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Friday, December 16, 2011

Christopher Hitchens: Dying as an Atheist

Image credit: Wikipedia
Christopher Hitchens, noted author and philosopher died December 15, 2011 leaving behind many essays, books, and other writings as well as contributing to several lectures, ethics/religion debates, and TV talk shows.  His acerbic style often ruffled feathers as he attacked religious dogmatism.

As one of the most famous outspoken atheists of this era, his thoughts on being diagnosed with an incurable disease would be a powerful insight into how atheists might approach illness and death.  Where others might retreat from the public spotlight, Hitchens attacked his cancer through writing.

As a doctor caring for patients facing their own mortality, understanding their spirituality becomes an important part of caring for the whole person.  I have seen many caring family members and friends inquire to me if their was enough time to get the appropriate clergy to help a patient convert or be saved.  A person dying as an agnostic/atheist or even not the right religion becomes a very important focus for some people.  Some have asked me or chaplains if we have ever seen any 'deathbed conversions' or someone who died without being saved.  I never really expected this before I became a palliative medicine fellow.

What surprises me about the inside peek that Hitchens gives us with his writings is that many of his feelings, thoughts and experiences are really about the human condition and I have seen and heard similar things from religious patients as well.  In reading his articles it helps me understand that despite all our differences we are all human and as we die our experience is both unique and universal.

I wanted to share a few choice quotes from his articles here.  Any one of them would be a good review for your team or learners on discussing the different approaches to dying that our patients experience.

The quotes come from the following Vanity Fair articles:
Unanswerable Prayers - Oct 2010
Miss Manners and the Big C - Dec 2010
Unspoken Truths - June 2011
Trial of the Will - January 2012 (published posthumously)

On stories about any possible deathbed conversions:
In which case, why not cancer of the brain? As a terrified, half-aware imbecile, I might even scream for a priest at the close of business, though I hereby state while I am still lucid that the entity thus humiliating itself would not in fact be “me.” (Bear this in mind, in case of any later rumors or fabrications.) 

On holding hope and realism:
The absorbing fact about being mortally sick is that you spend a good deal of time preparing yourself to die with some modicum of stoicism (and provision for loved ones), while being simultaneously and highly interested in the business of survival. 
On losing his voice:
Now, if I want to enter a conversation, I have to attract attention in some other way, and live with the awful fact that people are then listening “sympathetically.” At least they don’t have to pay attention for long: I can’t keep it up and anyway can’t stand to.
On sharing stories about other people's cancer:
...your narrative may fail to grip if you haven’t taken any care to find out how well or badly your audience member is faring (or feeling).
On a false cliche (What doesn't kill you makes you stronger.):
After all, if it were otherwise, then each attack, each stroke, each vile hiccup, each slime assault, would collectively build one up and strengthen resistance. And this is plainly absurd. So we are left with something quite unusual in the annals of unsentimental approaches to extinction: not the wish to die with dignity but the desire to have died. 
On pain:
It’s probably a merciful thing that pain is impossible to describe from memory. It’s also impossible to warn against. If my proton doctors had tried to tell me up front, they might perhaps have spoken of “grave discomfort” or perhaps of a burning sensation. I only know that nothing at all could have readied or steadied me for this thing that seemed to scorn painkillers and to attack me in my core.

Friday, December 16, 2011 by Christian Sinclair ·

Palliative Drug Shortages

There was a time when I heard about chemo shortages, and I thought that must really force some tough choices for patients and physicians.  But thankfully (I thought) drug shortages for generic non cutting edge medications that have been around for a long time like the ones commonly used for symptom control would probably be relatively immune.

But in the past 2 weeks I began hearing rumblings from our pharmacists about a possible shortage of IV lorazepam.  As I researched this more it appears to be a much bigger problem.  It wasn't just local or even regional but national.  Thanks to the American Society of Health System Pharmacist (ASHP) website I could find out lots of info that is up to date on the supply chain of key meds for hospice patients.  They have a drug shortage page which a pharmacist (Mick Schroeder) turned into an app for iPhone and Android.

Quick quiz: How many medications do you think are on the current drug shortage list? (Answer at the end of the post)

But the thing about the lorazepam shortage is that the other benzodiazepines you might consider for conversion are also involved in this shortage.  The reasons for the shortage are (via ASHP):

  • Bedford discontinued lorazepam in May, 2011 to concentrate on the manufacturing of other products.
  • West-Ward acquired Baxter’s lorazepam injection products in May, 2011. The company cannot provide a reason for the shortage.
  • Hospira states lorazepam vials are on shortage due to increased demand. The 1 mL iSecure syringes were discontinued in September 2011.
Converting patients to other benzos seems appropriate but midazolam and diazepam are also listed as having drug shortages on ASHP.  And even if you do have them in your pharmacy supply chain, without injectable lorazepam there is bound to be a run on these other two injectables thereby increasing the strain.  

While home hospice patients may do fine with PO/SL lorazepam, inpatient units and hospitals may depend more heavily on injectable benzos.  I am curious to see what other hospice and palliative clinicians are doing to handle this shortage that apparently is expected to last until February or March.  Please share your thoughts in the comment section.  

(Related: Outcome Resources blog has a post on the lorazepam injection shortage as well.)

Quick Quiz Answer: Approximately 210 drugs are listed as currently being in short supply.  I thought it was going to be 30.  Yikes!

by Christian Sinclair ·

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