Saturday, September 27, 2014

Physician-Assisted Suicide: A Clinicians Perspective

This article was published by Medscape Internal Medicine on September 25, 2014.

Joshua M Hauser MD

Joshua Hauser
Listening to Patient's Wishes

"When a horse breaks his leg, they put him down; why can't you do that to me?" The patient who asked me this recently is a 76-year-old man dying of gastric cancer who had pain from pressure ulcers he developed as he became increasingly debilitated and had no one to help get him out of bed. He also had haunting memories of caring for his parents as they died in pain decades ago. I explored how he was suffering; I suggested what we could do for his pain and what resources we might be able to gather to help him at home. I listened as he told me about his time with his parents. He was not satisfied.

And I left our interaction wondering what we would do next to help him. Two days later, we had a family meeting with his closest relatives, a niece and a nephew, and I asked how he was feeling about our conversation and wanting us to help him die. "Oh, that was just then. I feel OK now." I asked whether it was the pain medications or the newly developed plans for a nursing facility. "No, just not feeling that way anymore," he told me.

A second patient was a woman in her 40s who was dying of lymphoma. She was not dying as fast as she wanted to and requested our help in hastening her death. Evaluations ensued by our palliative care service, our psychiatry service, the ethics service, and multiple chaplains and she persisted in this desire. We all thought we had ideas about how to address her suffering; none were effective. Finally, after several days of intensive pain control and continued conversations, her desire for hastened death waned.

What made the difference? I asked her afterwards. The difference was, she told me, the result of the "sitter" who was called in because of caregivers' concerns—not about physician-assisted suicide, but because of worries about the patient's risk for "traditional" suicide.

Why did the sitter make a difference? Because, the patient told me, "she just sat there," "she read to me," and "she went and got me something to eat." What could be simpler? The patient proceeded to have several more months with her family.

Responding to Wishes for Hastened Death

Dying is unpredictable. These cases represent two phenomena which I believe are common in our care of dying patients: (1) how rapidly patients' wishes for hastened death can change; and (2) the unpredictability of the interventions that we use to address these wishes. Sometimes, despite all of the remarkable advances in palliative care that we have had over these past decades, we may not even know which specific intervention has made a difference.

I say this not to suggest that we abandon our attention to the core principles and interventions of palliative care used to combat the many forms of suffering that might affect patients, but because I believe we must redouble our efforts. We might not know which intervention is making a difference, so we owe it to ourselves and to our patients and their families to listen to their suffering, understand it as best as we can, identify what we cannot understand, and intervene in whatever way we can.

And as we do that, we must realize that wishes may change. Having patience with the possibility of wishes changing is difficult for us as clinicians who deeply desire to help and improve a patient's experience. It is even more difficult for the patient who is suffering. And yet, because many of us in palliative care have seen patients' desires change, patience is necessary.

Responding to Wishes for Hastened Death

Risks of physician-assisted dying. I have never practiced in a setting where physician-assisted dying has been legal, but even with safeguards that exist where it is legal, I worry that its availability could undermine this fickleness of patients' desires and short-circuit this observation about the unpredictability of interventions. I fear that even with the most altruistic of intentions, its availability would compromise the hard work of attending to suffering and the non-abandonment that is fundamental to palliative care.

For clinicians of all specialties, physician-assisted dying represents the ultimate measure of patient suffering and the ultimate challenge to our personal values as physicians. But whether we are the most passionate advocates for physician-assisted dying or its staunchest opponents, it is ultimately what the request represents for a patient that must be our focus. It is likely that those of us in palliative care witness patient requests for hastened death more often, but whether one practices in oncology, primary care, hospital medicine, cardiology, or many other specialties, we will confront patients who explicitly or implicitly want our help in hastening their death.

First and foremost, we must see a request as an alarm that a patient's suffering is out of control. Second, it should prompt us to explore with that patient and his family how he is suffering and its physical, psychological, social, spiritual, and existential sources. Third, it should lead us to interventions in these domains of symptom control and of psychological, social, and spiritual suffering.

We cannot be so presumptuous as to believe that we can solve each of these sources of suffering, but I know that we can bear witness in the deepest medical and human sense. And so a fourth step of non-abandonment is one that will allow space—for the unexpected sitter or the change of mind that cannot be predicted.

Joshua M. Hauser. Physician-Assisted Dying: A Clinician's Perspective. Medscape. Sep 25, 2014.

Joshua Hauser is assistant Professor of Medicine (Palliative Care), Fellowship Director, Northwestern Feinberg School of Medicine; Section Chief, Palliative Care, Jesse Brown VA Medical Center, Chicago, Illinois. He serves as an ethics and pain management consultant for CVS Health National Pharmacy and Therapeutics Committee

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