Physicians, Nurses, Pharmacists & Assisted Dying
Trying to come up with a Death with Dignity law that will cover all the contingencies and please all the stakeholders is next to impossible, but it is a process and we have to start somewhere. My interest is in encouraging the discussion so the best laws will be written to protect all of us while giving us the freedom to make our own healthcare choices.
The laws in Oregon and Washington are showing that fears of wholesale murder haven’t materialized. Old people are not lining up along the highways at the state line to be killed. The slippery slope is holding. But there are still issues that need to be addressed to improve the law and stop the legal battles that only hurt the patients while filling the pockets of lawyers and the media.
Physicians have been polled in states where the law has been brought to the attention of the voters and a good many of them don’t want to participate. If a patient asked, they would say no.
Some claim allegiance to an oath written around 400 BC, 100 years after Hippocrates’ death, during a time when citizens were being fed to lions and butchered in the streets, that says Primum non nocere (Latin for “First, do no harm”). Actually it didn’t quite say that originally, but “I will keep them from harm and injustice.” I don’t think that has the same meaning today.
It’s hard to believe 2400 years later that an educated person would swear an oath to Apollo Physician, Asclepius, Hygieia, Panacea, and all the gods and goddess… of the Greco-Roman pantheon (at which time it was believed the earth was flat and all else was on a dome that revolved around it). No wonder they came to have a God-complex!
Hippocrates was considered the father of medicine during the time thewas at war with just about everyone else as they conquered the lands around the Mediterranean. He was the first to recognize that illnesses come from natural causes and were not punishment from the gods, and he promoted natural healing and disapproved of the use of potent drugs. At the time, dissection was taboo in so he didn’t know much about anatomy or how symptoms related to disease. Their values and lives were quite different and more people died violent deaths than suffered debilitating and long-term chronic diseases like people today face. Then, 40 was old.
The truth is most medical school graduates today either don’t swear any kind of oath or use a more modern version, but let’s consider do no harm. Some synonyms for “harm”– (deliberately inflicted) hurt, pain, trauma; also wrong, wickedness, iniquity, sin. So it seems physicians don’t consider it harmful to allow a patient to suffer in agony for days or weeks as they are dying, but they do consider it harmful to end a dying person’s suffering by hastening his or her impending and inevitable death by a few days when that is what the person wishes.
Seems to me forcing patients to stay alive for more torture and medical insults is deliberately inflicted hurt, pain and trauma. A sin? Oh, please, save us from the beliefs of people who seek to impose the will of their imaginary gods and goddesses on the rest of us.
So apparently, according to some, helping to relieve someone, who is in the process of dying, from unbearable suffering or pain is doing harm. Really? Have you ever sat with a loved one who is dying that way, begging to die, begging for that little pill to set them free? (See my article “The Right to Die” )
The other part of the oath some physicians invoke states: I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.So when Socrates, considered the wisest man in Greece at this same time, was sentenced to death for speaking his mind, he gladly accepted the hemlock and his death rather than face exile. I wonder what Hippocrates thought about that. And here we are today debating about whether a person can choose to die or not when faced with death. Is one right and one wrong or are both right and the law should allow for individual choice?
The Hippocratic Oath also states To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else. So it’s a paternalistic, sexist document– and when was the last time anyone saw a physician who didn’t charge fees?
I don’t think we should throw the baby out with the bath water but can we get over this Hippocratic Oath defense and get practical? This is 2013, laws (and oaths) need to be relevant to the times and we need to get up to speed.
People who are conscious as they are slowly dying often see their loved ones waiting for them on the other side (read any books by Dr. Elisabeth Kubler-Ross). They’ve been traveling back and forth, out of their body, between one world and another, for days or weeks and are excited about going home. One’s final struggle is between wanting to stay and wanting to go. Some refuse to give up and fight to the end, and that is their choice; however when one is ready to go, when one requests it, let them go. The end is the same. It’s what’s in between that needs to be addressed.
Seems to me cruel and unusual punishment to force dying people to stay alive when they are ready to go, and it’s not just about pain relief. Some religious people believe suffering is part of life and seem to imply the more one suffers, the better. They believe in the “sanctity” of human life because they believe there is only one life. What if they are wrong… like the Greeks and Romans were wrong concerning Zeus and Juno and their brood?
As long as we identify with our body, we want to stay in it but once we realize we are more than our body, that we are spiritual beings temporarily living as humans in a physical world, we get the whole picture and realize that we don’t die when our bodies die…that our conscious awareness continues after our bodies give out. We just wake up, step out and move on.
My feeling is that to be done compassionately, and to dispel many of the concerns brought up by other stakeholders, a physician should be committed to his or her patients until the end. That means if a patient declines further medical treatment and requests assistance with dying, a physician should rightly be at the bedside supporting, informing, preparing, administering and monitoring until that patient expires.
I’ve read about doctors who abandon their patients to hospice when they think there’s nothing more to be done. This could be expected of surgeons whose forte is surgery, who see patients as organs or diseases, but greater compassion is expected of primary care physicians who may know the family as well as his or her patients.
Palliative care and hospice care should be given as options from the beginning of the diagnostic process and offered as a choice along with invasive options, drug therapies and clinical trials. Patients don’t seem to realize they can opt for no treatment or to stop treatment at any time. Doctors don’t bring these issues up unless patients ask when they are uncomfortable talking about death as if it meant giving up.
There’s concern about the accuracy of a “6 months to live” prognosis. Hospice patients often outlive their 6 months because they get so much comfort and attention from the highly compassionate hospice caregivers that they live longer. Instead of spending one’s last months having more surgeries, more treatments, more side effects from drugs, more pain and suffering only to die hooked up in the ICU, patients could have the opportunity to have well thought out end-of-life conversations with their families. They may get palliative care so they are pain-free and able to fill out Advance Healthcare Directives, complete their bucket list, write their memoirs, wrap up unfinished business, complete their life review and give away treasures to family before transitioning to hospice care where they get to say goodbye to loved ones and have a going away party before they pass peacefully (with or without assistance).
When doctors treat their patients holistically, there’s still a lot that can be done when it comes to healing body-mind and soul. Physicians generally just haven’t been taught how to deal with death with their patients. There were no courses in med school until recently due to all this controversy, but lately things are changing and new physicians are finding courses available to help them relate to their patients as people and understand death as merely a transformation of energy. In my opinion, those who have already graduated need some continuing education classes.
Do I think “physicians” are the ones who should ultimately fill this role? Not necessarily. As I just mentioned, they’re not trained for it and it doesn’t fit their mindset. The whole physician-training process needs to include dying in a holistic healthcare continuum for their attitude to change. MDs may be the only ones who are permitted to prescribe the medication, but a newly-designated medical specialist (e.g. MD or RN with PhD in Thanatology) could be at the bedside to protect the patient’s interests following certain guidelines and carry out his or her end-of-life wishes for a quick and peaceful release.
This way, someone capable would be at the bedside if anything goes wrong (e.g. patient falls asleep before ingesting all meds, patient throws up meds, something goes wrong with an IV line), as well as pronounce the patient and sign the necessary paperwork. Just as it takes great compassion to be with the dying as a hospice nurse but not all nurses have the passion to become hospice nurses, only certain physicians will have the sensitivity necessary to assist patients who request assistance with a quick and peaceful pre-planned death.
They may be those women and men who realize death of the body is just a transition, a transformation of energy from one state to another with continuation of consciousness, and that assisting the dying to have a peaceful and meaningful experience helps to heal the soul as it is leaving the body.
Polls show that a lot of nurses are opposed to participating as well. Back before the November election in Massachusetts last year, an organization of nurses put out a statement of opposition to passage of the Death with Dignity Act. Hospice nurses who are more attuned to the needs of the dying could develop a transition guide specialty, but they would have to shift their mindset beyond only stopping eating and drinking being acceptable. It’s OK for a person to starve to death over a week or two along with their other ailments, aches and pains as they are dying? It’s OK to pump them full of morphine so they are comatose for days? It’s OK to force people to live but not OK to allow them a peaceful passing? It’s not OK to be OK with dying and wanting to speed up the process if one is dying anyway? Hmmmmm….
There’s a wonderful book by two hospice nurses, Peggy Callanan and Nancy Kelly, Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying, in which they talk about their experiences at the bedsides of hundreds of people as they were dying. They describe how wonderful and how terrible it can be for the dying and for the families in different circumstances. For some people, they say “I’m going now,” close their eyes and take their last breath. For some, it’s like a fight to the finish to rip the soul out of the body. We don’t know how it will be when it’s our time, but those who have gotten their prescription say they take comfort in knowing that they have the option if they decide to exercise their desire for death with dignity. It doesn’t mean they will, in fact, most do not. Some have a peaceful death without it. Some wait too long and are not able to take it without assistance.
The other issue that comes up here is euthanasia, which means a physician or another person administers the lethal dose either by mouth or injection. This is where it gets tricky with the law because it’s considered murder to kill another person. It’s not illegal to commit suicide, but no one can legally help you do it. You don’t want your relatives to be put in prison for helping you out but you may be incapable of doing it yourself. That whole thing with Final Exit and the helium bag over the head– it’s just insane that a person should be forced to resort to such measures, but it’s got to be better than blowing one’s brains out.
For people facing Alzheimer’s, should they be eligible for a dignified, peaceful death before succumbing to the agony of losing their mind? For someone dealing with MS or ALS or locked-in syndrome, should they be eligible for assistance if they decide they want out of their progressively worsening condition? I don’t think people should be required to live that way if they don’t want to… whatever their reasons. If they’re OK with it, fine… live on. I certainly don’t believe in wholesale killing of the elderly and disabled, and am fully aware of Hitler and others like him, which is why I believe we need good laws to protect the vulnerable but still allow freedom of choice. This is still America, not Nazi Germany.
As for people in a vegetative coma, if it were me… just shoot me now! But I stress the importance of filling out Advance Healthcare Directives at an early age because you never know what accident, medical procedure or infection might suddenly put you there and leave your loved ones with gut-wrenching decisions about the care of your body because they don’t know what you would have wanted or some well-meaning organization steps in and decides you must be kept alive because you might wake up 20 years from now… and some people do, and loved ones tend to hold out for that hope. You need to decide how long to wait before it’s OK with you to pull the plug.
Perhaps we need a new definition of murder? My dictionary says– “the unlawful premeditated killing of one human being by another.” Could we just add— without consent? So if a person consents to euthanasia, it wouldn’t be unlawful. Or if the definition exempted ending of life under the care of a physician at patient’s request. It just seems to me that a simple injection would be easier on a person than swallowing all those pills now required for the process and that a responsible person should be there to make sure all goes well, no mistakes, no question the person made his or her own decision willingly, and that the death was peaceful. And who else’s business is it besides a patient and his/her doctor any way? This paternalism is getting really boring.
Another voice is the pharmacist. Now some of them are citing religious or moral values that say assisted-suicide is murder and we’re not going to dispense these prescriptions so people can kill themselves. I don’t know that they have a right to question a physician’s judgment or not fill a prescription. They fill all those prescriptions for psychotropic drugs so many people are hooked on without question turning us into a nation of prescription drug addicts who often overdose, but someone who wants out early at the end of their life must be denied because some pharmacist doesn’t think it’s right or it goes against his beliefs. I don’t think so.
They dying patients are the ones who suffer when these people force their judgments and beliefs on vulnerable people who just want control over their own lives and a peaceful death. Religious organizations and moral absolutists pour money into negative propaganda to scare people into thinking someone wants to make it easy to kill off old, sick and disabled people thereby denying the rights of dying people who are capable of making their own end-of-life decisions. They squash support for personal freedom in healthcare instead of funding educational programs to help people make informed decisions about their end-of-life healthcare options. They have their priorities backwards. Help to strengthen the law to protect the vulnerable but don’t force your beliefs and opinions on people you don’t even know.
COMING NEXT: Discussion about The New England Journal of Medicine open forum about whether physician-assisted suicide should be permitted or not in a particular case scenario.