Death Care

Reprinted from AAPS News, Volume 72, no. 4, April 2016

In the post-Hippocratic, post-Christian, post-modern era, facilitating or even causing death is becoming a form of treatment, often called “end-of-life” care. This is now supposed to be voluntary, although the decision might be made decades prior to the event. There is a continuum, and it is “evolving.”

The leading edge is in Canada, which is the first jurisdiction in the world to require physicians to perform assisted suicide or euthanasia or make an “effective referral.” This is considered “an appropriate balancing of the rights of patients and the conscience rights of physicians” (source). A government panel also recommends forcing all publicly funded institutions, including Christian hospitals and nursing homes, to kill patients on demand (source).

Mental illness, even treatable depression, can make one eligible for death. Quebec doctors are reportedly withholding life-saving treatment after a suicide attempt, interpreting the attempt as a refusal of treatment (source).

The Canadian parliament worries about disparities—the indigenous populations might not have equal access to death. Statistician William Briggs worries that intransigent Christians might be diagnosed as having a mental illness, Christianity being perceived as the major stumbling block to acceptance of the utilitarian view (a religion not called religion) that life is not worth living unless useful to society (source).

Euthanasia has been legal in Belgium since 2002. A new draft law would require all physicians to accede to a euthanasia request within seven days, or refer the patient to a physician who will. It would also eliminate the five-year “sunset clause” to living wills, making them valid indefinitely (source).

In the U.S., the debate over physician-assisted dying (PAD) is at a “turning point,” writes Zosia Chustecka. A 2015 poll in the United States found that more than half of physicians surveyed favored medical assistance in dying. During 2015, 23 states sought to codify PAD, and eight of these states have done so. This unprecedented legislative wave represents six times more such bills than in 2014 (MedScape 1/21/16,).

While public opinion is also shifting in favor of assisted death, the percentage of people who think everything possible should be done to save a patient’s life increased from 15% in 1990 to 31% in 2013. Families often disagree with physicians about whether care is “futile,” and families may prove to be correct. There is good reason to fear that a “do not resuscitate” order will lead to poorer care. A 2015 study showed that when cardiac patients with the best prognosis had a DNR, their survival rate was poorer than that of similar patients without one (Leigh Page, MedScape 3/16/16, ).

The Third Path to Death

Death can be hastened without active physician help by simply withdrawing “treatment,” now defined to include food and water, perhaps aided by “terminal sedation.” The Robert Wood Johnson Foundation and George Soros’s Open Society Foundation are among the advocates of this path, having between them pumped at least $40 million into transforming “healthcare” into “managed death care,” writes Mary Ann Kreitzer of the Fitzgerald Griffin Foundation (source).

Medicare’s paying for “conversations” about end of life is “Just the First Step,” according to a Health Affairs headline. Doctors need to be trained in how to deliver the message (Kaiser Health News 3/16/16, source).

Better interoperability of electronic health records is needed to assure that doctors know the patient’s end-of-life wishes “in a split second” (KHN 3/23/16, source).

AAPS president Melinda Woofter, M.D., points out that another means of end-of-life planning is being developed or implemented in all but five states: Physician Orders for Life-Sustaining Treatment (POLST) or a variant (J Am Phys Surg, spring 2016).

The ObamaCare mandate to keep medical spending below a predetermined level could spell premature end of life to patients who have a good chance of recovery and want to live. Starting as early as this year, federal standards on “quality and efficiency” could limit care that hospitals or doctors could offer even to patients willing and able to pay. Violating standards could mean ineligibility to contract with any qualified health plan, according to a March 6, 2014, report prepared for the National Right to Life Committee (source).

Redefining Death

The legal definition of death has been revised to include “brain death,” which is also assumed to be final and irreversible. There are supposedly rigorous standards, but hospital policies are inconsistent and may omit procedures intended to prevent errors (NPR 12/28/15, source).

Many errors have occurred. One was in the case of George Pickering III, whose father held off medics at gunpoint for some hours when they tried to turn off his life support. While his dad served an eight-month prison term, his young son recovered fully from the mistaken diagnosis of brain death.

Since her diagnosis of brain death two years ago, when her family was pressured to donate her organs, Jahi McMath has gone through puberty. She responds to commands from her mother and has brain wave activity. Her family is still fighting in court to void her death certificate (source).

Psychiatrist’s Response to “Want to Die” Consults

Samuel Nigro, M.D., writes of his experience doing ICU consults at St. Vincent’s Hospital. When the patient said the equivalent of “I want to be put out of my misery,” he replied, “We do not do that here. We can arrange hospice in due time if indicated.” This generally seemed to lead to a clear sense of relief and no more talk of death-causing acts. To engage may be to promote. Doctors should not become entrapped in self-fulfilling dialogue.

Dr. Nigro would confirm that the patient was very sick and might not make it, but he had seen some walk out after a similar illness. He said, “I know we’re doing something wrong that was upsetting; please tell me what that is and what we could do to make matters better.” Most said it was torture to be confused and bewildered about who people were and what they were doing.

“Despair and other affects are contagious. Medical care must be immune to patients’ affects.” He instructed staff, even housekeeping, to respond brightly and positively, and to engage and explain, every time, who they are and what they are doing. They should find out the patient’s interests and provide distractions from despair—say a virtual tour of Rome or Las Vegas.

Unless medically contraindicated, he prescribed low-dose lithium, “the only medication documented to reduce suicide and death ideation” (also see here).

The results: “Some got their wish and died naturally. Most were transferred glad to be alive still.”

The right to life means the right to a natural death, Dr. Nigro writes. “To violate the right to natural death is to violate thousands of years of medical tradition and the Oath of Hippocrates.”

The Death Bed

An anesthesiology resident describes meeting her first organ donor in a dimly lit ICU room (JAMA 3/15/16). The electronic medical record warns her she is about to enter the record of a deceased person—but he looks very much alive, young and handsome, his hand warm and soft. Later in the OR, the team reads aloud farewells from the family [to him, as if he could hear, or just to themselves?]. She reminds herself that there is no need for pain medicine, and vital signs do not change while surgeons open the chest. Then, the vital signs are gone, as is the glow of life. The skin is gray and cold. Dead.

Futile Care in Texas

While 46-year-old Chris Dunn prayed for his life, Houston Methodist Hospital went to court to try to wrest custody from his mother so it could remove his ventilator. Under the Texas Advance Directive Law, patient consent is not required for discontinuing support, only 10 days’ notice so family could seek alternate care (source). Dunn died a natural death about a month after the hospital declared treatment to be futile.

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“[A] systematic training in objectivity must be given to you. Its purpose is to eliminate from your mind one by one the things that you have hitherto regarded as grounds for action. It is like killing a nerve. That whole system of instinctive preferences, whatever ethical, aesthetic, or logical disguise they wear, is to be simply destroyed.”

C.S. Lewis, That Hideous Strength, 1945

The Trouble with VSED

Compassion and Choices (formerly the Hemlock Society) is an advocate for suicide by voluntarily stopping eating and drinking. But most demented patients continue to eat willingly, despite wishes formerly expressed in an Advance Directive: hence the idea of VSED-by-proxy, whereby a proxy can ensure that no one offers a patient spoonfeeding (source).

Profiting from Death

Soon after California proposed its aid-in-dying law, Valeant Pharmaceuticals hiked the price of a lethal dose of Seconal to $3,000 (in 2009 it cost less than $200). Medicaid and most private insurers will cover it, though coverage (and physicians’ prescriptions) remain voluntary ().