Saturday, December 24, 2011

A Lethal Injection

I entered the exam room as an intravenous catheter was being inserted expertly. The procedure had been explained to me. I wanted to be there to comfort my friend in his last moments. Life had been getting difficult and the infirmities and pain too severe. The doctor entered the room with an appropriate look of sympathy on his face and reviewed the case agreeing that my friend's quality of life was severely impaired.

The sodium pentothal was slowly injected IV. I saw a questioning look on my friend's face, he then slumped to the table and died. Being unconscious, his breathing almost immediately stopped, then the heart beat ceased a few minutes later. It seemed so fast.

I loved my friend, my companion, my dog. We walked in the park or on the beach every morning. He greeted me, my wife, my children, and my grandchildren each day like long lost friends. His goal in the yard (thus in life) was to be protective seemingly at all costs.

Today we grieve, but not like when I lost my mother or father, or when I lost a patient. It's a mixture of sadness for our loss, but contentment that he didn't suffer and could have a peaceful end.

Many patients over the years asked me for a peaceful painless end. Before hospice and palliative care, a patient would often sense abandonment or a loss of control at the end saying, "Doctor, my dog was treated more humanely at the end than my father was." Ironically, my experience today has brought me to question how humane we humans really are in our treatment of each other at the end. Do we have lessons to learn?

Tuesday, December 13, 2011

Making Our Values Known

One day in my office, an elderly couple said that they had a document they wanted to add to their advance directive. It went as follows:
"I have a firm belief that God created me, that there is a natural cycle of life, that death is inevitable, and that dying should be peaceful, comfortable, at home, if possible, and without tubes, artificial nutrition and ventilator support. If I cannot carry out self care, do not have my usual mental faculties, or have an incurable disease or intractable pain, please treat me with the best care for comfort but not invasive life support care. It is quite acceptable to withhold fluid and nutrition from me and treat me with a morphine drip as part of this care for comfort, letting nature take its course. I have no wish to be a burden to my loved ones, or to spend resources and energy on heroic efforts to prolong my life when life is at end. Only in the acute situation (e.g. trauma) would I want heroic life support to try to get me back to my present state of good health. My worst nightmare is to spend my days in a nursing home with a feeding tube. Quality, not quantity,of earthly life is more important". I was delighted that they had taken the initiative and that we could talk things over.

This type of statement can be added to one's living will and serves as a very important guide to the physician and your loved ones. The conversation is focused on your values, not just on what high tech marginally beneficial treatment could be attempted. Please consider doing this or something similar such as a Five Wishes form or one from Compassion and Choices. Also, general values statements can be of use.

The ultimate document putting values into medical orders is the POLST form, but this form is generally most applicable in the last year of life, for hospice patients, or for the frail elderly who are sure what they would or wouldn't want in a medical crisis. For the rest of us, the addition of a values statement to our living will (plus having the important discussions with our family, friends, physicians, and durable power of attorney for health care) will be our best assurance that indeed our wishes will be respected.

Saturday, December 10, 2011

Saying Goodbye - The Descendants

The young woman lays dying suffering severe brain trauma from a boating accident. Her husband and two daughters are devastated each in a very different way. Friends try to help and also need to say goodbye. The advance directive is clear and there is no conflict that her wishes need to be carried out. A date for removal of the ventilator is set, and all come to say goodbye is their own way. Grief is mixed with anger, blame, love, confusion, and a need to control.

This story doesn't sound like Hollywood, yet this end-of-life story was surprisingly released in this pre-Christmas season. George Clooney's leading role in The Descendants plus the film's gorgeous setting in Hawaii should help draw folks to the box office even though some critics find the story depressing - a mixture of humor and sadness.

The thing that strikes me about this very well done movie is that it's really not about the end of a life. It's about how we grieve and become more real as we finally face emotions as they surface, as we assimilate new facts and as we deal with old unresolved conflicts. Can we be angry at the dying person or each other? You bet. Can teens act at their worst? Of course. Can we make more ethical decisions about how to live our lives? Maybe.

So if you want to laugh, cry, grieve, and have hope for our humanness, go see The Decendants!

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