Death with Dignity: Why I Don’t Want to Have to Starve Myself to Death

World of Psychology
Death with Dignity: Why I Don’t Want to Have to Starve Myself to Death

Death with Dignity: Why I Don't Want to Have to Starve Myself to DeathDr. Ron Pies writes an eloquent defense of why physician-assisted suicide should not be made a legal right in Massachusetts. He compares it to a doctor helping one of his patients jump from a bridge — something most doctors would never do.

But in making this analogy, I believe we’re removing all context and logic from the decision behind wanting to end your own life because of a terminal illness. For the patient, it’s not about the act of suicide or ending their lives — it’s about alleviating suffering from the disease and choosing one’s own way of dying with a little dignity. It’s about patient empowerment, human dignity and choice.

That’s why in the two states where it is legal for doctors to help patients with a terminal illness, it’s referred to as the Death with Dignity law.

Because the alternative takes much of the dignity out of dying in today’s modern medical system.

“Physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges,” says Dr. Pies.

Most would agree physicians have little business helping a person jump to their death. But it appears that Dr. Pies undermines his own argument when he suggests it is perfectly okay for a physician to let his or her patient die of willful starvation and dehydration. His rationale? Death this way is solely in the patient’s hands, and isn’t as painful as we imagine it to be. He points to the scientific evidence, because there have been studies assessing patients’ pain and suffering as they’re dying through starvation and dehydration. Well, no, not quite. The evidence he points to is a single study that surveyed — not patients — but hospice nurses.

Now while I have great respect for the work and opinions of hospice nurses, let’s not confuse their opinions with data that would be more helpful – from the patients themselves. But there is no such data. So we don’t honestly know — and can’t say — whether a patient whose doctor is okay with letting them starve themselves to death is in greater or lesser pain than one whose doctor has voluntarily prescribed a medication to hasten a terminal patient’s death.

Dr. Pies seems to be splitting hairs here. His objection appears to be that patients can end their lives if done solely on their own, because physicians shouldn’t help patients along to their death — especially with a prescription. Yet he’s okay with a patient starving themselves to death — something no physician would ever be okay with in any other situation (such as a patient who had anorexia). 1

Physicians of such starving patients don’t just leave at that point. They too actively help the patient starve themselves by alleviating the discomfort associated with starving and dehydration. Physicians do this by prescribing a sedative, a practice known as terminal sedation or palliative sedation.

It’s not that starving to death isn’t a painful process (it is) — it’s because the patient has been prescribed drugs — by a physician — to make their “natural” death less painful.

Last, Dr. Pies argues it is not a right to die with dignity at the end of our lives, in the time and manner of our choosing. But nobody is coercing physicians to comply with the proposed law in Massachusetts. Just as most physicians do not perform abortions, I suspect many physicians will also not be interested in prescribing drugs to help a person at the end of their life hasten their own death.

We need such a law not to compel physicians or mess with their moral code, but because government has determined that the people cannot be trusted to have access to certain medications. Because government has restricted our access to such drugs, it is necessary to seek access to them through the government- and guild-defined methods imposed.2

If my liberty to purchase and administer such drugs wasn’t restricted in the first place, we wouldn’t need such laws. But since my liberty has been restricted, a law is needed. This law would not impose an obligation on physicians to prescribe such medications to any patient who asked, as it would be completely voluntary for physicians to participate:

(2) Participation in this chapter shall be voluntary. If a health care provider is unable or unwilling to carry out a patient’s request under this chapter, and the patient transfers his or her care to a new health care provider, the prior health care provider shall transfer, upon request, a copy of the patient’s relevant medical records to the new health care provider.

One of a physician’s primary purposes is to help alleviate suffering. Suggesting a patient starve themselves over a period of one to two weeks, while being prescribed and administered a sedative, hardly seems in the spirit of this purpose.

For me, it’s not about a physician’s rights — it’s about a human being’s inalienable rights and having the right to choose. So I will be voting “Yes” on Question 2 for the Death with Dignity Act in Massachusetts. Because I believe that people with a terminal illness have a right to die at a time and place of their own choosing — with the dignity deserving of a human life.

 

Further Reading

Footnotes:

  1. Imagine someone presents to an ER severely dehydrated and emaciated. Would any physician stand idly by and let that person die of dehydration and starvation?
  2. In this case, that means gaining access to the drugs largely through a physician, because that’s the way the American Medical Association, the physician’s guild in the U.S., wants it.

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1 in 5 Spine Surgery Patients Develop PTSD

Psych Central News
1 in 5 Spine Surgery Patients Develop PTSD

1 in 5 Spine Surgery Patients Develop PTSD  Nearly 20 percent of people — or 1 in 5 — who go through low back fusion surgery develop post-traumatic stress disorder (PTSD) symptoms, according to a new study.

While past studies have documented PTSD symptoms in trauma, cancer and organ transplant patients, the new study from the Oregon Health & Science University is among the first to monitor for PTSD symptoms in patients undergoing an elective medical procedure, according to Robert Hart, M.D., an orthopedic surgeon, professor of orthopedics and rehabilitation, and senior author of the study.

“It is maybe not surprising that significant surgical interventions have psychological as well as physical impacts,” he said. “I think it means that we in the medical community need to monitor for these effects in our patients and to manage them when they occur.”

According to the study, the strongest factor in determining whether someone suffered PTSD symptoms after the spine surgery was whether the patient had a prior psychiatric diagnosis — such as clinical depression or an anxiety disorder — before the surgery.

But some patients who had no pre-surgery diagnoses also suffered PTSD symptoms after the surgery, the study found.

The study involved 73 of Hart’s surgical patients who underwent lumbar spinal fusion surgery. This type of surgery involves a procedure in which two or more lumbar vertebrae in the back are fused together.

It usually includes implantation of metal screws and rods as part of the procedure.

The study results might offer guidance to surgeons, said Hart, who suggests that patients identified as being at higher risk for PTSD symptoms receive treatment before the surgery.

“At the end of the day, I hope this will make changes in the way we prepare people for surgery, to reduce these psychological impacts,” he said. “This is analogous to how we currently optimize patients’ physical condition before major surgery.”

The study was published in the journal Spine.

Source: Oregon Health & Science University

 

Psychological Support Vital for Defibrillator Patients

Psych Central News
Psychological Support Vital for Defibrillator Patients

Psychological Support Vital for Defibrillator PatientsHeart patients who receive an implantable cardioverter defibrillator (ICD) should be offered routine screenings and appropriate treatment for anxiety, depression and post-traumatic stress disorder, according to the American Heart Association.

Each month, 10,000 people, including children, have a cardioverter defibrillator implanted to restore normal heart rhythm and prevent sudden cardiac death.  Depression, anxiety and post-traumatic stress disorder are common among these patients.

According to a scientific statement from the American Heart Association, improved patient education and ongoing psychological support will help individuals cope with the psychological distress of having an implanted defibrillator.

The statement, published in the American Heart Association journal Circulation, includes recommendations for improved patient care and identifies areas where more research is needed.

“A shock from an ICD can be lifesaving, but it can also affect a person’s quality of life and psychological state,” said Sandra B. Dunbar, R.N., D.S.N., chair of the statement writing group.

“It’s important to look at this issue now because 10,000 people have an ICD implanted each month. They range from older people with severe heart failure to healthy children who have a gene that increases the risk of sudden cardiac arrest.”

Before implantation, patients  should be given clear information about the benefits and limitations of the ICD, prognosis and impact on lifestyle including activity and occupation.

“Education and support need to include the patient and the family and be broader than just a focus on maintaining the device. Providers need to help patients address ICD-specific concerns about symptoms, heart disease treatment, physical activities and end-of-life issues,” said Dunbar, of Emory University in Atlanta.

Although less than 1 percent of ICD recipients are children, complications are more common and these patients will live with the defibrillators for a much longer period of time, according to the statement.

“Experiencing a shock is distressing and patients have a wide variety of responses,” Dunbar said. “Some find it very reassuring that it’s working, while others find the actual physical sensations frightening and overwhelming. That’s why we suggest that clinicians provide an ongoing assessment of ICD patients’ psychological needs.”

Source:  American Heart Association

Merciful Assistance or Physician-Assisted Killing?

World of Psychology
Merciful Assistance or Physician-Assisted Killing?

Merciful Assistance or Physician-Assisted Killing?Imagine that your father, age 85, has been diagnosed with a terminal illness and given only three months to live.

Fortunately, he is still well enough to walk, and finds himself one night near a tall bridge. Having contemplated the suffering he believes will attend his final days, he decides to end his life by jumping off the bridge. However, he is too weak to hoist himself up atop the protective railing.

Suddenly, he sees his very own physician, Dr. Jones, walking by. He begs Dr. Jones to help him climb atop the railing, adding, “Don’t worry, Doc, it will be my decision to jump.” The doctor is taken aback, but quickly determines that his patient is not psychotic or severely depressed, and is capable of making a rational decision regarding suicide. The doctor tries to persuade your dad that pain and suffering can usually be well-controlled during the final days, but the patient is insistent: he wants to end his life.

Would you agree that Dr. Jones is fulfilling his obligations as a physician by assisting your father in jumping off the bridge?

If not, would you support the doctor’s providing your father with a lethal dose of medication?

From the standpoint of medical ethics, I see no fundamental moral difference in a doctor’s assisting a patient to jump off a bridge — without, of course, pushing him off — and a doctor’s prescribing a lethal dose of medication to “assist” in the patient’s suicide. The main difference is that whereas anybody can assist a suicidal patient in climbing over a bridge railing, only physicians and a few other health care professionals are authorized by law to prescribe medication — and, in Oregon and Washington state, to prescribe lethal medication for “physician-assisted suicide” (PAS).

Of course, there are important procedural differences between my bridge scenario and the way PAS is handled in these states. There are numerous procedural safeguards in place to ensure that dying patients are thoroughly evaluated, and not pressured or coerced into requesting lethal medication — though the evidence is mixed as to how effective these safeguards have been. One study of physician-assisted suicide in Oregon and the Netherlands found no evidence that disadvantaged groups (such as the elderly or disabled) are being disproportionately affected by the laws (Battin et al). On the other hand, another study (Finlay and George) concluded that, “…there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.”

From a strictly ethical perspective, I believe physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges — regardless of how “voluntary” the patient’s decision may be. Clearly, neither action is compatible with the traditional role of the physician as healer. Indeed, psychiatrist and ethicist Dr. Thomas Szasz has argued that “physician-assisted suicide” is merely a euphemism for “medical killing.” For these reasons, I am opposed to the November ballot initiative in Massachusetts for a measure that would allow terminally ill patients to be prescribed lethal drugs.

And yet, as always, there are two sides to the story. When my 89-year-old mother was in her final days, she was in a good deal of discomfort much of the time. Despite having first-rate home hospice care, and the availability of powerful pain relievers — which my mother often refused to take — her dying was not an easy or peaceful process, for her or for our family.           

There were times when I wondered if I could ever bring myself to provide her with the Oregon “solution.”  Fortunately, my mother never requested this, and overall, I believe my family made her final days as dignified and comfortable as she would permit.

The debate over PAS often is clouded by a mistaken understanding of the dying process. Some advocates of the Oregon and Washington approach argue that the dying patient who wants to end her life has no recourse but to take a lethal drug prescribed by her physician. But in truth,  competent, dying patients may end their lives by simply refusing food and drink. Indeed, medical ethicist Cynthia Geppert MD, PhD informs me that voluntary refusal of food and drink is now considered an accepted approach to dying, in palliative care medicine.

Many readers will instinctively recoil from this claim. “How could you let your loved one die of hunger and thirst?” they will understandably ask. But we usually ask this based on our own unpleasant experiences of hunger and thirst, as healthy, active persons. For the dying patient, voluntary refusal of food and fluids does not result in an agonizing or painful death, as a report in the July 24, 2003 New England Journal of Medicine concluded. According to the 307 hospice nurses surveyed in this study, most patients will die a “good” death within two weeks after voluntarily stopping food and fluids.

We may agree, as a society, that competent adults ought to be at liberty to end their own lives. But this is not the same as asserting their “right” to commit suicide, much less insisting that physicians should be complicit in fulfilling such a right. Unlike liberties, rights impose reciprocal obligations on others. And, in my view, the physician’s obligation during a patient’s final days is to do everything medically possible to relieve pain and suffering — not to relieve the patient of his life.

 

Acknowledgement: Thanks to Bret Stetka MD and Medscape for permitting use of some material contained in my essay, “Do We Need ‘Thanaticians’ for the Terminally Ill?”, available at: http://www.medscape.com/viewarticle/771274.

References:

Battin MPvan der Heide AGanzini Lvan der Wal GOnwuteaka-Philipsen BD: Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007 Oct;33(10):591-7.

Finlay IGGeorge R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups–another perspective on Oregon’s data. J Med Ethics. 2011 Mar;37(3):171-4. Epub 2010 Nov 11.

Ganzini L, Goy ER, Miller LL et al. Nurses’ Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death. N Engl J Med 2003; 349:359-365 Accessed at: http://www.nejm.org/doi/full/10.1056/NEJMsa035086

For Further Reading

Pies R: End-of-life care and contingent vs. non-contingent duties: contributions from WD Ross’s ethics and the Judaic tradition. Accessed at: www.hektoeninternational.org/End-of-life-care-and-contingent.html

Szasz T. Fatal freedom: the ethics and politics of suicide. Syracuse: Syracuse University Press; 1999.

Arehart-Treichel J: A Few Psychiatrists Choose Path Strewn With ‘Heartbreaking Work.’ Psychiatric News,  2012;47:8-25. Accessed at: http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1217914

4 Steps to Better Boundaries

World of Psychology
4 Steps to Better Boundaries

4 Steps to Better BoundariesMy second job out of college was with a religious giftware company. I was a product-development coordinator for “inspirational” brands.

This meant I was required to do things like write directions on how to bury St. Joseph for a “St. Joseph Home Sales Kit.” My boss sat me down a few weeks into the job and explained that there were four stages to becoming a competent employee. She said I was at number one. (You’ll know what that means in a second.)

I’ve thought a lot about these four steps because they also apply to building personal boundaries.

1. At first, you are unconsciously incompetent.

Say what??? Yep. You don’t know how much you don’t know. And the ignorance can be bliss until you get sick or suffer from stress-related symptoms like dizziness, a weird rash, a neurological disorder, or chronic fatigue. You’re baffled as to why you’re always run down, because you don’t realize how much energy you’re expending in stuff that’s not your problem. I just have too much to do! you say to yourself. And there is no way around it. Right? Wrong. Time to wake up to your boundaries problem.

2. Then you become consciously incompetent.

Holy boundaries! you wake up one day and say to yourself. I have leaks of energy all over and I don’t have the faintest idea how to plug them all. Now you’re getting somewhere! Now you can do something about your fatigue because you’ve identified the problem…boundaries that look like your grandmother’s window screens: with more holes than wire, and totally ineffective. In twelve-step language, I guess this would be the first step: We admitted we had no boundaries–that our lives had become unmanageable.

3. Third, you become unconsciously competent.

It’s a little confusing, I know. All four steps only use two words. In the third stage, you start to erect boundaries and to take care of yourself but you don’t realize it yet. Actually, I think this is where I am. All I know is that I’m using the word “no” a lot lately and I’m feeling extremely selfish, sometimes cruel. And yet I think I must be doing something right because I have more energy and friends are telling me that I look good, even relaxed! Plus my feelings of guilt have subsided a little.

4. Finally, you are consciously competent.

Yay! This is the goal: to be so confident in our boundaries skills that we no longer worry about not being nice or generous or Christian. Our boundaries automatically erect in dangerous (energy-leaking) situations, so that we don’t need to expend so much energy and time analyzing them, or whether or not we are building them the right way.

The person at stage four is proof that the stuff of the serenity prayer is really possible: God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

Benzodiazepines Tied to Higher Risk of Dementia in Elderly

Psych Central News
Benzodiazepines Tied to Higher Risk of Dementia in Elderly

Benzodiazepine Medications, Such as Xanax and Ativan, Linked to Increased Risk of Developing DementiaA new study has found that people who begin taking anti-anxiety medications such as Xanax, Ativan or Valium after the age of 65 have a 50 percent greater chance of developing dementia within 15 years than people who have never taken this class of drugs.

Xanax, Ativan and Valium fall into a class of drugs called benzodiazepines, and are some of the most frequently used drugs in psychiatry. They are primarily prescribed to treat anxiety and sleep problems.

“Considering the extent to which benzodiazepines are prescribed and the number of potential adverse effects, indiscriminate widespread use should be cautioned against,” researchers say in the study, which was published in the British Medical Journal.

Benzodiazepines are widely prescribed for insomnia, anxiety and sedation for people over 65 in many countries, including 30 percent of this age group in France, 20 percent in Canada and Spain, 15 percent in Australia, according to the researchers. Many take this type of drug for years despite guidelines suggesting it should be limited to a few weeks, the researchers note.

Researchers carried out a study on 1,063 men and women with an average age 78 in France who were all free of dementia at the start of the study in 1987, with a planned follow-up in 20 years.

The researchers used the first five years to identify the factors leading to the first prescription for a benzodiazepine medication, then evaluated the association between the new use of this drug and the development of dementia. They also assessed the association between further benzodiazepine drug use during the follow-up period and risk of subsequent dementia.

Rates were adjusted for many factors potentially affecting dementia, such as age, gender, educational level, marital status, wine consumption, diabetes, high blood pressure, cognitive decline, and depressive symptoms.

According to the researchers, 95 of the 1,063 patients started taking a benzodiazepine medication during the study. The researchers confirmed 253 cases of dementia (23.8 percent) — 30 in benzodiazepine users and 223 in non-users.

The researchers found that the chance of dementia occurring was 4.8 per 100 person years in the group taking a benzodiazepine medication compared to 3.2 per 100 person years in the group not taking any of the drugs. A “person year” is a statistical measure representing one person at risk of developing a disease during a period of one year.

The researchers note that while many of the benzodiazepine medications remain useful for treating anxiety and insomnia, there is increasing evidence that their use may induce adverse outcomes in the elderly, such as serious falls, fall-related fractures and, now, dementia.

They say that their findings add to the accumulating evidence that the use of these drugs is associated with increased risk of dementia and, if true, that this “would constitute a substantial public health concern.”

The researchers recommend that physicians should assess expected benefits of the drugs and limit prescriptions to a few weeks. They caution against “uncontrolled use.”

They conclude that further research should “explore whether use of benzodiazepine in those under 65 is also associated with increased risk of dementia and that mechanisms need to be explored explaining the association.”

Source: British Medical Journal

 

Elderly man taking pills photo by shutterstock.

For Most People, Phone Therapy as Effective as Face-to-Face

Psych Central News
For Most People, Phone Therapy as Effective as Face-to-Face

Therapy Over The Phone Just as Effective as Face-to-Face  A new study in England reveals that for most people, cognitive therapy over the phone is just as effective as meeting with a psychotherapist face-to-face.

Researchers also found that providing talk therapy over the phone increases access to psychological services for people with common mental disorders, while at the same time saving money.

The researchers analyzed data from 39,000 patients in the east of England who participate in Improving Access to Psychological Therapies services, an initiative that aims to expand the availability of psychological therapies.

The researchers, who compared cognitive behavioral therapy (CBT) delivered face-to-face versus over the phone, found that for all but an infrequent, identifiable clinical group with more severe illness, therapy over the phone was as effective as face to face.

The cost per session was also significantly lower — about 36 percent less than the face-to-face cost.

The researchers note that many patients may be unable to access mental health services because of transportation issues, work commitments or physical disability. Increasing the availability of talk therapies over the phone make mental health services more accessible to patients.

“Providing therapy over the phone will not only help individuals gain much-needed access to mental health treatment, it will provide a more cost-effective way of providing these services at a time when everyone is concerned about cutting costs,” said Peter Jones, Ph.D., principal investigator of the study from the University of Cambridge.

Mental illnesses affect one in four adults in Britain every year, the researchers said, noting that Britain’s National Health Service spends more on mental health than it does on cancer, heart disease, stroke and asthma put together. General practitioners in the UK spend more than a third of their time on mental health issues.

Collaborating on the study were researchers from the University of Cambridge, the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care, and NHS Midlands & East.

The research was published in the journal PLoS ONE.

Source: University of Cambridge