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Sunday, January 6, 2008

The Changing Faces of Death; Pal-Pourri; Pallimed Party

There have been a few pieces in the media recently that have caught my eye in regards to how we as a society look at death and dying. The Montreal Gazette published an opinion article with the title "What if we could choose our time to die?" The author, Hugh Anderson, writes the piece in response to letters from his previous piece about growing old. He never makes a strong statement about hastened death, but his title alone is provocative to start a few conversations.

What if we took our current concepts of medical care and instead had a very open approach to time of death, similar, for example, to our medical approach to time of birth. Time of birth used to be wholly a natural event, for better or for worse, but the advancement of modern C-sections, medicines & delivery techniques changed the natural prognosis (expected timing and medical outcomes) for births. What would our current system of hospice, palliative medicine, and intensive care units look like if in 1950 American society determined choosing the time of your own death was an inalienable right? I doubt if we took the quick road to death that the modern hospice movement would have evolved as it did. Would this change our approach to organ transplants as well? What other areas of medicine would be vastly different because of this massive social change? If there are any literary minded Pallimed readers who would be interested in doing some creative writing, we could collaborate on an alternate history of the approach to death in American society. Exploring alternate history is a wonderful tool for insight into current situations and values via taking what we hold as normal and turning it completely around. I think you could take this idea and explore it in various outcomes, from dytopia to utopia. Obviously movies like Soylent Green and books like The Giver explore some of the social ramifications of euthanasia, but a focus solely on our medical culture would be an interesting approach as well. (Disclaimer: Not endorsing hastened death, physician-assisted suicide or euthanasia, just using these examples to explore the deep intricacies of such a profound part of life. Besides, Hugh brought it up, not me. I can't help wanting to share some potentially provocative ideas. Great dinner conversation!)

Speaking of how society feels about death, the Supreme Court heard a potential landmark case (Baze v. Rees, 2008) today noting the 3-drug lethal injection (thiopental, pancuronium, potassium) is unconstitutional because of the potential for severe pain without the ability to identify it (secondary to the paralytic). You can read the transcripts of the oral arguments here for you legal junkies. What is interesting is to read some of the amicus briefs in support, opposition and neutral positions. The American Society of Anesthesiologists weighs in as well as heavyweight medical ethicists/palliativists Robert Truog, Bernard Lo, and Margaret Campbell (with fellow critical care providers and ethicists.) One of the arguments heard today for changing lethal injection is to co-opt the methods for hastened death in the Netherlands or Oregon, by using inordinately large amounts of barbiturates. How would this change the debate on physician assisted suicide if it was a similar clinical approach to capital punishment?

Wired Magazine had a recent article showing us that death is nothing we need to worry about because of some new miracle drugs that focus on our mitochondria. Some great quotes are found in the article from bench researchers:

"They die of natural death ....probably their heart stops to beat!" wrote Fontana of the rodents in his and other studies, which betray little evidence of the histopathological lesions -- tissue and organ damage or abnormality -- mentioned by Bartke. "The animal drops dead and we cannot really know why.... One expanation (sic) is the failure of the electrical conductive system of the heart because of metabolic alterations.... No pain, no suffering, no medical and social cost for society!"
Well this post is already getting too long so I won't comment on the broad assumptions in the last part. Maybe it is because I fear I might lose my job if this comes true. But it did make me chuckle to think of how these little mice will change lifetimes of angst about death.

YouTube clip of Ingmar Bergman's The Seventh Seal - Knight Facing Death in Chess
(wait until about 2 minutes in, there are some great lines here)

  • Did not see much press (unfortunately) about Dr. Byock's initiative for Reclaiming the End of Life and discussing this with Presidential candidates at town hall meetings. Since the NH primary should soon be over and the last news report on the website is Sep 2007, we might not see more action from this until the Presidential election in November.
  • Speaking of politics, political candidates are (sadly) bringing up the unfortunate case of the 17 year old who died while awaiting a liver transplant as a way to point out failures in our current medical system. While most media outlets seemed to pitch the most emotional part of the story ("A girl was denied a life-saving treatment by an evil insurance company"), Maggie Mahar at Health Beat does a great job of highlighting the complex ethical issues in this case that has some good teaching points for palliative care (prognostic accuracy, second opinions, goals of care, etc.) There were not easy answers in this case, and there are many tragedies here as well, which now seems to by devolving into finger pointing.
  • Feedback on some of the DonorsChoose Projects are included in the comments section. Thanks to all of those who participated on behalf of Pallimed!
  • Winners of the HPCFUSA BOOK and Coffee Mugs will be contacted soon and later announced.
Pallimed will be represented at AAHPM by Drew and Christian so due to popular demand, we will be having another Pallimed Gathering @ AAHPM in Tampa, FL. We do not have the location yet, but we have planned on Friday night Feb 01, so mark your calendars and bring your friends. We had a great turnout last year, and hope to meet more Pallimed readers this year. Look here for more info soon.

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