We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
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Monday, April 25. 2016
I read this short piece, Death and the Psychiatrist, and do not feel that it was worth publishing (or linking, except as an example of a weak essay). Of course, I saw plenty of dying during my medical training. There are many ways to die, but the worst one is to die in agony and terror. Nobody needs that.
It seems common enough these days to see terminally-ill patients tortured by heroic medical efforts. I hate to hear about this. Physicians, of all people, should know when to let go even if families do not. Hope is not a plan.
When your 104-lb body is packed with cancer and wracked with pain, would you chose one more round of chemotherapy, or hospice care where you would be gently eased out of it all, floating on a sea of morphine?
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I will take the comfort of morphine and the Assurance of Heaven, Thank You.
I have watched, often in horror and sadness, while three members of my family died from cancer.
The chemo turned them into literal vegetables. It was disgusting, made even more so by the doctors who were ''so proud'' that they had extended life.
It is no coincidence that my sister, my mother and my father had excellent health insurance. The cost of the chemo etc was, well, beyond excessive.
At some point, and my view is most of the time, chemo is a scam to delude people into thinking they can be saved.
In reality, the only interest is "saving'' the insurance payments.
I have known others in the same situation.
Better to do without, die as a human being, conscious and able to communicate with you God.
We are born of pain, and die that way. what some doctors call being alive isn't. it is a sick joke.
The problem is it is easy to go from the truest terminal to the inconvenient. With my dogs over the years I've learned to fight the inconvenience factor and focus on their condition.
One other thing is that for thousands of years and still today medicine consisted of mostly futile treatements. Only by trying and observing are insights gained. So I'm reluctant to dismiss all heroic efforts. I'm old enough to remember the first heart transplant which was futile by some definitions
Don't know if they still say this; but, decades ago they refused to give my grandfather more morphine for his pain from cancer because "he will get addicted."
He was dead a month later, as they predicted, but, thank heavens at least he wasn't "addicted"!
Had this happen a couple of time with my family members. They even stopped surgery on my grandfather as he was going to die in surgery to cut the nerves to kill his pain. He went on to suffer a good number of months in total agony.
I will be forever grateful to the doctors at St Joseph hospice in Marshfield, where they gave my dad, dying of non-Hodgkins lymphoma at the age of 62, as much morphine as he wanted.
The only bad thing (other than the obvious) was that there was an order in his chart to give him some kind of drug to counteract any slowing of his breathing. My sister is a nurse practitioner. She read his chart and told us that if his breathing was slowing, it was probably because he had had a lot of morphine.
"If he is in that much pain that he needs that much morphine, it is time for him to go," she said. "I want to have the order for this drug removed."
We agreed and it happened. My dad was in pain, but he was in as little pain as possible, I think, because every single time we asked for more morphine, we got it.
A couple of times or more now, I've given someone up for dead only to find I was unreasonably pessimistic. It makes me hesitate, though there are still conditions that obviously call for hospice and the easing of pain rather than continued heroic treatment: terminal congestive heart failure in the elderly, for instance, and usually late-stage cancer.
You can call it "physician-assisted dying" or think of it as "physician-eased dying" but these are simply euphemisms for what it really is: death by physician.
We are going down this slope even now in Canada and it is a slippery one indeed.
Years ago I attended a bible-study with a resident who was becoming a bit of an expert on pain-management, and who was very anti-euthanasia. He had a very clear concept of a difference between providing an intentionally lethal dose and providing a dose that was adequate to ameliorate the level of pain being experienced, even if that dose might be lethal. He also told me that most doctors completely under-estimate the tolerance to pain-killers that someone in severe pain will have. Giving adequate dosages doesn't make them dopey, it makes them feel more normal.
He was supervised by a very pro-euthanasia doctor. One day he came in beaming, and when asked what was up told us of a terminal patient who had been begging to be killed on account of his pain, and the head physician had written instructions for presumably what he thought would be a lethal dose, with a stern warning to my friend that if he made any change to it he would be sacked. My friend had a look at the chart, and as it was pretty close to what he thought was necessary for pain-management, he thought it seemed a pretty good start. It turned out not to be lethal, and with that level of morphine the patient was comfortable and having a great time with his attending family members and friends.
I've spoken with physicians in the Netherlands and Canada who have a great fear that the legalization and normalization of "voluntary" euthenasia will lead to inhumane pressures not just from family-members who would benefit from a death but from medical systems that are already rationing care. Why should resources be wasted on terminal patients, when treatments for younger/healthier people are being delayed?
Euthansia is a gambit of "Managed Care." and I am very suspicious of it in that setting. June marks 50 years since I graduated from medical school and I agree completely with the Hospice movement and with the comment about "heroic treatment." I have known very few "heroic" patients.
I have some stories about this in my latest book called "War Stories: 50 Years in Medicine." I don't want to violate any comment rules so will not add a link.
I loved your book. What amazing stories. I gave a copy to my ailing father who is also a physician (not a surgeon) who did his residency a long time ago in London. I bought the Kindle version for myself and found it both hysterically funny and horrifying. I would recommend it to anyone, you are such a gifted writer and probably a very gifted surgeon as well. Thank you!
"It seems common enough these days to see terminally-ill patients tortured by heroic medical efforts."
You call it heroic, I call it a profit motive. Caveat Emptor.
When my father was dying after resection of a Grade 3 /Grade 4 brain tumor, we insisted on discontinuing radiation treatment after he lost almost all cognitive function. His radiation oncologist accused us of "euthanising" him and dragged us before the ethics board at the hospital where he was being treated.
I trotted out the studies that showed the mean time to failure (aka Death), was resection, plus 9 to 11 months. I prevailed, and she still got a six figure check. At that time, we were in month 6, Pop lived three more.
Sorry, the medical community is as run through by avaricious thugs as any docks in the Phillipines.
I just looked at some info about the Hippocratic oath and it seems that doctors don't have to take or it's been altered, so there's no actual "do no harm" clause in present version. Happened along the same time that we removed God from "education" and everything else.
No wonder. We have this conversation in my house often. How everything revolves around money. The new worship is money.
@Mike, I put your book in my amazon cart.
Thanks. A lot of misbehavior, at least in California, is coming from hospitals buying up medical practices and giving new young doctors rules they have to follow. A friend of mine, who is a gastroenterologist, has a nice endoscopy suite in his office that he built 30 years ago. Last year he was "invited" to do some of his endoscopy in the hospital GI lab. It was along the lines of "nice little practice you have there. It would be a shame..."
He went by to check out the place and looked at some charts to see what they were doing. He said every chart showed maximum lab work ordered, whether it was needed or not. The older docs are retiring or going to cash practices to escape the bureaucrats.
Sorry. The previous century alone offers enough examples of what happens when humans take it upon themselves to determine whose life is not worth living...
Combined with ANY system that intervenes between buyer and seller of health care services - this is a recipe for disaster. In the current political climate, this is just one more front in a general attack on "inhuman" Western moral standards, using the same cheap emotional mau-mauing.
There must be a bright line distinguishing what doctors and others can and cannot do to the infirm and incapacitated.
Patients or legal caretakers are always free to:
Check out and go home.
Line up a sympathetic doctor.
Buy an insurance policy that covers hospice.
But all that requires forethought and taking responsibility for your moral choices. How passe! I'll just declare myself a victim - and everyone who disagrees with me a 'hater'.
Sorry. As your last meaningful act as a citizen, don't compromise the moral underpinnings of the society you lived in quite well, whose freedoms you enjoyed.
Hospice care may well be as good as it gets but it is still rather careless and cruel. My father in law lived for thhree months or so in hospice care, nurse visit twice a week, pain killers delivered by UPS and a family member always there to change the sheets and feed him. But do not take him to the hospital if it takes a turn for the worse because that is the deal you agree to by accepting hospice. Do not call 911 when his breathing becomes labored or he throws up blood because you are in hospice and are supposed to just die not be treated. You are on your own, I assume if one of his limbs fell off that too should be ignored since it isn't covered under hospice. No! Give me the needle. Keep your hospice, thank you.
I am a critical care registered nurse. The agony that some patients experience is truly that: agony. I am all for treating that patient's pain appropriately. If the patient and family have decided they are done with treatment and they simply want comfort measures, then I am all for giving them all the narcotics they need to achieve comfort, even if we are risking death from respiratory depression/failure. But it is an ENTIRELY different thing to expect the medical community to assist in murdering someone. The public should NOT want doctors and nurses having that sort of power because it will be abused.
I love my job. I love the doctors I work for and all are committed to helping patients live the best quality of life, which does not always mean squeezing out the longest life possible. But our mindset must always be on life, and making a patient's life as pain free as possible. Our goal can never be death, no matter how noble the cause may sound. Once that door is opened, no one will be able to close it and there will be no end to all the real and perceived ills we will be asked to "help." I wish there were some other way.
I come from an older generation that still had (I think) some humility and connection with patients. Now, we have ethics committees and trial lawyers ready to second guess every decision. I'm glad to be out of it. Even 20 years ago, I have had a family vote on whether to keep the IV in Dad when he was obviously dying.The vote was 5 to 4, sort of like the Supreme Court.
The one lawsuit that my malpractice carrier paid out a small amount on was one in 1986 for giving a kid 8 units of blood as he was bleeding out. I saved his life and then five years later, he developed AIDS. There was no test for HIV in blood when I did his surgery. That was early in the epidemic and five years' survival with HIV was rare. The family got $1500. And lost the whole support system that had cared for the kid since he was 8 years old.
That story is in the book, too.
I had a friend in the early 80s whose young son survived leukemia only to die a few years later of AIDS. She never even dreamed of blaming the doctors; no one knew then of the danger of all those transfusions. I'm so sorry that happened to you.
I felt very sorry for the family.
I had seen that boy every six months for GI bleeding from the time he was 8 until I had to operate on him at age 18. He then never bled again and I saw him for various things until he was 25. I would write letters to employers as he was a little slow mentally and people were afraid of his history. I got doctors to see him who would not otherwise treat Medicaid. Finally, when the AIDS diagnosis was made, we arranged for him to see an excellent clinic in Laguna. The family got a lawyer who wanted to sue the Red Cross even though there was no test for HIV then. He told them they had to sue me too.
They were apologetic but hoped for some money from the Red Cross. All the doctors then dropped them. I don't know what happened to him after that.
Since the Doctor who helped patients die, Dr. Kovorkian, has died himself, your only choice now if you want to end your life is Obamacare.
"...would you choose one more round of chemotherapy, or hospice care..." - the problem is that will NOT be the choice. Forget hospice care and the wafting off on a sea or morphine, it's cheaper and more cost-effective just to "off" Granny and be done with it so that is what will happen.
Our family walked with my mother and aunt through their final days. It wasn't easy, particularly to one daughter who was in the room when her great-aunt died. And those walks took a toll on us. But, if you ask the family, they would be definite that they were glad they took those walks.
How is it possible to see no moral issues, and then say a particular inaction is immoral? Is not the question to ask, "What is the basis of moral decisions"?