Thursday, November 26, 2009

Palliative Care as "Cure" for Aid in Dying?

Jennifer Gait writes for Martlet, a British Columbia site, that increasing access to palliative care is a "cure" for aid in dying. It's a common argument: Why not use the resources we have to manage suffering rather than legalize the hastening of death?

When I started nursing in Britain in the early 1960s, patients had far fewer options.  Often the best thing we could give them was love — shown through our presence and physical touch. I realized just being with someone during their suffering can make a difference.  

But watching someone suffer can be harder on the observer than the sufferer. The Dutch physician who euthanized a woman grieving the death of her two children may have done so to kill his own feelings of helplessness rather than to support her. After all, physicians need support in order to support their patients. 

Coming to terms with whatever is causing us to suffer leads to growth and can reduce pain since psychological pain intensifies physical pain. People facing death generally have to work through many things, and depression and fear of pain may lead them to want death quickly — but this can change.

A 1995 study of 200 terminally-ill patients, reported in the American Journal of Psychiatry, found that the desire to die was correlated with pain and low family support, but mostly with depression. Follow-ups with six patients two weeks later found the desire to die had decreased in four of them.

Physicians also euthanize to save patients loss of dignity while dying. I see the gradual dissolution of the body and loss of functions as an important part of preparing for death through dissolving the ego. We spend half our life building our ego and the second half trying to get rid of it. I have seen huge shifts in people as they approach death.

Euthanasia is a flawed response to suffering and would be difficult to monitor and control. It threatens the psychological and physical health and safety of vulnerable groups and risks interfering with the patients trust in their physicians — and perhaps ultimately with the role of the physician in society.

Instead, provinces should work to strengthen palliative care and give physicians more support mechanism for the difficult decisions they have to make.

Of course there are other arguments against aid in dying. But to those who are accustomed to the "pro-life" contest, the call for increased palliative care is one that appears on the surface much more rational and convincing an argument against hastening death. Yet it fails to account for several important issues in the debate, including that of patients' rights.

The prescription of "coming to terms with one's ego" and "facing depression," even from a long-time nurse, smacks of overvaluation of the redemptive aspect of suffering that predominantly Christian cultures where westernized medicine exists ascribe to. For the two patients out of six who are not cured of physical or psychic pain (hardly a viable statistic), encouragement to "tough it out" and "accept your suffering" mean little.

And Gait writes at a time when Canada is struggling with the issue of aid in dying. Calls for its legalization have engaged the country in end of life discourse that is by turns uninformed, emotional, ideologically motivated, and unengaged with individual patients' rights.

As death with dignity laws exist in the US, a patient must be terminally diagnosed, mentally competent, and must request a lethal prescription from their doctor repeatedly. Patients who use the law do not go to it lightly. Depression nor loss of dignity, nor pain are killing them; old age or disease are.

They realize that their choices are few: either wait in suffering for death to come; end their life in some way that is traumatic for themselves and their families; or enter hospice where palliative care will perhaps manage their pain. Continuous deep sedation (CDS), the most common manner of allowing a person a peaceful death, often requires that the patient be in a medical facility, not at home. And while statistics vary, not all physical suffering can be alleviated with medication.

I am a strong supporter of palliative care and advancements. I find it a crime that the specialty has received so little support and funding and that few are trained in palliative care. I also believe that hospice is a blessing to those families and patients who face death. But watching my father die in a hospice facility when all he wanted to do was die at home, watching pain and delirium consume his final weeks and days, I believe he should have had another choice.

It is this moral choice, to consume a few pills in the company of one's loved ones, in one's home, that I support. Suffering does not belong to the medical profession, the state, nor the church. It is best quantified and addressed by the patient. Human rights and personal autonomy require nothing less.

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