Thursday, April 15, 2010

The Ethics of Palliative Sedation.

Dr. Jim deMaine writes thoughtfully about an experience with a terminal patient he calls Larry. An excerpt that I hope urges you to read the whole post:

On examining Larry, I can see the distended neck veins and the barrel shaped chest. It is apparent that the lungs were over expanded and the diaphragms flattened and moving poorly. There is a trace of swelling in his legs. The blood gases now show an elevation in his carbon dioxide. He can’t breathe sufficiently to either maintain oxygen or get rid of the CO2. Chronic respiratory failure due to chronic tobacco abuse is his long standing diagnosis. He finally kicked the habit 5 years earlier which helped some but not enough. He hates the oxygen tubes and prednisone side effects. He now has the “moon face”, bruising of the arms, muscle wasting, and weakness – all the scourge of chronic prednisone use.

A few weeks after his request I arrange to meet Larry at a restaurant nearby the hospital. After some pleasantries, Larry lets he know that he wants to talk about dying: “Look, I’ve lived a long time and what I’m doing now isn’t really living. These flare-ups are torture, I feel like a fish out of water and I don’t want to die that way. My biggest fear is suffocating to death.”

We talk about ventilators to support breathing, “No”; ICU care with aggressive support, “No”. Larry is clear; he wants to be in control. “Look Doc, all I want you to do is promise me that you’ll help me at the end”.

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