can trust as a sounding board, together you are able to share the burden. If it wasn't obvious, it will be now that you have a responsibility to listen and respect the opinions of all involved - nurses, family, other carers; but, if you are making the final decision, for the moral security of all, it is best if you too are involved in the final step.

If, like you said, you go through the difficult yet privileged steps of final informed consent, then a relative asking you who will pull the plug is demonstrating their trust in your empathy. I have no doubt that in such a situation to be able to reciprocate by saying it will either be you or a named colleague will bring them further solace.

it has been demonstrated eloquently that non-practitioners do not realise the turmoil a doctor goes through in making such a decision each time, such that your competence and compassion is likely to be taken as arrogance on occasion. By remaining emotionally intelligent while intelligently ethical I have no doubt in each given situation, traumatic as it may be, you will make the right decision for your patients. 

Thank you all for your enlightening exchanges of ideas. I sincerely appreciate all your insights and opinions. One thing for sure though, my being a lawyer does not make the topic any easier. Merry Christmas to all. 

Generally, turning off life support leads to death which most legal system consider a crime and unethical especially where there is no advance directive or it is done without the consent of the patient, same could be done safely with a court order though

as in the case of Nancy Cruzan and Quin Ann.