Monday, August 31, 2009

Death Panels - now really!

A friend recently sent me an article from a conservative ethicist. The author was very concerned with end of life counseling. He repeatedly referred to the pervasive "culture of death" making headway in our society, trying to tie this issue to the abortion debates. There is a book and several articles discussing the alleged culture of death. Actually I ran into this when my own father was dying at age 94 after 5 years in a nursing home. He had said repeatedly that he was ready to go and wanted no artificial measures to prolong his life. Initially he stopped eating, then after a week stopped drinking and slipped into unconsciousness. Per his wishes we elected to have no IV fluids or tube feedings. He was offered fluid sips and had excellent mouth care to help diminish any sensation of thirst. If he appeared uncomfortable, small doses of morphine seemed to help. Fortunately I was able to sleep on a cot in his room and was with him at the end. It was a sad but good feeling that I had, that is until a friend told me, "well, you're just going to prevent care for these old folks, starve them and leave them out there to die." I was flabbergasted by the insensitivity and accusatory nature of the comments.

As I met with a senior group the other night to give an end of life planning talk, one fellow came in early and asked, "Is this where the death panel meets?" Then he laughed and said, "The whole things crazy isn't it. How can those idiots believe what they're saying."

Hospice associations, ethicists, and large physician groups have spoken out against this kind of willful political gamesmanship. The problem is that there is a segment that believes the hype, and the lies are being promoted to undermine the needed rational discussions about health care reform. The logic that physicians discussing end of life planning are somehow in a conspiracy to promote euthanasia simply doesn't fly. The program I present helps to clarify an individual's values, advises how to talk to loved ones and their personal physician, and how to get their ideas down on paper. Especially important for everyone is to have someone close to your heart as the "durable power of attorney for health care decisions." This person can speak for you and be an advocate when you are no longer able to. Research is showing that people in hospice care are actually living longer than predicted. Hospice is a Medicare benefit, thus a government program. Hospice is loved by patients, families, nurses, volunteers and physicians. This end of life care has no death panels, no government interference - and believe me none would be tolerated. When surveyed, most people with a terminal illness would prefer to die at home with loved ones present and with good palliative care for symptoms.

Sunday, August 30, 2009

Doctor, I want to die

Several years ago, I was called by the ER to manage a young man I'll call Dan who was becoming acutely paralyzed. It turned out that he was the only one in the family to eat his wife's home canned spinach and had developed acute botulism. He needed rapid intubation, then transfer to the ICU for on going ventilator and supportive care. He received anti-toxin as soon as we could get it. His wife was devastated and needed a lot of support from their pastor and the social worker. Dan required tube feeding, an air bed to prevent pressure skin ulcers, close monitoring of his ventilator and a close watch for infections. The anti-toxin had no measurable benefit, so on we went with care. His wife, I'll call Sue, was with him constantly and the two kids aged 2 and 4 we're allowed to visit at the family's discretion.

The medical prognosis was that of complete recovery but it was going to take a few months for his paralysis to clear. After about 6 weeks, Dan was able to communicate that his life dependent on a ventilator and with full body care was not worth living, even if he might recover. The psychiatrist judged him competent and not clinically depressed, but it was possible that he could not able to realize the fact that he indeed was going to get better. I told Dan, after discussing with my colleagues, that we couldn't agree to remove the ventilator because of his excellent prognosis. Our ethics committee agreed with this stance although the usual ethical principle of autonomy seemed to be violated here. Basically the other ethical principles of beneficence and non-malfeasance were the ones that seemed most appropriate to us.

Dan made it clear that he wanted a lawyer. Fortunately, I think, the lawyer went along with the wife and medical team and told him he couldn't go for a court order or guardianship in these circumstances. We were aware of famous "wrongful life" cases but felt that we needed to be an advocate for this man's healthy future and that there were legal risks in either course.

Personally in the ICU I have, to respect the patient's wishes, withdrawn life support in terminally ill patients. This is generally done with consensus of all the loved ones and occurs daily in all ICU's across the country. Ethics committees are invaluable in the more difficult cases.

But Dan's case was unique - and he did survive and returned to his life as a husband, father and productive citizen. When I saw him later in my office, I asked, "So how do you feel about our keeping you going against your wishes." He paused, then said "Well, I'm very happy to be alive but there's still a part of me that's pissed off."

The funeral as we know it is becoming a relic — just in time for a death boom

By   Karen Heller April 15 Ed note: Funerals are changing in ways that will bring culture shock and a shake of the head of s...