Showing posts with label Euthanasia. Show all posts
Showing posts with label Euthanasia. Show all posts

May 5, 2015

A Time to Die with Dignity for All

My patient had been having chest pains for several days before his heart stopped. Paramedics managed to revive him, but not before his lungs, kidneys and brain were severely damaged by the lack of blood flow. The prognosis was grim. A neurologist in the intensive care unit said the best possible outcome would be life in a persistent vegetative state.
Most doctors would recommend purely palliative treatment at this point, and that is what we did. There was no chance of organ recovery, little chance the patient could ever be weaned from the ventilator. However, his family members said they were willing for him to be in this state as long as he was alive. They asked us to start dialysis for his failing kidneys.
Of all the situations a doctor can encounter in a hospital, perhaps none is as nerve-racking as a so-called futility case. It has been estimated that there are at least 12,000 such cases in the United States every year, each typically costing hundreds of thousands of dollars. A vast majority are settled through discussions between doctors and patients’ families or mediation by a medical ethics team. But a large number cannot be resolved.
For most doctors, these cases present a crisis of conscience. How can we obey a central pillar of our profession — to do no harm — when we are forced to provide treatment that will only prolong suffering? Though doctors can refuse to treat patients under certain circumstances — for example, if a patient is violent or extremely intransigent — refusing to treat on the basis of conscience is controversial.
Futility disputes are governed by state laws, but these laws are inconsistent. In Texas, for example, a medical team can unilaterally withdraw treatment after 10 days if a hospital ethics committee agrees that further therapy is futile. However, in New York, doctors must continue to provide such treatment until care is transferred to another physician. Because transfer is often precluded by the severity of the underlying illness (or by the unwillingness of other hospitals or physicians to take on such a case), doctors may find themselves in the discomfiting position of delivering treatment that they consider inhumane.
Matters of life and death should not be subject to the vagaries of state legislatures. Critical care physicians, patient advocates and other experts should come together to establish uniform standards to govern futile care. Hospital review boards should uphold these standards, even in the face of political pressures. Hopefully, states would write legislation that would adhere to these principles.
Unfortunately, there is as yet no consensus on how to balance the competing ethics in these disputes. No doctor wants to go against a patient’s or family’s wishes, but we also want to avoid treatments whose risks and burdens exceed their benefit.
Embracing the ethic of social justice can help us out of this morass. Social justice in medicine promotes the allocation of limited resources to maximize societal benefit. For example, we don’t usually offer heart transplants to patients over 70 years of age. Scarce goods, such as health care, should be distributed fairly.
Though social justice as an ethic has been historically undervalued in my profession, this is beginning to change. For example, residency programs across the country* ~~~~~~~~~~~~~~~~~         
 New York, NY 20 hours ago
I have frontal lobe demencia, I am 5-7 years from showing any symptoms. I have lived through my father's life with this disesase and now my older sister is in going thru this. I have made the decision that I in no uncertain terms do not want to live with this disease. I am not going to put my family thru 10-12 years of caring my me in my non communicative brain dead self. I deserve to die a peaceful death. But this country does not allow that. So if I want to die, which should be my right, my only choice is to kill myself. I think this country needs to fix this. A person with demencia can live up to 12 years. That is a huge financial burden on a family. And for what? Life is prescious to what end. Why doesn't my wishes matter? I truly believe that we need to start all over again and overhaul this problem within the medical community.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ *are now teaching trainees about the costs of certain tests and procedures, such as PET scans, and encouraging them to take these costs into consideration when deciding treatment plans.
This is a welcome development. Though cost considerations have remained largely hidden in medical practice, de facto rationing goes on every day on the basis of ability to pay, insurance access, socioeconomic status, even race. For example, a patient without health insurance would be hard-pressed to find a hospital willing to provide a liver transplant, regardless of the need. It is best that these issues be discussed openly rather than remain covert.
Arguments for limiting such care based on quality of life, or what is best for a patient or his family, will always be fraught. Quality of life is a value judgment, and such judgments rightfully belong to patients or their surrogates.
Far better for us to decide that we cannot afford to pay for nonbeneficial care. We need to have this discussion without alarmist rhetoric about “death panels.” Rational judgments about end-of-life issues should not give way to idiosyncratic desires.
This discussion cannot happen soon enough. America is aging. Already, a large percentage of I.C.U. clinicians report experiencing conflicts weekly over end-of-life care. Without clear guidance, many of these physicians will continue to provide treatment that is morally repugnant to them.
Unfortunately, that is what happened with my patient in the I.C.U. We encouraged the family to reconsider dialysis, but they insisted, so after much discussion, we relented.
That night, when a nurse flushed the dialysis catheter, my patient’s blood pressure dropped precipitously and he went into cardiac arrest. CPR was performed for 45 minutes, but he could not be resuscitated. In the end, and this happens not infrequently, dialysis not only didn’t help — it probably accelerated his demise.

April 27, 2015

“I want to die NOW!” please


An old man lies up there dying. We’ve left him all alone. Roger Kusch swiftly closes the door to the apartment and we hurry down the stairs. For legal reasons, it’s safer to go while the old man is still fully conscious. According to some lawyers, failure to offer assistance may create problems. So we leave. We meet a woman on the staircase, pass her quickly and continue down the steps. What will the woman tell the police later when the old man is found? “I’m not worried about that,” Kusch says outside.

In the apartment above us, Rudolf Meier, whose name has been changed, has done something that lawyers call “voluntary suicide of one’s own free will.” Kusch helped. He provided Meier with drugs that, according to Kusch, were prescribed by a doctor. That’s not a criminal act. But aren’t we fleeing like thieves in the night? Meier is lying completely alone on his bed with two empty beakers on his bedside table.

Kusch is chairman of the Sterbehilfe Deutschland (Help to Die Germany), or StHD. For an annual fee of 200 euros, members can get suicide assistance, at their own request, after meeting all the requirements. The association currently has around 600 members. A onetime payment of 2,000 euros for a lifetime membership is also possible. And for a onetime fee of 7,000 euros there’s “Membership S.” According to the association’s rules, this entails “making every effort” to “ascertain particularly quickly” whether the conditions that StHD calls “ethical principles” are met. These include having reached the age of majority, having the ability to understand suicide and “consider the alternatives” to it, and dealing with the possibility of continuing to live.

Should a person who won’t get help to keep living receive help to die?
Meier is not terminally ill. Nor are many other StHD members who wish to die. Around half of the 41 suicides that the association assisted in during 2013 were committed by people who were not suffering from imminently life-threatening physical illnesses. Rather, they either had severe depression for decades or, like Meier, age-related conditions that, for fear of ending up in a nursing home, they no longer wanted to endure.

More than 3,000 people over the age of 65 kill themselves in Germany every year — most the old-fashioned way. The World Health Organization estimates that globally, the number nears 1 million. Euthanasia is legal only in Belgium (where estimates suggest around five people die per day via assisted suicide), the Netherlands, Luxembourg, and Colombia. Assisted suicide — meaning the doctor doesn’t actively participate in the means of death, but simply makes it available — is legal in a few countries, Germany included, and in some U.S. states, including Oregon, Washington, Vermont, New Mexico and Montana. In every area in which it takes off, fears of a “slippery slope” take off just as fast. It’s the third rail of conversations about aging, human rights and ethics.

The elderly make up a growing proportion of people who wish to die. Yet the association can hardly be held responsible for the older generation’s death wish. This trend started before the activities of organized suicide assistants, who are involved in very few suicides by seniors. What is questionable is whether providing help to die is justifiable for people in generally good physical health. Should a person who won’t get help to keep living receive help to die?


Meier has been diagnosed with unsteadiness when walking, caused by arthritis and possibly the radiation he underwent for cancer a few years earlier. He complains of pain in his limbs and takes an opium-based medicine for it. He also has hypertension and glaucoma. But none of that is life-threatening. Yet Meier has fallen over many times, once in the bath when the faucet was running and the overflow was closed. He lay for hours, fully conscious, in the water on the floor. Another time, he collapsed on the street. Passers-by wanted to call an ambulance, but Meier got a taxi to take him home: “I’m not going to any hospital.”

Most euthanasia debates have centered on the chronically ill in the final stages of life, but Meier fits a new breed. He’s a regular member of StHD with a onetime payment. He tries to donate money to the group just before he dies, but Kusch refuses to accept it. “I have more than 7,000 euros in my account,” the 84-year-old says to Kusch. “I wanted to make you happy.”
Which makes us pause. Why, oh why, didn’t he make himself happy with that money? Meier’s one-bedroom apartment needs renovating. It’s still clean because someone comes to clean it every fortnight. But the furniture is worn and the wallpaper is yellowing. On the day of his death, Meier wears baggy pants and an old shirt. Why didn’t the former public servant use his generous pension and savings to make his twilight years more comfortable?

His desire to die comes from him alone. Yet he doesn’t want to act on it until “daily life becomes unbearable.”

The life story he told a few months before his death was a sad one. At least two long interviews are carried out with people wishing to die before StHD assists with a suicide. At the first one, a year ago last February, Meier told of the death of his son, who couldn’t handle school during puberty and froze to death outdoors during a trip with friends. Meier’s first marriage broke up as a result: “My wife said, ‘I’m not doing anything else in bed.’” He didn’t say anything else about this marriage.

He married two more times. Both wives died from cancer. He has a daughter, who is far away abroad. Sometimes he phones her. But only one former work colleague knows about his StHD membership. He visits Meier regularly and used to join him on daytrips: “A taxi to the city park and a nice walk.” But that’s no longer possible. Meier shuffles unsteadily around his apartment with his walker, which is itself fragile with age. “I sleep till noon, then I eat something.” The food is brought by social services.

“Christianity is a fairy tale,” he said, when asked about religion, and during the rest of the interview he was undoubtedly clear in his thoughts, answering  everything that Kusch, a 60-year-old former Labour and Social Justice Party senator, asked him. Yes, he knew no suicide method works every time. Yes, he had made a living will. His desire to die came from him alone. Yet he didn’t want to act on it until “daily life becomes unbearable.” So he would wait until the spring, after his daughter had visited. 


Seen a second time in April, Meier seemed brighter. He’d “eaten well” with his daughter. But although she seemed to have lifted his spirits, he talked about her very little. He briefly mentioned her professional success and then changed the subject. He talked about his childhood in southern Germany — “That was a happy time” — and about his later travels through Europe. And he repeatedly mentioned his savings, as though to him the money symbolized that everything had been taken care of. The last thing to take care of was StHD. An improvised suicide attempt four years earlier had failed: “I made myself a tincture out of foxgloves, but there was nothing but diarrhea and sickness.”

The fact that Meier was more talkative during this second meeting could have been because he had a different listener. Johann Friedrich Spittler, 72, is a psychiatrist and neurologist who provides StHD with expert assessments of the mental and physical condition of people wishing to die. Spittler is a quiet man who got Meier to talk. Spittler asked him which home help he could envisage himself having and gave Meier examples of social services.

Meier bluntly brushed it all aside. He absolutely did not want to go into a nursing home, which could be a possibility for him if he fell down again: “I don’t want to be looked after until I die and then leave my family having to pay a big fat check.” He had an obsession with money. “Palliative medicine is all about profit.” Several years earlier he had refused operations on his joints for his arthritis: “I’m no spare parts depot.”

“Are your thoughts about suicide irrevocable?” Spittler asked him. “Yes, I’ve worked out my position in my mind and I’m sticking with it.” Spittler certified him as having an unimpaired ability to understand and assess. And because Meier maintained a constant, considered desire to die, he legally reserved the right for self-determination. No one could stop him. Spittler’s bill for his report was more than 1,200 euros. Meier paid in cash.

A few weeks later, Meier received a letter from StHD. He’d gotten the “green light” for assisted suicide. He could now fix the date. But he waited some more because it was spring.
Both Kusch and Spittler were charged with manslaughter in May 2014, in a case of two elderly women who took their lives in 2012 with the help of StHD. Spittler concedes he was present at the double suicide and stayed until both women were dead. He called the police afterward. But both men deny the charge; they say what they did is legal, and will continue to maintain that claim in the future. Hamburg regional court has not yet decided whether the case will go to trial. But Kusch announced on the day after the arraignment that the association would continue with the practice of assisted suicide “with no ifs or buts.” The German Parliament has discussed passing a law making assisted suicide illegal, but nothing has happened so far.


Rudolf Meier’s assisted suicide takes place in October. This time it’s Kusch who comes, not Spittler. It’s 11 a.m. Meier opens the door, supported by his walker. He’s been expecting Kusch. Inside the apartment he’s laid out papers, stating where certain documents can be found after his death and whom should be called. He’s arranged for his former work colleague to come and visit him in the evening. The man has a key but has no idea what he’ll find. “The poor guy,” says Meier. “He’s in for a shock.” His daughter is not supposed to find out that it’s suicide.

To Kusch’s question about how he’s doing, Meier replies that — like the previous weeks — he hasn’t slept well. Kusch asks: “What’s going through your mind? Are you scared?” Meier answers: “No, I’m not scared. I want it to end now. It’s clear to me that I don’t want to continue living. Hopefully it will soon be over.”

Kusch sets up a video camera that’s meant to record everything that happens. It’s 11:30 a.m. Meier has sat down on the bed and stuffed cushions behind his back. Kusch asks him repeatedly whether he really wants to die today. The appointment can be rescheduled or even canceled. And if Meier takes the drugs, an ambulance can still be called. “I don’t want an ambulance,” Meier says.
Kusch goes into the kitchen, where he can’t be watched. He doesn’t say which drugs are being used. The sound of a grinder can be heard coming from the kitchen. Meier remains seated on his bed. We’re silent.

Kusch comes back with two beakers and places them next to Meier. “Mr. Meier, there are now two beakers here. Once you’ve drunk up the first one there’s no turning back. You then have to drink the second one as well.” Meier takes the first beaker in his hand. “It is my will that I die today,” he says.
He drinks up the beaker in one go with a grimace. “That really tastes terrible.” Kusch passes him a bottle of apple juice to counteract the bitter taste. Meier sips the juice and immediately takes the other beaker, which he also drains completely. “Take another sip of apple juice,” Kusch says. Meier replies: “I’ll drink that later.” These are his last words. Kusch says, “You can’t drink any more later.” Meier now drinks some apple juice. It’s just after noon.

Meier sits silently on his bed. Kusch takes down the video camera and packs his bag. We leave.

March 3, 2012

Dutch Euthanasia Opposed by Some But Still Humane

Dutch euthanasia organisation Life-End will be offering its home services free of charge to Dutch citizens. Photograph: Etienne Ansotte/EPA
A controversial system of mobile euthanasia units that will travel around the country to respond to the wishes of sick people who wish to end their lives has been launched in the Netherlands.
The scheme, which started on Thursday , will send teams of specially trained doctors and nurses to the homes of people whose own doctors have refused to carry out patients' requests to end their lives.
The launch of the so-called Levenseinde, or "Life End", house-call units – whose services are being offered to Dutch citizens free of charge – coincides with the opening of a clinic of the same name in The Hague, which will take patients with incurable illnesses as well as others who do not want to die at home.
The scheme is an initiative by the Dutch Association for a Voluntary End to Life (NVVE), a 130,000-member euthanasia organisation that is the biggest of its kind in the world.
"From Thursday, the Life End clinic will have mobile teams where people who believe they are eligible for euthanasia can register," Walburg de Jong, a NVVE spokesman, said.
"If they do comply, the teams will be able to carry out the euthanasia at patients' homes should their regular doctors be unable or refuse to help them," he added.
The Netherlands was the first country to legalise euthanasia in 2002 and its legislation on the right to die is considered to be the most liberal in the world.
But doctors cannot be forced to comply with the wishes of patients who request the right to die and many do refuse, which was what prompted NVVE to develop a system to fill the gap.
Sick people or their relatives can submit their applications via telephone or email and if the patient's request fulfils a number of strict criteria, the team is then dispatched.
Legal guidelines state that the person must be incurably sick, be suffering unbearable pain and have expressed the wish to die voluntarily, clearly and on several occasions.
According to De Jong, the team will make contact with the doctor who has refused to help the patient to die and ask what his or her reasons were.
More often than not, he said, the motivations are religious or ethical, adding that sometimes doctors were simply not well enough informed about the law.
If the team is satisfied that the patient's motives are genuine, they will contact another doctor with whom they will start the euthanasia process.
"They will first give the patient an injection, which will put them into a deep sleep, then a second injection follows, which will stop their breathing and heart beat," De Jong said.
Every year 2,300 to 3,100 mercy killings are carried out in the Netherlands, although opponents of the practice claim the figure is much higher because many cases are not registered. The Royal Dutch Medical Association (KNMG) supports euthanasia in principle if there is no alternative, but has distanced itself from the NVVE initiative, arguing that giving it the name Life End will foster the idea that it is for those who it said are simply "weary of life" rather than those who are sick.
It has also questioned whether Life End doctors will have the chance to forge the necessary relationship with a patient to be able to ascertain whether or not his or her life should be ended.
But Jan Kuyper, of the Life End Clinic Foundation, said: "We're not trying to push any boundaries here." He said it was quite possible that the mobile teams would not end up carrying out a mercy killing, either due to medical questions about the case or if doubt is cast on the patient's motives.
Little is known about the Life End teams. But one of the team leaders is believed to be a 67-year-old retired doctor who carried out 20 mercy killings during his medical career.
The teams would be limited to one house visit a week to minimise the psychological burden on them.
In neighbouring Germany, where mercy killings are strictly illegal, euthanasia opponents were particularly vocal in expressing their outrage at the developments. "This is an inhumane proposal," said the German Hospice Foundation, while the group Life Rights for Everyone called it a "warped understanding of [the meaning of] autonomy"

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