Tag: Assisted Dying

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Is turning off a pacemaker ever the right thing to do? When a life-saving heart implant becomes a painful burden

  • After almost 20 years of living with a pacemaker, Nina made a decision
  • Ms Adamowicz, 71, no longer wanted the device that was keeping her alive
  • After some consideration doctors agreed, and the woman died peacefully
  • Thought to be the first case in the UK, their choice has sparked controversy

By Rachel Ellis

[A]fter almost 20 years of living with a pacemaker, Nina Adamowicz decided she no longer wanted the device that was keeping her alive.

It had been implanted in 1996, and for the first decade it ‘improved’ her life and symptoms — she had a form of hereditary heart disease.

The pacemaker sent regular electrical pulses to keep her heart beating steadily, and she was grateful for ‘being given extra time’, she later recalled.

However, she then had a heart attack and her health declined so that by 2014, her heart was working at just 10 per cent of its capacity.

Last year, Polish-born Ms Adamowicz, 71, who had lived in the UK for more than 30 years, revealed she wanted the pacemaker turned off, even though she knew it would lead to her death.

After almost 20 years of living with a pacemaker, Nina Adamowicz decided she no longer wanted the device that was keeping her alive
After almost 20 years of living with a pacemaker, Nina Adamowicz decided she no longer wanted the device that was keeping her alive

It was like being ‘in line for execution and being told “not yet”, she said in an interview for BBC Radio 4.

‘It’s not about “I want to die”, I’m dying,’ she added.

After a series of medical examinations and psychological tests to determine whether she understood what switching off her pacemaker would mean, doctors agreed, and last October Ms Adamowicz went into a local hospice with her family for the pacemaker to be turned off – a procedure that took 20 minutes.

She described her body as feeling heavy and she felt a little nauseated – but she also felt at peace, her family told the BBC.

She slept through the night, returned home in the morning and died that night.

Her case – thought to be the first of its kind in the UK – raises profound ethical issues about when it is right to turn off someone’s pacemaker, or indeed withdraw other medical treatment such as dialysis for kidney failure, if that’s what they want.

In fact the law itself is very clear on this point, according to Miriam Johnson, professor of palliative medicine at Hull York Medical School.

‘A mentally competent adult has the right to refuse medical treatment, whether it is turning off a pacemaker or stopping dialysis, even if that treatment is prolonging their life and withdrawing it will lead to their death,’ she says.

‘By turning off the device, the disease or illness will kill the person, not the doctor.’

However, some doctors feel it’s uncomfortably close to euthanasia — the difference is that euthanasia involves overriding Nature.

Some doctors feel that turning off a pacemaker is uncomfortably close to euthanasia — the difference is that euthanasia involves overriding Nature
Some doctors feel that turning off a pacemaker is uncomfortably close to euthanasia — the difference is that euthanasia involves overriding Nature

‘The difficulty with a case like this is that when a patient is dependent on a pacemaker, there is a direct connection between withdrawing the treatment and them dying within the next few hours,’ adds Professor Johnson, explaining that doctors’ role after all is to protect the vulnerable.

Around 35,000 patients in the UK have a pacemaker fitted each year. The device’s role is to keep the heart beating steadily – it gives it a boost by delivering electrical impulses so that the heart contracts and produces a heartbeat.

The computerised match-box sized device is implanted just under the skin, usually just below the left shoulder and electrical leads are then fed down a vein into the heart.

‘In a significant number of pacemaker cases if you suddenly took the pacemaker away, the heart would stop beating,’ explains Dr Adam Fitzpatrick, a consultant cardiologist and electrophysiologist at Manchester Royal Infirmary and Alexandra Hospital, Cheadle.

He adds: ‘It is very unusual for a patient to ask for their pacemaker to be turned off.’

Even if the patient is dying, a pacemaker does not need to be switched off, says the British Heart Foundation.

'A pacemaker's purpose is not to restart the heart and it won’t cause discomfort to someone who’s dying,’ said a spokesperson for the British Heart Foundation
‘A pacemaker’s purpose is not to restart the heart and it won’t cause discomfort to someone who’s dying,’ said a spokesperson for the British Heart Foundation

‘Its purpose is not to restart the heart and it won’t cause discomfort to someone who’s dying,’ said a spokesperson.

But the picture is slightly different with other heart devices such as Implantable cardioverter defibrillators (ICDs) which are used to correct an abnormal heart rhythm rather than helping the heart beat steadily.

These devices, implanted in around 9,000 people in the UK every year, kick in when an abnormal heart rhythm occurs which can cause sudden cardiac arrest (where the heart stops beating).

Implanted under the collarbone as a pacemaker is, they work by firing a small electric shock into the heart to kick-start it (some pacemakers have this function too).

This might happen once every few months or not even for years.

However, this can be both painful and traumatic, especially at the end of life, and can lead to a prolonged and distressing death by continuing to give electric shocks.

In one particularly upsetting case reported in a US medical journal, a man suffered 33 shocks as he lay dying in his wife’s arms — the ICD ‘got so hot that it burned through his skin’, his wife later reported.

Implantable cardioverter defibrillators work a bit differently from a pacemaker, as they are used to correct abnormal heart rhythm with an electrical current
Implantable cardioverter defibrillators work a bit differently from a pacemaker, as they are used to correct abnormal heart rhythm with an electrical current

‘Dying patients often have multi-organ failure which can cause metabolic and chemical changes that may trigger arrhythmias, faulty heart beats and in turn activate the ICD,’ explains Dr James Beattie, a consultant cardiologist at the Heart of England NHS Foundation Trust, Birmingham.

‘If the device goes off when the patient is conscious, the shock is like a blow to the chest, causing discomfort and distress. It may also fire repeatedly.

‘This may result in a distressing death for the patient and distress for the families.’

Yet despite this suffering, 60 per cent of hospice patients do not have their implant deactivated before death, according to U.S. research published in the Annals of Internal Medicine.

Furthermore, a 2011 survey by the National Council for Palliative Care suggested that only 40 per cent of UK hospices have access to the technology to deactivate the device urgently, potentially risking an undignified and painful death in hundreds of patients should they suddenly deteriorate.

Switching off the device involves holding a magnet over it, temporarily closing a magnetic switch incorporated in it.

To turn it off permanently the device has to then be reprogrammed remotely using a ‘wand’ attached to a computer.

Despite the risk of suffering, 60 per cent of hospice patients do not have their implant deactivated before death, according to U.S. research
Despite the risk of suffering, 60 per cent of hospice patients do not have their implant deactivated before death, according to U.S. research

Medical professionals and families face a number of dilemmas when deciding whether to turn off an ICD.

One is the difficulty in accurately predicting when the patient is reaching the end of their life.

‘Determining this isn’t always clear, especially with a condition such as heart failure when patients may have survived crises over many years,’ explains Professor Johnson.

‘This can be complicated further if the patient is suffering from dementia and unable to make decisions about their care.’

There is also an understandable reluctance by patients and their families to take away anything that can prolong life.

‘Patients and their families frequently think of the device as entirely beneficial,’ says Professor Johnson.

‘There is also often unrealistic expectation about what doctors are able to do to keep people alive.’

Many doctors shy away from these conversations, too. A 2008 report from the National Audit Office found a significant lack of confidence in handling end-of-life care across all medical specialities — with cardiologists topping the league.

‘Given they are trained to save lives, talking about death can be seen as professional defeat,’ says Dr Beattie.

But if patients and doctors don’t have that conversation ‘we’re storing up trouble because decisions then have to be made at times of crisis and without planning’, says Simon Chapman, of the National Council for Palliative Care.

New guidance for patients and medical staff to guide them through the ethical minefield of withdrawing heart devices was published earlier this year in the journal Heart.

Just how difficult making such decision can be was dramatically highlighted in the case of Fred Emery.

When his health suddenly went downhill six years ago, doctors recommended turning off the defibrillator that had been keeping him alive for the past 14 months.

When Fred Emery's health suddenly went downhill six years ago, doctors recommended turning off the defibrillator that had been keeping him alive for the past 14 months
When Fred Emery’s health suddenly went downhill six years ago, doctors recommended turning off the defibrillator that had been keeping him alive for the past 14 months

The 73-year-old former manual worker from Kings Langley, Hertfordshire, had had the matchbox-sized device implanted in his chest following a 26-year battle with heart disease.

During that time he’d had two heart attacks, and had already undergone two triple heart bypass operations as well as having several stents (tiny metal tubes) inserted to prevent his arteries blocking.

However, Fred then developed heart failure and ventricular tachycardia — a potentially fatal heart rhythm

Having a defibrillator not only helped with the heart failure, but also any sudden cardiac arrest triggered by the faulty heart rhythm.

But Fred’s condition deteriorated and doctors suggested that as he was nearing the end of his life, it was time to turn off this life-line — to spare him and his family the ordeal of it repeatedly jolting his heart back to life when his body had reached the natural moment of death.

However, despite doctors’ predictions, Fred pulled through and later had the defibrillator reactivated, and it went on to save his life several times before his death this year. His family was angry that doctors had written him off before his time.

Despite doctors’ predictions, Fred pulled through and later had the defibrillator reactivated, and it went on to save his life several times before his death this year
Despite doctors’ predictions, Fred pulled through and later had the defibrillator reactivated, and it went on to save his life several times before his death this year

‘It was awful when they told him to turn it off,’ his wife Shirley, 70, told Good Health. ‘Fred was taken ill at 4pm, and by the next morning the defibrillator was turned off. It was too soon to make that decision — he wasn’t himself and was under pressure to switch it off.

‘After it was reactivated, Fred had six more years. Without the ICD we would have lost him several years ago.

‘He kept it on until a week before his death. By then his heart was working at 15 per cent, he was in a hospice and there was no coming back so we made a decision to turn it off to give him some dignity at the end. He knew what was happening.

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How doctors are failing us in death

Never mind assisted-dying, our health care system needs to change the way it deals with the natural end of life

By Mohamed Dhanani

Mohamed Dhanani, left, with his father-in-law Ijaz Ahmad at a wedding last year. "The eight different doctors who treated my father-in-law all had different ideas about what (his wishes not to be life support) meant, and how involved the family should be in making treatment decisions," writes Mohamed Dhanani. "This inconsistency — the waiting, the arguing, the feeling of powerlessness — was our family’s worst experience with a health care system of which we are so often proud."
Mohamed Dhanani, left, with his father-in-law Ijaz Ahmad at a wedding last year. “The eight different doctors who treated my father-in-law all had different ideas about what (his wishes not to be life support) meant, and how involved the family should be in making treatment decisions,” writes Mohamed Dhanani. “This inconsistency — the waiting, the arguing, the feeling of powerlessness — was our family’s worst experience with a health care system of which we are so often proud.”

I’ve spent much of my career in the health care field, but it took a very personal experience to drive home just how poorly prepared health care providers are to help us through the one certain life-experience that awaits us all: death.

It happened in a hospital in southern Ontario. My father-in-law, Ijaz Ahmad, who lived with insulin-dependent diabetes for 35 years, went into the hospital for a partial foot amputation due to a bone infection.

Prior to surgery, a routine diagnostic test was performed requiring dye to be inserted into his bloodstream. After the surgery, the dye put him into kidney failure while it was being metabolized. Within a day of the surgery all of his organs started to fail and he was put on life support for what we were told would be two to three days so his organs could rest and strengthen — after which, we were told, “the doctors would bring him back.”

He spent the next 18 days on life support. And what became clear over that long 18-day ordeal is that what had clearly become the end of his life would have been unnecessarily prolonged depending on which of the eight doctors we interacted with was treating him that day.

Like so many families who have had the difficult but essential conversation with an aging parent around their end-of-life wishes, we had spoken with him about his wishes. He was clear he did not want to be on life support.

The eight doctors who treated my father-in-law all had different ideas about what those wishes meant, and how involved the family should be in making treatment decisions. This inconsistency — the waiting, the arguing, the feeling of powerlessness — was our family’s worst experience with a health care system of which we are so often proud.

Some of the doctors acknowledged his wishes but said life support was an essential part of the treatment plan; it was just a temporary measure to aid in his recovery. Others made very little effort to consult with us, and another outright refused! Another doctor assured us he would “bounce back,” though nurses told us this was increasingly unlikely and that the doctor was prone to sugar-coating discussions with families.

Because of this inconsistency, different members of my family were hearing different things — and that made it even more difficult for us to make a decision we all felt comfortable with. Finally, I pulled aside the latest doctor treating my father-in-law and asked him for an absolutely frank and direct discussion. Only then were we able to make an informed decision that respected my father-in-law’s wishes and provided as much comfort as possible to our family.

On my father-in-law’s 18th day on life support, and on what was to be the final day of his life, a new doctor was treating him. This doctor had trained and practiced in the U.K., and had only recently started to work in Ontario. His European training and experience gave him a different perspective on end-of-life care, and one for which we were grateful.

In Europe, the societal conversation on end-of-life care is more advanced than in Canada — they have grappled publicly with these essential issues of decision-making in health care for many years, and physicians have therefore become more comfortable discussing end-of-life decisions with their patients and families.

Not only is this an essential conversation we need to normalize as families and as a society, it is something our health care system must take on as an essential part of its work. All doctors must be trained to discuss end-of-life care in a direct and compassionate way with patients and their families. This will only become more important as people live longer, and as their health issues become more complex as they reach the end of their lives.

Over the last few years, Canadians have engaged in an impassioned debate on assisted death, a debate that culminated in landmark — and controversial — legislation in Parliament. But assisted death is just a small part of the issue.

As my family’s experience illustrates, end-of-life care and the difficult discussions surrounding that care are too inconsistent — inconsistent between institutions and inconsistent between doctors within a single hospital. It is something we can and must fix.

Surrounded by family and friends my father-in-law peacefully passed away within minutes of removing the breathing tube. He was 66 years old. May his soul rest in eternal peace.

Complete Article HERE!

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Do You Want to Be Awake For Your Death?

By Chris Bodenner

 

 

Jennie Dear has an evocative piece for us examining the scant evidence that scientists have so far about the mysterious threshold between life and death—what the body goes through and how a person subjectively feels it, both in terms of pain and hallucinations:

“A lot of cardiac-arrest survivors describe that during their unconscious period, they have this amazing experience in their brain,” [neuroscientist Jimo Borjigin] says. “They see lights and then they describe the experience as ‘realer than real.’” She realized the sudden release of neurochemicals might help to explain this feeling. … Most of the patients interviewed [for a study at a hospice center], 88 percent, had at least one dream or vision.

One reader says of Dear’s ostensibly morbid piece (“What It Feels Like to Die”): “The article is comforting in a way I did not anticipate.” Another reader agrees:

I kissed my dad goodbye on the forehead right before he died. He smiled briefly. So, this article was some comfort in maybe explaining that smile of his.

This next reader also lost her father:

I remember when my dad was dying, and my mom forbade any of us from telling him that he was dying. I thought that that was terribly selfish on her part, and I told my husband that if I were dying I would want to know.

When my mom passed away, she was “treated” to the experience of my sisters bitterly arguing as to who was the favorite. (I knew I wasn’t and just held her hand.) My husband got my sisters to stop. Finally, the doctors came in and actually said she had permission to die … Mom was like that; you had to have permission in her mind for everything.

My dear husband is gone now, and I just hope that when I go, I’ll be thinking of him.

That reader’s line—“if I were dying I would want to know”—prompted a question in my mind I’ve long answered in the affirmative: “Do you want to be awake for your death and know it’s coming?” The conventional wisdom says most people prefer to die in their sleep, but, as long as there’s no intense pain involved, sleeping seems like a disappointing way to experience one of the most profound parts of life—it’s ending. And whenever I think of that question, I’m reminded of these lyrics from Björk’s “Hyperballad”:

I imagine what my body would sound like
Slamming against those rocks

And when it lands
Will my eyes be closed or open?

Would you rather be sleep or awake? How exactly would you prefer to die? What’s the ideal situation? Email hello@theatlantic.com if you’d like to share.

Back to a few more stories from readers regarding the death of a loved one. This memory is particularly poignant:

Twelve months ago, my 33-year-old daughter Phoebe began to die from metastatic melanoma. Over the next 10 weeks at a hospital in Melbourne, she went through each of the experiences outlined in Jennie Dear’s article. During this time, Phoebe asked her nurse how would she know when she was about to actually die. Donna told her that something would happen and she would know—both vague and oddly specific, but Phoebe was satisfied.

A week before her death, having gotten her pain under control, Phoebe was at home to say goodbye to her animals, clean out her cupboards, and give away her possessions. She was standing in the yard throwing a ball for the dog when she suddenly sat down, as I watched from the kitchen. I’m sure she realized as she collapsed to the bench that her time had come. I doubt that there could be a lonelier moment in a person’s life.

She didn’t speak again. Her hearing and hand gestures reduced over a few days to squeezing, then nothing but breathing quietly. Her brother-in-law, who was with her at the end, said she simply stopped breathing.

Each person’s death is different, so I found Dear’s article comforting in a way I did not anticipate.

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One more reader for now:

My father was put into hospice, and all his meds were stopped. He “recovered” and lived another six months. After they “kicked him out” of hospice, he and I spent a lot of quality time together. When the end came, he was ready even though he could no longer speak. The hospice nurse came and looked at all the meds and found that while we still had the liquid morphine, we no longer had the Ativan, so we ordered a stat delivery from the pharmacist.

Giving morphine to a dying person can feel a lot like murder, and listening to the death rattle is more distressing than listening to a crying infant, but I think that the death experience is far worse for the person attending the death than for the one who is dying.

The Ativan was given to my father late in this process, but that was the drug which provided him with joy and relief. Shortly after he received the drug, I believe I witnessed him greeting his mother who had died 40 years ago.

My father then developed what is called a Cheyne-Stokes respiration; he would breath rapidly for a few minutes and then stop breathing. He resumed breathing like clockwork at 65 seconds from his previous breath. This lasted for hours. His last breath sounded much like a laugh, and I thought it was his way of saying good-bye.

I thought the event would be gruesome, but it was a special bonding experience which has helped me to reduce my fear of dying.

Complete Article HERE!

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Belgium minor first to be granted euthanasia

Belgium is the only country that permits euthanasia without age restrictions
Belgium is the only country that permits euthanasia without age restrictions

A terminally-ill minor has become the first to be helped to die in Belgium since age restrictions on euthanasia requests were removed two years ago, officials say.

The head of the federal euthanasia commission confirmed the case but gave no further details.

Belgium is the only country that allows minors of any age to choose euthanasia.

They must have rational decision-making capacity and be in the final stages of a terminal illness.

The parents of the under-18 year olds must also give their consent.

“Fortunately there are very few children who are considered [for euthanasia] but that does not mean we should refuse them the right to a dignified death,” Wim Distelmans of the federal euthanasia committee told the Het Nieuwsblad newspaper.

He told Reuters news agency the case had been reported to his committee by a local doctor last week.

The case occurred in Flemish-speaking Belgium, reports RTBF (in French), the public broadcaster for Belgium’s French-speaking community.

The age of the minor has not been reported.

The Netherlands also allows euthanasia for minors, but they must be aged over 12 years old.

Belgium lifted the age restrictions in 2014. The law passed by parliament said the child would have to be terminally ill, face “unbearable physical suffering” and make repeated requests to die before euthanasia is considered.

Many people, including church leaders and some paediatricians, questioned whether children would be able to make such a difficult choice.

Belgian Paralympian Marieke Vervoort, who suffers from an incurable degenerative muscle disease, says she will choose euthanasia, but not yet.
Belgian Paralympian Marieke Vervoort, who suffers from an incurable degenerative muscle disease, says she will choose euthanasia, but not yet.

Where is assisted dying permitted?

  • The Netherlands, Belgium and Luxembourg permit euthanasia and assisted suicide
  • Switzerland permits assisted suicide if the person assisting acts unselfishly
  • Colombia permits euthanasia
  • California last year joined the US states of Oregon, Washington, Vermont and Montana in permitting assisted dying
  • Canada passed laws allowing doctor-assisted dying in June of this year

How old must the patient be?

Only the Netherlands and Belgium permit euthanasia for patients under the age of 18.

In the Netherlands, a competent patient between the ages of 16 and 18 may request euthanasia or assisted suicide. The parent or guardian does not have a veto, but must be consulted. Competent patients aged between 12 and 16 may also qualify, but only if their parent or guardian consents.

In Belgium, a competent patient under the age of 18 may request euthanasia with parental consent. Additional scrutiny of the child’s competence is required, and suffering based on a psychiatric disorder is excluded.

How many people take this option?

The rate of euthanasia in the Netherlands has remained fairly stable at 2.8% of all deaths (in 2010), according to Penney Lewis, Professor of Law at King’s College London.

The most recent survey of doctors in the UK was in 2007-08. The rate of euthanasia was reported to be 0.21% of all deaths, and a similar rate has been reported in France (in 2009), even though euthanasia remains illegal in both countries.

In contrast, research carried out in Flanders, Belgium found the rate prior to legalisation was unclear, with separate surveys reporting rates of 0.3% of all deaths in the region (in 2001-02) and 1.1% (in 1998). The rate has risen steadily since legalisation in 2002 to 4.6% of all deaths in the most recent survey in 2013.

What do the different terms mean?

Euthanasia is an intervention undertaken with the intention of ending a life to relieve suffering, for example a lethal injection administered by a doctor

Assisted suicide is any act that intentionally helps another person kill themselves, for example by providing them with the means to do so, most commonly by prescribing a lethal medication

Assisted dying is usually used in the US and the UK to mean assisted suicide for the terminally ill only, as for example in the Assisted Dying Bills recently debated in the UK

Complete Article HERE!

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Musings on Mortality: Difference between suicide, medical aid in dying

By Deborah Alecson

There is a profound difference between suicide and medical aid in dying, otherwise known as death with dignity. It is not a matter of semantics.

Death with Dignity Campaign

In a death-phobic culture such as ours, one in which we prevent ourselves from projecting into our dying time, we cannot grasp the distinction. True, both result in the taking of one’s own life, but one is an act of desperation and self-destruction, while the other is an act of self-love. How can choosing death over life be motivated by self-love, you are wondering. We will explore this later in the column.

People commit suicide often in the prime of their lives because living for them is unbearable. Unlike the terminally ill who choose medical aid in dying, people who seek to commit suicide are not in their dying time but in their living time. More often than not, there are underlying and unresolvable emotional and psychological torments. There is depression or a psychiatric illness that has not been or cannot be treated. For the elderly, suicide can be motivated by the suffering that comes from living a compromised life without the support of family, friends, or community. Loneliness and feelings of abandonment are factors in suicide, especially for the elderly.

Suicide is considered a failure of the person and of our society. Help was needed and not found. In our culture, suicide is to be prevented at all costs including the involuntary psychiatric hospitalization (or incarceration depending on how you view that which is “involuntary”) of the person who discloses his or her suicidal thoughts. There are consequences for a patient in therapy to even talk about suicide: The therapist must report him or her to the authorities. The horrible irony is that the one place a suicidal person can get help to understand his or her own feelings, with a therapist, is the one place where he or she can’t talk about these feelings.

In a death-phobic culture, thoughts of suicide are considered aberrant. But let’s be honest, who hasn’t thought about suicide at least once in their life?

The will to live is an instinct of such force that human beings kill other human beings to stay alive. Human beings accept life-prolonging treatments during what would be their natural dying time that in the end, diminish the quality of time that they had bought with more treatment. People will do unbelievable things to ensure their own survival.

So, choosing to die under the weight of the instinctual and societal will to live is either accomplished out of sheer terror of life itself or incredible courage. Courage to venture into the unknown.

Since most of us have not been around dying people and as I wrote earlier, rarely imagine ourselves in that situation, we have no idea what dying is like. We don’t understand what it asks of us and what it takes out of us. While hospice care can be a possibility for how we live our dying time, it is not for everyone.

Medical aid in dying is now possible in five states. This means that people who are dying of a terminal illness can request a lethal dose of medication to end their own lives. Those few terminally ill patients who request and qualify for medical aid in dying do so to have a dignified death on their own terms. That’s all. This choice is a logical, sound, and deeply compassionate act of relief, not a desperate escape of a circumstantial situation as suicide often can be.

How can choosing death over life be motivated by self-love? When your dying time comes, you may want to spare yourself and your loved ones a prolonged and brutal decline. This to me is self-love. It is not suicide.

Complete Article HERE!

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The sobering thing doctors do when they die

By Carolyn Y. Johnson

The sobering thing doctors do when they die

In “How Doctors Die,” a powerful essay that went viral in 2011, a physician described how his colleagues meet the end: They go gently. At the end of life, they avoid the mistakes — the intensive, invasive, last-ditch, expensive and ultimately futile procedures that many Americans endure until their very last breath.

“Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits,” Ken Murray wrote.

A new study reveals a sobering truth: Doctors die just like the rest of us.

“We went into this with the hypothesis we were going to see very large differences,” said Stacy Fischer, a physician who specializes in geriatrics at the University of Colorado School of Medicine. “What we found was very little difference to no difference.”

The study in the Journal of the American Geriatrics Society examined 200,000 Medicare beneficiaries to bring some hard data to the question. They found that the majority of physicians and non-physicians were hospitalized in the last six months of life and that the small difference between the two groups was not statistically significant after adjusting for other variables. The groups also had the same likelihood of having at least one stay in the ICU during that period: 34.6 percent for doctors vs. 34.4 percent for non-doctors. In fact, doctors spent slightly more time in the ICU than non-doctors, the study found — not enough time to signify a clinical difference, but suggesting that, if anything, doctors may be using medicine more intensively.

In one regard, doctors seemed to die slightly better than non-doctors: 46.4 percent of doctors used hospice during their last six months compared with 43.2 percent of non-doctors. Doctors also spent nearly 2½ more days in hospice than non-doctors.

But these differences are small, and overall, they are far from the powerful mythology that doctors are dying better than the rest of the populace.

“Doctors are human, too, and when you start facing these things, it can be scary, and you can be subject to these cognitive biases,” said Daniel Matlock of the University of Colorado School of Medicine.

This is striking because it is the opposite of what doctors say they’d prefer. Onesurvey asked doctors and their patients what treatment course they would choose if they were faced with a terminal illness. Doctors said they would choose less medicine than their patients in almost all cases.

Many people have witnessed a death that seemed to be exacerbated by modern medicine: a drug that came with side effects but never seemed to halt the disease’s progress, the surgery that was totally unnecessary and might even have sped up someone’s death. Doctors have seen that happen even more often.

“Patients generally are not experts in oncology, and yet they have to make decisions without knowing what the whole course of their illness will be,” Craig C. Earle wrote in the Journal of Clinical Oncology. “We, on the other hand, have shepherded many patients through this journey toward death.”

That’s why powerful anecdotes about doctors who die better, whose last moments are spent peacefully and with family, give us hope: There is a better way.

But Matlock and Fischer think their data may reveal the odds against the patient, even when the patient is a doctor. The health-care system may simply be set on a course to intervene aggressively.

“These things that encourage low-value care at the end of life are big systems issues,” Matlock said. “And a strong, informed patient who knows the risks and benefits — maybe even they have a hard time stopping the train.”

There are definite limits to the study: It could not control for differences in education or income among people in the sample. Most of the doctors who died were white men.

But the findings may reveal a deep bias that lies at the root of medicine. Fischer pointed out that the entire health-care system is aimed at fixing problems, not giving comfort. For example, a hip replacement the day before someone dies is something the medical system is equipped to handle: Surgeons can schedule it, and health insurance will pay for it. But, Fischer pointed out, if a patient needs less-skilled home care — such as help with feeding and bathing — it’s much harder to write a prescription.

Complete Article HERE!

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“Dying with dignity” versus “doctor-assisted suicide:” ballot initiative sets off language battle

Coloradans will decide whether to allow doctors to write life-ending prescriptions for terminally ill people

By

dignity_human

In November Coloradans will decide whether to allow doctors to write life-ending prescriptions for terminally ill people who have less than six months to live and want to die on their own terms. Whether the initiative is called “doctor-assisted suicide,” “dying with dignity” or “medical aid in dying,” though, will depend on who is paying for the campaign ad.

The language behind the fight is becoming almost as impassioned as the years-long battle over “pro-choice” and “pro-life” that morphed into “abortion rights supporters” and “abortion rights opponents.”

People in favor of the initiative use the terms “dying with dignity” and “right to die” but named their Colorado ballot measure the more neutral “end-of-life options,” although the secretary of state’s office calls it the Medical Aid in Dying initiative. The campaign also uses “medical aid in dying,” which is what proponents predict doctors will call the procedure if it becomes legal in Colorado, as it is in five other states.

Opponents of the proposed law — including many for religious reasons and others who fear it would target people with disabilities — call it “physician-assisted suicide.”

The loaded words on both sides are a case study in the power of language, and how rhetoric — or the art of public persuasion — can shape political debate.

“To communicate and attach ourselves to language is a very natural thing for a human to do, to the point that people will come to blows over ‘physician-assisted suicide’ or ‘dying with dignity,’” said Dr. Christina Foust, chair of the communication studies department at the University of Denver.

“When I think of the word suicide, I think of the words that sound just like it — homicide, infanticide. It has such a negative connotation,” she said. On the other side, “dying with dignity” connotes the ability to choose one’s own death, which is an affront to somebody who “might rest that power in God or a higher power.”

Coloradans probably will get tired of both terms by the election, after they are bombarded with TV and radio ads. But Foust and Dr. Jeff Motter, who teaches political rhetoric at the University of Colorado at Boulder, find it fascinating.

A similar linguistics battle exists over greenhouse gases: Is it “global warming” or “climate change”? There is the intense division over the #blacklivesmatter versus #alllivesmatter, a matter of a single word. And for more proof that language is powerful, consider that the words “date rape” and “spousal rape” weren’t part of the lexicon until the 1970s or 1980s, and their mere existence effected change, Foust said.

Motter, who recently moved to Colorado from North Carolina, has picked up on the way the cannabis industry is “very careful to always use the term cannabis and not pot or marijuana.”

“They are trying to reinvent the story, and the story of cannabis is the story of medical, clothing, the fiber of it, and it’s not about the recreation of it,” he said.

In Colorado’s latest social debate, “death with dignity” and “doctor-assisted suicide” tell two “very different stories,” Motter said. “Is it a story of human compassion or a story of murder?”

“Medical aid in dying” is a more neutral term because it sounds clinical, like most of the vocabulary used in medicine, Faust said. Motter agreed but questioned whether the word “aid” is innocuous because it implies “it’s not just optional; aid is essential.”

Opponents of the measure say the campaign is attempting to “sanitize” the act, in which a doctor writes a prescription for secobarbital that is later self-administered.

“If I was on their side, I’d want to sanitize it too,” said John Stonestreet, who is with the Chuck Colson Center for Christian Worldview. “It’s a hard thing to swallow. But some things are hard to swallow because they should be hard to swallow.”

“Dying with dignity” is a “euphemism for killing elderly and terminally ill patients by giving them a cocktail of toxic drugs,” Stonestreet wrote on his blog. He told The Denver Post “medical aid in dying” doesn’t convey the reality of what’s at stake. The phrase makes it sound as if doctors are only making their patient comfortable as they die, not providing the prescription that ends their life, he said. “A doctor should never do anything to cause death or harm,” Stonestreet said.

But proponents of the measure said “suicide” is a pejorative, shame-inducing word that implies someone has a mental illness and is choosing to die. “People who use medical aid in dying are victims of a terminal illness,” said Barbara Coombs Lee, president of the national Compassion & Choices organization and a board member for the Colorado end-of-life options campaign.

She compared the “choice” that terminally ill patients have to the one made by people who jumped out of buildings on Sept. 11, 2001, to avoid burning to death.

The political movement initially used the term “dying with dignity” in the late 1980s and 1990s, and was successful in passing a law by the same name in Oregon. “We knew the term was biased in our favor — it was our term,” Coombs Lee said.

The term “medical aid in dying” arose because the medical community needed language to distinguish the new practice from the crime of aiding and abetting a suicide — coercing someone to jump from a building or persuading them to overdose. “Those are heinous crimes,” she said. “They should be clearly disassociated from a legitimate and authorized medical practice. Doctors stab people with knives, and we call it surgery. They inject people with poisonous toxins and we call it chemotherapy.”

The ballot measure says two physicians must agree that a person — who must be at least 18 years old — is terminally ill and has six months or less to live and is mentally competent. It also requires that the person self-administer the secobarbital, which historically has been used in low doses as a sleeping aid.

The divisive language has left news organizations considering what is the most objective term to describe the procedure. KUSA-Channel 9 recently informed viewers the station will call it “assisted suicide,” going by the Oxford definition of “the action of killing oneself intentionally.” Others, including The Denver Post, use “medical aid in dying,” noting that the word suicide carries meaning beyond the dictionary definition.

“Language does matter,” Motter said. “Both sides want their frame, and that’s because both sides are creating their story.”

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