Monday, July 21, 2008
An International Review of Hastened Death
(Hopefully not a recurring feature)
*Please read disclaimer at the end of post*
The New York Times #6 most emailed article today is about the underground practice of hastened death via the procurement of barbiturates in Tijuana, where the medications are intended for euthanizing animals, not humans. It is interesting this practice fits under neither commonly used terms for hastened death by medical means:*Please read disclaimer at the end of post*
"euthanasia" - the administration by a medical professional (or other person) of a prescribed medication with the intent of causing a hastened death
"physician-assisted suicide" - the self-administration of a medication prescribed by a physician with the intent of causing a hastened death
This article describes people obtaining the medication without a doctor's prescription, therefore 'physician-assisted' is a disqualified descriptive. They merely need to show a picture of the medication they want at the Mexican veterinary stores. So I guess this is simply 'suicide?' Although I think 'suicide' is too broad to define the particulars about a situation where someone is in the terminal phase of a condition versus someone suffering from a severe depression but no terminal illness. But to label this 'terminal suicide', 'hastened death in the terminal phase' or some other contortion feels clumsy and is bound to cause even more confusion.
Regardless of the term used, the issue has been made more relevant with a couple high profile cases of medicine and hastened death.
In Australia, Exit International and Philip Nitschke have been making the papers and TV (and are featured in the NYT article) with a public campaign to legalize euthanasia including You Tube Videos, film screenings, book promotions (attempts at banning it are underway in Australia and New Zealand), workshops and political initiatives. More focus has been on Mr. Nitschke and his group since the recent manslaughter conviction of a woman who gave a barbiturate to her partner who had Alzheimer's. Another recent case is also being featured of a woman who was depressed but not terminally ill who supposedly relied on information form Exit International's materials to kill herself.
In Germany, a lawyer/politician advised, and videotaped a 79 year old woman who prepared and self-administered a 'lethal cocktail.' The woman was not terminally ill but chose hastened death because she did not want to go to a nursing home. The politician, Roger Kusch, was inspired by Dignitas, a pro-euthanasia organization based in Switzerland who has many people from Germany requesting its services.
In Scotland, a Member of Scottish Parliament, Margo MacDonald has filmed a documentary with the BBC and proposed legislation to adopt the euthanasia and assisted suicide laws similar to The Netherlands.
In Italy, a case eerily similar to Terri Schiavo and Nancy Cruzan is being discussed publicly and was recently covered in TIME magazine. A 20-year old woman in a car accident (in 1992) now comatose and with a feeding tube that her father wants to have removed (and has fought for since 1999) was allowed by Italian courts to stop her artificial nutrition via feeding tube despite much opposition. The case is now pending appeal despite already having gone to the Italian Supreme Court in 2002.
In Canada, Samuel Golubchuk, an 84 year old man whose family fought hard to continue aggressive life-prolonging measures died 9 months after doctors initiated discussions about end-of-life decisions. He died on full life support measures. If his life support was withdrawn it would have been illegal since a court ordered physicians and the hospital to continue partly based on the family's belief of hastening his death would be a sin under Orthodox Jewish law. The case was to be heard by a full court in September. Doctors refused to care for him, likening his medical treatment to 'torture.'
In England, a man who was refused Sutent, a prostate cancer drug, by the National Health Service suffocated himself.So why is this all important to palliative care?
Because guess who thinks about these things:
Because guess who thinks about these things:
- your patients
- their families
- medical professionals who consult you
- the public
Good hospice and palliative care practices can help people discover hastened death does not have to be the easy way out. If the lines are too blurred between the legal and illegal our field has significant trust to lose with the public and our peers. Being educated and aware of the public debate over hastened death is a responsibility for palliative medicine to ensure the safe, ethical, and legal care of the patients and families entrusted to us.
(My Standard Disclaimer: Pallimed, Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine. Links do not represent endorsement.)
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10 Responses to “An International Review of Hastened Death”
July 22, 2008
Are there any recent cases I have missed? Please add them here, or your own comments about the cases above.
July 22, 2008
Lots of terminal cancer patients (and non-cancer patients also) have their 'stash' ready. I do. I know it's not unusual because I've talked to other TPs about it. Quite common, in fact.
Why?
I can immediately identify in myself a recurrent and very deep fear of being trapped in a situation where the pain and other costs (not financial)are too much - for me, for those near and dear to me - and I have no guaranteed quick exit. I guess this implies a certain disbelief in the medical industry's (esp palliative care providers) unvarying willingness to invariably use appropriate medications or, sometimes, appropriate dosage rates of the right medication. I have had a doctor tell me he wouldn't prescribe morphine to pain-filled TPs because it's addicitive. To say that to someone in much pain and without a significant lifespan is so appallingly insensitive - and plain bloody stupid. Death cures all addictions.
Some of us also fear being left to the not-so-tender 'mercies' [sic] of those whose own religious beliefs cannot countenance such things as the inherent humanity of assisted death; euthanasia, if you will.
They shoot horses, don't they?
I'm involved in an international drug trial (I'm in NZ). Last week, at my regular test interview, I mentioned to the clinic staff member I was with that I intend having a sign on my hospice bed that simply says 'Have mercy on me.' Her eyes were damp with tears and she just said, "Richard, I hope they do."
I joined the drug trial knowing that it can do me no good; but it might help others down the line. That's reason enough to participate. I'm a third of the way into writing my second book - the first is to be published early this coming September.
In short, I'm still functioning okay. But I know that can't last. I want to know that if I feel that I must end my life, I can. Not just for my own cessation of pain (though that's included, of course) but also for those who love me and who will grieve as I shrink into a non-viable 'thing', devoid of all conscious thought, ugly from lesions, wracked with pain, and in a vegetative state. Comatose. No longer human - but still recognisable as something that once was, and someone whom they loved dearly.
Who can truly look me in the eye and tell me that I - and all those others I know who feel exactly the same - are wrong?
I do not seek to impose my (non) religious views on the world. I just wish that the world would return the compliment.
Lastly, what makes doctors refusing to help people such as me to die so bloody sure that they ARE actually acting ethically?
July 22, 2008
PS:
Death's just another way of reducing your carbon footprint.
July 22, 2008
Given the recent comments/discussion on another post about hospice patients receiving inadequate analgesics as they die due to attending physician concerns for hastened death/'euthanasia' I can understand the wide-spread and ongoing mistrust patients have that despite everyone (pc community included) claiming that no one should die in pain/physical distress without (largely theoretical) concerns about 'hastened death' - patients still remain at the mercy of the competence of their docs/nurses as they die. I personally don't think the right way to respond to this as a medical community is to embrace/endorse assisted suicide - it is instead to redefine (and enforce as a community) standards of appropriate terminal care. Patients who don't want to wait around for those efforts to be successful - well I understand.
RQ: I can't speak for NZ but I'm not sure that it's true that a good number of dying cancer patients have a stash. In Oregon, where PAS is legal, a tiny tiny fraction of terminally ill patients even begin to pursue obtaining a 'lethal precsription.' Sure there are hoops to jump through which are probably prohibitive for some patients (including the issues with actually having to discuss with a physician your concerns/plans - not an easy thing to do to be sure) but even if those pursuing lethal prescriptions were just 10-20% of those interested it would still be a small % of dying patients.
July 22, 2008
Thanks, Dr Rosielle, for your considered response. Community fear of having an insensitive doctor is quite widespread in NZ.
It is based on well-publicised examples of medical neglect of dying patients.
Within the last several weeks in NZ a man was convicted of manslaughter for assisting his 'in care' mother to die, by administering morphine to her.
The day he did it, he visited and found her in very great pain. Uncontested evidence that the woman had not been visited by a doctor in the fortnight preceding her death was presented to the court.
Whilst convicted, the man clearly acted out of love and received a non-custodial sentence; community work. Some sense was brought to the matter by the Judge. It should never have needed to get that far.
Might redefining the terms and aims help clarify what is needed? That is: patients believe that the attending physician should willingly provide sufficient analgesic medication to ensure that the patient is pain free. If, as a side effect, the patient dies, where then is there an ethics (or any?) problem?
Another facet that I didn't cite earlier is one's dread at asking a family member to take on the task of being a living executor/executrix. I don't want to put the burden of making a DNR decision on anyone else, so I'm trying to obviate difficulties now, not leave them unresolved for others to deal with.
I mentioned a doctor I discussed morphine with. He refuses to prescribe it for terminal patients in extremis, suffering badly. I told him that I thought he was a monster. I still think the same.
Death may well not ever be the dignified affair we would wish it to be. But it could be somewhat easier to contemplate if we but felt that our physicians were there solely with our best interests (a loaded phrase, I know) at heart.
This would do much to relieve the fear and allow a bedrock of trust between patient and physician.
Otherwise, we just keep our stash. Euthanasia is quite a hot topic in NZ.
A book has recently been published here by a woman sentenced to jail for 'killing' her mother. Said woman is a nurse. Morphine, again.
As the bulging - in various senses -'baby-boomers' cohort of society age, the issue of euthanasia can only become more troublsesome if not addressed properly now.
How about "No euthanasia ever but always sufficient analgesics to allow patients to be pain-free" as a desiderata? Same result; differing terminology and ethos.
Thanks Dr Rosielle, for engaging in debate about what is such a fiercely-contested, emotionally-charged issue.
July 27, 2008
RQ wrote:
as I shrink into a non-viable 'thing', devoid of all conscious thought, ugly from lesions, wracked with pain, and in a vegetative state. Comatose. No longer human - but still recognisable as something that once was, and someone whom they loved dearly.
People who are sick are not things or vegetables, they are people. It is exactly this attitude that results in inhumane treatment in some hospices - withholding water from a patient who is thirsty, talking in a room as if the patient isn't there, etc. You, of course, cannot know that one who is unable to respond is devoid of conscious thought. I pity your sense that someone with lesions is ugly - your materialism has led you to wrong conclusions.
July 28, 2008
To clarify Richard Quinn has stated in his comments that he is posting from the point of view as a terminal cancer patient himself. How he chooses to view himself is his own decision.
His 'objectification' of himself is wholly unrelated to the philosophy of hospice; therefore I object to the assumptions of 'objectification' of patients as the basis for why a hospice would:
"withhold(ing) water from a patient who is thirsty, talk(ing) in a room as if the patient isn't there."
When considering withholding water or artificial hydration, this is often a much more complex matter than it appears on the surface. Check out the second heading on this post for further discussion.
Contrary to djshedlock's position, hospice and palliative care staff are actually attuned to returning personhood to a patient who may have been 'over-medicalized' into a 'thing.' It is way too easy in the classic medical arena to view a patient as a 'thing' when the main points discussed are vital signs, lab values, culture sensitivities, CT scans, chemo regimens, time on dialysis, PICC lines and ports, ICD's and IVC filters and a 5 inch thick paper chart split into two volumes. To see the person through all that is a constant uphill battle for the entire medical field. It is a struggle that finds a champion in hospice and palliative care. Painting hospice with a disdain for the individual person is inconsistent with decades of good clinical practice and research about end-of-life care.
A valid point is made about the lack of knowledge about the consciousness of those unable to respond. We can make hypothesis based on past and current information, but there is not a significant test to validate with certainty the thoughts of those unable to communicate by any means. This has long been a philosophical and medical dilemma that often does not have neatly wrapped up conclusions.
If Richard Quinn, djshedlock or others have any further comments the forum is open to them, but I would remind all readers and posters that we encourage a civilized tone as noted in our comments policy.
July 29, 2008
RQ states:
"...one's dread at asking a family member to take on the task of being a living executor/executrix. I don't want to put the burden of making a DNR decision on anyone else, so I'm trying to obviate difficulties now, not leave them unresolved for others to deal with."
Many patient's will worry about the burden they place on family members and friends. But it is important to realize that some burdens are borne more easily than others especially with help and support from those who can share the metaphorical heavy lifting.
Patients will often talk about 'not wanting to be a burden.' And families often quickly reply, 'Don't worry, you are not a burden."
No one seems to believe it; so maybe the answer is to say, "Yes there is a burden here. But it is one that I will carry because of love, friendship, the willingness to serve others, etc." That seems much more honest to me in many regards.
Also, I do agree with Drew on the 'stash' issue. Not many patients I have worked with or their families have openly discussed their 'stash.' Yes it may be there, but I have been in many open frank and honest discussions about death and dying with numerous hospice patients and families without hearing this come up but a few times.
July 29, 2008
Dear djshedlock:
Thanks for your consummate, insightful, compassionate and psychologically penetrating remarks about pitying me and my materialism.
I would ask how you garnered so much information from the subtext of my posts, but I think I already know the answer: from your own rather febrile imagination.
For your information - though you know it all already, methinks - my gravest concerns are not for myself, but for those who love me. I endure a private form of hell thinking about what they will have to endure.
Lastly, because it is clearly time for me to stop reading or posting to Pallimed, would you believe that even atheists can be - and are - spiritual beings? True.
Whoever you are, djshedlock, and wherever you are, go well: but perhaps be just a bit slower next time to so roundly condemn that or those whom you have not understood at all well.
Bless you, my child and may all good things be yours.
March 27, 2011
RQ wrote:
as I shrink into a non-viable 'thing', devoid of all conscious thought, ugly from lesions, wracked with pain, and in a vegetative state. Comatose. No longer human - but still recognisable as something that once was, and someone whom they loved dearly.
People who are sick are not things or vegetables, they are people. It is exactly this attitude that results in inhumane treatment in some hospices - withholding water from a patient who is thirsty, talking in a room as if the patient isn't there, etc. You, of course, cannot know that one who is unable to respond is devoid of conscious thought. I pity your sense that someone with lesions is ugly - your materialism has led you to wrong conclusions.
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