Thursday, March 4, 2010

Washington State Reports on First Year of Death with Dignity.

From Seattle Times:

Sixty-three suicide prescriptions were dispensed during the first nine months of Washington state's "death with dignity" act and at least 36 people used that lethal dose of medicine to end their lives, state officials said Thursday.

The prescriptions for lethal doses of medication were written by 53 different doctors and dispensed by 29 different pharmacists, the Department of Health said in its first annual report on the law that took effect in March 2009.

The statistics show that use of the program has been similar to the first year of Oregon's assisted suicide law, said Health Department spokesman Donn Moyer. Oregon adopted the nation's first "death with dignity" law in 1997.

Montana became the third state to allow assisted suicide at the end of 2009 after the Montana Supreme Court ruled that nothing in state law prevents patients from seeking physician-assisted suicide.

Washington state has received zero complaints from the public about doctors and pharmacists and their compliance with the law, the agency said.

"We're very satisfied with the compliance by the health care provider community," Moyer said.

Of the 63 people who received lethal doses of prescription medicine between March and December 2009, 47 are known to have died. Thirty-six of them died after taking the medications and seven most likely died from their ailment.

The agency said it doesn't know the details of the other four because the death certificate or death report hasn't been filed.

Those who died were between the ages of 48 and 95. Nearly all of them lived west of the Cascades. Most had terminal cancer and all were expected to die within six months.

Under the Washington law, any patient requesting fatal medication must be at least 18 years old, be declared mentally competent, and a resident of the state and have a terminal condition and six months or less to live.

From conservative LifeNews.

From The Guardian.

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Is a Default Choice Still A Choice?

A shameless reposting of Joanne Kenen's post at The New Health Dialogue, because the entire piece reveals the default "choice" of aggressive care that individuals must work against to direct their own care:

I’m traveling this morning to a palliative medicine conference in Boston, so it seemed a good time to leave you with my thoughts about a recent Narrative Matters essay in Health Affairs, called “Shock Me, Tube Me, Line Me."

Perhaps I don't really have to write much. The title says it all.

I usually like these narrative essays. They are thoughtful, literary and evocative. But this one has been bugging me for weeks. The author, Boris Veysman, an ER doc at an academic medical center in New Jersey, writes about taking care of a terminally ill woman, suffering from metastatic cancer. Her wish to have a low-tech death, not tied up to tubes and machines, merely confirmed his own desire to have “everything” done to prolong his life when his time comes.

Let’s be clear. People in our medical system have a right to choose aggressive care, as Veysman has. That’s not the point of his essay. He is not arguing that we are taking away that right. He is arguing against exercising it. And while he understands the components of end of life care, from ICUs to hospice, he has the sequence all mixed up.

This patient arrived at the ER, conscious. Her daughter dropped her off, and went to park the car. Almost immediately, the woman collapsed and was close to death. Dr. Veysman, appropriately, asked if she had a DNR, do not resuscitate. Or a DNI, do not intubate. No one knew the answer immediately -- the daughter was still parking. Without that knowledge, the ER team did the appropriate thing. They resuscitated. They intubated. They did aggressive and forceful CPR, with the doctor doing the compressions himself, not trusting anyone else's strength and expertise but his own. “Yes, she is now sort of alive because of me," he wrote. They put in a central line and got her on an external pacemaker. They gave her heart electric shocks. They stabilized her.

Then they found out she had a DNR. And a DNI. And metastatic cancer that had stopped responding to one chemotherapy treatment after another. But he had saved her. "The interventions were optimized and performed without delay by skilled hands," he wrote. She awoke, gagging, coughing and reaching for the breathing tube in her throat. He ordered sedatives and powerful painkillers.

She had been weak, he learned. She had little appetite and had felt unwell. She was depressed. Her kidneys were failing. She was dying.

He did not think it was time for her to die. He thought she might have a few weeks left. He thought she should spend them on dialysis.

"I think there’s a good chance she is fixable in the short term," he told the family. "She needs dialysis, but other than that we can address every other comfort issue. I think she can wake up and talk, probably even write or use a computer. I think her depression, weakness, appetite, dehydration, and malnourishment can be effectively treated. Whatever her prognosis is from the cancer, I think she can probably get at least a few good weeks, which is done best by a hospice. She might want to do something with that time. To finish up. To say goodbye and good luck. I think it’s too early to die. To give her a chance, however, we must go all out and ‘do everything’ for the next several days."

He had never met this patient before. He did not know her values, her beliefs, the length and depth of her illness, the severity of her pain. He was right of course that hospice could help with both the physical and existential symptoms. We can only wonder regretfully why the family had not gone that route earlier -- and wonder whether or why her oncologist had failed to suggest it. We can only wonder what the final course of her life would have been had she gotten palliative care even earlier, helping her all through the course of her deterioration and illness, even before it was time for hospice. But now her kidneys were failing. She was ready to die. The ER doc disagreed.

He wanted her to get dialysis so she could get hospice so she could die a little later. (Never mind that, according to a hospice industry official I consulted, a hospice was unlikely to take a patient just beginning dialysis in order to survive long enough for hospice. Patients can continue dialysis and get hospice services if the kidney disease is not terminal, is not the disease that qualifies them for hospice. But the idea of starting dialysis in order to get hospice would be unusual to say the least).

End of life, he writes, can be done better. He’s correct. It can. "Give me a motorized wheelchair and a feeding tube if I need them, along with a tracheostomy to help me breathe and dialysis to filter out toxins. Those do nothing to stop a good mind and a strong spirit, while permitting both to overcome obstacles of blood and flesh." That's his opinion and his wish. Today he could have that wish granted -- and Medicare, meaning the taxpayer, would pay for it all. But then, after having all those machines and tubes and procedures, he does acknowledge that time would come when maybe he wouldn't want them any more. "If I wish to die, let me die," he writes. Hopefully when his time comes, his ER doc will be aware of his wishes.

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Suicide Prevention and Assisted Suicide.

There's a clinical reason why advocates prefer to call it aid in dying and not assisted suicide; they recognize that there's a difference between grief, a normal and emotional reaction to trauma, and depression, an illness that with medical and psychiatric treatment can be addressed.

Yesterday Michael Gerson at the Washington Post had a well-meaning column on the prevalence of suicide in the U.S. He starts the column by noting a number of celebrities who have recently committed suicide and works to explain what it is and what signs we can detect in loved ones who may be isolated, depressed and suicidal.

Suicides outnumber homicides in America, making self-hatred more lethal than violence by others. In 2009, the Substance Abuse and Mental Health Services Administration reported that 1.1 million Americans had attempted suicide during the previous year. By one estimate, "successful" suicides have left behind 4.5 million family survivors, who live with ghosts each day.

He encourages us to reach out to those in our community who may be depressed and at risk (The National Suicide Prevention Lifeline is 1-800-273-TALK.) It's not a bad column and while Gerson is not my favorite columnist, I am pleased to see those with soapboxes addressing a tragic issue.

But then along comes Wesley J. Smith who takes up Gerson's column and does what he does best: applies absolutist and convoluted pseudo-rational thinking to conflate the idea of depression (which can cause suicide) and terminal disease. To Gerson's sentence, "For those who yield to the logic of the nightmare, it is difficult to be harsh or judgmental. Empathy, like grace, can reach to the grave," Smith writes:

But that doesn’t mean we shouldn’t criticize those pushing suicidal people toward different conclusions about self destruction. And that’s where Gerson misses the obvious–as so many similar articles do these days. There is a multi million dollar suicide promotion campaign ongoing in the country and around the world–aided and abetted by the mainstream media–that says that if you are sick, or disabled–suicide is empowering and rational. Indeed, it claims that such suicides are so right and worthy of being honored that the state should permit third parties to help make sure the suicidal person is made dead. As far as I am concerned, that is the express and implied fundamental message of assisted suicide advocacy.

It seems to me that society can’t be half against suicide and half for it. You can’t have suicide prevention and assisted suicide promotion at the same time. The former message is subsumed by the latter. Suffering suicidal people don’t think that the quality or reasons for other guy’s suffering makes suicide okay, but theirs does not.

It's an old rhetorical schtick for Smith - and other "pro-life" activists - who make their living subtracting nuance from bioethical debates for their own ideological purpose. For decades, Smith has been writing about "the culture of death," dropping anyone into that category he can and pretending that a growing segment of society is out to kill minority groups like the disabled, the brain dead, the terminally ill, the suffering, the elderly.

By confusing suicide and clinical depression with aid in dying, he capitalizes on the common use of the term "assisted suicide" to attack aid in dying supporters, much as those who deny evolution conflate the scientific term "theory" with the common use of the term meaning "unproven supposition." ("Theory" to scientists means proven fact that needs to have some details flushed out.)

I'm not personally opposed to the use of the term assisted suicide (for the medical practice as it is legalized and strictly regulated in Washington and Oregon) but I do contest the way that Smith and others use it: to perpetuate the terminal suffering of others. As medical advancements have created new definitions of death (end of a heart beat? end of consciousness? end of breathing?) so too has it created new definitions of suicide. (And pregnant, but that's another post. The definition of murder has long been understood to have many meanings.) Ignoring this fact is an absolutist, and frankly, unworkable approach to contemporary bioethical debates. Pretending that we live in a less complicated world does not move us toward ethical discussions of medicine.

This work of Smith's is irresponsible (and disingenuous) for a host of reasons, most importantly because it allows those who oppose assisted suicide to think they are addressing the important issue of suicide. And it removes the focus among his constituents from addressing the very real problem of depression to fighting the right that terminal patients should have to determine how their disease will end their lives.

The aid in dying movement in the U.S. seeks to make Death with Dignity (as the laws in Washington and Oregon are called) legal: a terminal patient with six months to live, one who is going to die because of multiple sclerosis or Lou Gehrig's disease, who is determined of sound mind and who has received the opinion of two doctors, to receive a lethal dose of medication from their doctor which they may then choose to take themselves to end their life before the disease makes it unbearable.

In every case of Death with Dignity, immanent death is certain. The patient has endured most likely years of fighting their disease with a concerted will to live. The patient does not want to die but they have realistically accepted the fact that their disease will soon kill them. Their grief at the loss of life has an absolute physical cause. And their simple objective is singular: to end suffering.

Smith's point that society is pushing isolated individuals to suicide is only correct in that we fail to distinguish the serious difference between suicide-causing depression, and say, a bad day or the natural process of grief that follows a death or an end of marriage. "I'm depressed," we say when our car breaks down. "How depressing," we say when an election is lost or a friend snubs us, detracting semantically from our ability to discern the downward spiral of serious grief that can lead to dangerous depression.

Grief is an emotional process that facilitates recovery from a loss. Depression is an illness. There's a significant and important difference that Smith misses. What he calls "half against suicide and half for it" is a false construct. "The culture of death" is a rhetorical tool used to create fear among the vulnerable and to assert influence over the easily swayed. It takes autonomy away from various patient groups like women, the disabled, the ill. "Culture of death" fear-mongering is prevalent among those who wish to assert their largely religious ideology on our pluralistic society; it seeks power and it imposes suffering.

Accepting death, as Death with Dignity patients do, is not a depression that can be cured. It is a factual analysis of the physical body in immanent, unpreventable demise. Yes it's sad, for both family members and the patient. But statistically, Death with Dignity does not leave behind the same scars as suicide from depression does.

Smith and others only distract from the serious consideration that must be given to treatment of depression.

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