29 y/o plans her death for Nov 1st

[AMEHigh]

Yeah, something like quadriplegia, for instance, would also be fine in my book.

I believe that in the few states with the death with dignity act, the patient has to be physically capable of taking the medication themselves.

I read a story about a man with ALS who waited too long to take the meds, then became too weak, so he could no longer be prescribed the medication.

Just another point of view to think about.

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[Doctor Bob]

So if your 18 year old daughter with a non-terminal illness came up to you and told you this you'd support her decision?

I don't have an 18 year old daughter.

Its easy to say these things when its not someone you care about.

Sure it is. Because when it comes to end of life decisions, it's not about what's best for me, it's about what's best for them. So long as it's a well thought out and reasoned decision, made with consideration, then an intervention on my part to stop them is selfish. And the system we currently have in place for PAS allows for... nay, requires... well thought out and reasoned decisions.

Here's the thing though, I don't think a physician (or any other person for that matter) should play an active role in killing someone, beyond self defense, protection, etc.

You can be as for death with dignity as you want (and I don't have a problem with people choosing how they want to die - regardless of how I personally feel), but its selfish to expect someone else to take the responsibility of helping you kill yourself.

You want to kill yourself, do the right thing and choose one of the many relatively painless ways to do it yourself. You don't need me to write you a lethal prescription to do it.

Understood. Your reluctance is reasonable. And it is why as a doctor you would have the right to refuse to write these prescriptions. But what we are asking is that you not make that decision for those of us that would.

 

[Mass Effect]

A patient approaches his physician and says "I am 30 years old and have been diagnosed with depression, confirmed by multiple psychiatrists. The prescribed treatments have not improved my quality of life and have often reduced it via side effects. In my case, several years of therapy in conjunction with various medications have not reduced my symptoms. I will likely have this condition my entire life and I experience great suffering on a nearly daily basis as a result of my diagnosed medical condition. My quality of life is unacceptable. I am of sound mind and body and would like for you to end my suffering by prescribing a lethal dose of medication for the purpose of killing me and ending my misery. I understand that this will kill me and ha I may not take it immediately but will take it the next time I have a severe depressive episode which degrades my quality of life even further below what it is currently."

Someone in refractory depression is not of sound mind, by definition. Your example doesn't work.

 

[alpinism]

No, which is why you arent allowed to make end of life medical decisions with the presence of serious pain....

And no, as said above, this is an ethics 101 question that youve failed. You do what they want, NOT what's best for them. Period. Patients have autonomy.

That's not what autonomy means.

Autonomy is the patient's right to make their own medical decisions. Ie they must have the ability to choose and refuse treatment.

It does not mean that you should do what the patient wants.

Since we're talking about bioethics 101, I'm sure you know the next 2 principles:

1. Beneficence - always act in the best interest of the patient.

This is why if a patient wants Abx for their viral URI, you do not do what they want (give them Abx), you do what's best for them (deny their request).

Same thing for dangerous and unproven treatments, unnecessary CT scans, unnecessary surgeries, etc...

2. Non-maleficence - first do no harm

Assisted suicide in the context of a non terminal illness provides no proven medical benefit (does not treat or cure a disease) and only serves to harm the patient (by ending their life).

This one is non debatable.

 

[alpinism]

That is basically the opposite of what we do for patients nowadays. It used to be that we didn't discuss things much with the patients or family and we just did what we felt was the right treatment. However a huge shift has occurred and now we explain things to patients and let them make their own decisions.

True, but a key distinction is that even though patients can make their own decisions, we still have the right to choose which treatments we will provide.

If you don't think a treatment is in the best interest of a patient, it is your right not to provide it to the patient. Regardless of what they want.

 

[that redhead]

I guess I see it differently than many: euthanasia is one of the most valuable tools we have in veterinary medicine. We can peacefully, humanely end the life of an animal, often ending or preventing suffering. I don't see what greater gift you can give a patient with terminal illness or unmanageable suffering. (FWIW...cattle sent for food are not euthanized by veterinarians but by trained plant personnel, although vets are present on the floor.)

@GUH, I find it interesting that you perceive the role of a physician to only be healing. You mention your oath, so I imagine you think, "First, do no harm" is the leading principle... but isn't allowing a person to suffer doing them harm? And what about the harm you do by prescribing certain drugs (such as chemotherapeutic agents) or performing invasive surgeries, for example? Attempting to heal a patient is always the goal, I certainly agree. But when it becomes clear that the person is suffering and will continue to do so for any length of time, the option to end that suffering is a form of healing, too, both for that person and for their families left behind.

 

[Mad Jack]

That's not what autonomy means.

Autonomy is the patient's right to make their own medical decisions. Ie they must have the ability to choose and refuse treatment.

It does not mean that you should do what the patient wants.

Since we're talking about bioethics 101, I'm sure you know the next 2 principles:

1. Beneficence - always act in the best interest of the patient.

This is why if a patient wants Abx for their viral URI, you do not do what they want (give them Abx), you do what's best for them (deny their request).

Same thing for dangerous and unproven treatments, unnecessary CT scans, unnecessary surgeries, etc...

2. Non-maleficence - first do no harm

Assisted suicide in the context of a non terminal illness provides no proven medical benefit (does not treat or cure a disease) and only serves to harm the patient (by ending their life).

This one is non debatable.

http://en.m.wikipedia.org/wiki/Euthanasia_in_the_Netherlands

It's pretty debatable, as demonstrated by the way physicians in other countries have approached the issue. Physicians are not just healers- we should be able to provide interventions that minimize suffering, as life without quality is often a fate worse than death. The interventions we provide for some of our patients would be considered torture were they against their wishes.

So this brings us to people that have, say, quadriplegia. They are physically incapable of ending their own lives, regardless of their intent to do so. This leaves them with two options- refusing nutrition until they starve to death slowly over weeks, or humane euthanasia. I fail to see how forcing a person to slowly suffer to death rather than allowing them to pass peacefully is the morally correct way in which a physician should act.

 

[SurgeDO]

am i the only one who is a little skeptical of this woman's condition and decision? or have i just become that much of a cynical dingus? i mean, c'mon...choosing to die the day after your husband's birthday? sounds like the plot of a Lifetime original.

it was only 1-2 months ago where that big news story broke about the mother who faked her daughter's cancer for secondary gains. ****ed up **** like this has happened in the past.

i am probably wrong, but my sense of suspicion is tingling.

 

[Kahreek]

Whether or not its the right choice, I think it should be the choice for each person to make. As I understand Oregon's law, while the physician provides the oral medicine, the person must be conscious enough to take it themselves. I find this story interesting, assisted suicide doesn't always work

http://drugtopics.modernmedicine.co...on-board-investigates-failed-assisted-suicide

Pruiett, 42, is the only Oregonian to survive a full dose of the barbiturates prescribed under the state's physician-assisted suicide law. After waking up, he reportedly told his wife that while he was unconscious, God had told him that his action wasn't the way to get into heaven. He died from lung and bone cancer two weeks after his failed assisted-suicide attempt.......The 2004 report found that 40 physicians wrote 60 prescriptions for lethal doses of medication. Thirty-five of the prescription recipients died after ingesting the medication.

useless, i am more worried about those who cant even put a pill in the mouth and swallow

 

[Mad Jack]

am i the only one who is a little skeptical of this woman's condition and decision? or have i just become that much of a cynical dingus? i mean, c'mon...choosing to die the day after your husband's birthday? sounds like the plot of a Lifetime original.

it was only 1-2 months ago where that big news story broke about the mother who faked her daughter's cancer for secondary gains. ****** up **** like this has happened in the past.

i am probably wrong, but my sense of suspicion is tingling.

You've just gone stone cold.

Personally I think she should do it after his birthday rather than the day of, because "being a widower" is generally the last thing most guys want as a gift.

 

[Mad Jack]

Whether or not its the right choice, I think it should be the choice for each person to make. As I understand Oregon's law, while the physician provides the oral medicine, the person must be conscious enough to take it themselves. I find this story interesting, assisted suicide doesn't always work

http://drugtopics.modernmedicine.co...on-board-investigates-failed-assisted-suicide

Pruiett, 42, is the only Oregonian to survive a full dose of the barbiturates prescribed under the state's physician-assisted suicide law. After waking up, he reportedly told his wife that while he was unconscious, God had told him that his action wasn't the way to get into heaven. He died from lung and bone cancer two weeks after his failed assisted-suicide attempt.......The 2004 report found that 40 physicians wrote 60 prescriptions for lethal doses of medication. Thirty-five of the prescription recipients died after ingesting the medication.

This guy was tripping hard.

 

[jakeislove]

am i the only one who is a little skeptical of this woman's condition and decision? or have i just become that much of a cynical dingus? i mean, c'mon...choosing to die the day after your husband's birthday? sounds like the plot of a Lifetime original.

it was only 1-2 months ago where that big news story broke about the mother who faked her daughter's cancer for secondary gains. ****** up **** like this has happened in the past.

i am probably wrong, but my sense of suspicion is tingling.

I would be nice if things like this were done privately, though. Being done in a way that draws attention, err sorry the PC term is awareness, is always going to ruffle a few feathers.

 

[SurgeDO]

I would be nice if things like this were done privately, though. Being done in a way that draws attention, err sorry the PC term is awareness, is always going to ruffle a few feathers.

i don't know...again, i'm probably just an dingus, but there is something with this story that just doesn't seem right to me. brain cancer; newly wedded couple; taking away their dream to have kids; 6 months to live; dying right after her husband's birthday. it hits on nearly every sympathetic bone in the human body and then directs you to a webpage with a big "DONATE" button. why aren't their any statements from physicians/hospitals/medical personnel?

i am probably wrong. i hope i am wrong.

 

[SouthernSurgeon]

i don't know...again, i'm probably just an dingus, but there is something with this story that just doesn't seem right to me. brain cancer; newly wedded couple; taking away their dream to have kids; 6 months to live; dying right after her husband's birthday. it hits on nearly every sympathetic bone in the human body and then directs you to a webpage with a big "DONATE" button. why aren't their any statements from physicians/hospitals/medical personnel?

i am probably wrong. i hope i am wrong.

In this day and age it's probably appropriate to have a healthy dose of skepticism.

 

[Mad Jack]

i don't know...again, i'm probably just an dingus, but there is something with this story that just doesn't seem right to me. brain cancer; newly wedded couple; taking away their dream to have kids; 6 months to live; dying right after her husband's birthday. it hits on nearly every sympathetic bone in the human body and then directs you to a webpage with a big "DONATE" button. why aren't their any statements from physicians/hospitals/medical personnel?

i am probably wrong. i hope i am wrong.

I hope you're right.

 

[Wordead]

That's not what autonomy means.

Autonomy is the patient's right to make their own medical decisions. Ie they must have the ability to choose and refuse treatment.

It does not mean that you should do what the patient wants.

Since we're talking about bioethics 101, I'm sure you know the next 2 principles:

1. Beneficence - always act in the best interest of the patient.

This is why if a patient wants Abx for their viral URI, you do not do what they want (give them Abx), you do what's best for them (deny their request).

Same thing for dangerous and unproven treatments, unnecessary CT scans, unnecessary surgeries, etc...

2. Non-maleficence - first do no harm

Assisted suicide in the context of a non terminal illness provides no proven medical benefit (does not treat or cure a disease) and only serves to harm the patient (by ending their life).

This one is non debatable.

True, but a key distinction is that even though patients can make their own decisions, we still have the right to choose which treatments we will provide.

If you don't think a treatment is in the best interest of a patient, it is your right not to provide it to the patient. Regardless of what they want.

You are defining terms by your own moral standards, not what they are actually defined by. And twisting words. When did I say you should just do whatever the patient wants? Im saying patient has CHOSEN to die, with knowledge of all options, and you provide the method.

And yes, you can refuse to treat a patient. That's not the issue. We do PLENTY of interventions that do not cure a disease. That is not the definition of medical benefit.

 

[jakeislove]

i don't know...again, i'm probably just an dingus, but there is something with this story that just doesn't seem right to me. brain cancer; newly wedded couple; taking away their dream to have kids; 6 months to live; dying right after her husband's birthday. it hits on nearly every sympathetic bone in the human body and then directs you to a webpage with a big "DONATE" button. why aren't their any statements from physicians/hospitals/medical personnel?

i am probably wrong. i hope i am wrong.

No one would be surprised if you were right.

 

[tmn]

See, I've still never totally understood this. We're talking about depression. Not psychosis. I'm not saying you aren't correct - no ethics committee I know of would let a person with clinically diagnosed depression decide to end their life. However, there seems to be a disconnect. Either a person has medical decision making capacity or they don't. So if a depressed person doesn't have capacity, based on lack of "sound mind", then do they have a right to refuse any care? Example: A person w/ hx depression on zoloft (but acting appropriately and mentating well) comes to my ED for abdominal pain. I think they need an IV and abd labs. They decide they don't want a needle and refuse. Do I now have the right to have them tied to the bed and forced to receive and IV and blood draw? Because seriously like 1 in 5 of my patients is on an antidepressant, and I'm going to be forcing a whole lot of refused care on people if we're going to define depression as being mentally incapacitating.

My point being that I don't think there's a lot of consistency in a lot of what we do. For good or for bad.

Which is why judgment is so important. I understand the desire to protocolize everything single thing, but not everything fits nicely into a box. An outright ban on physician assisted suicide is a box. I would rather have the judgment in the hands of individual, ground-level physicians than in the hands of law makers.

 

[DoctwoB]

The only problems I see are

(1) not every state allows it so people have to disrupt their life and support network to recieve PAS.

(2) I don't like the idea of prescribing pills that the patient then takes themselves. If we are going to do this, we should do it right. Have an anesthesiologist give induction sedation so the patient feels nothing. Have someone who can responsd to circumstances to adjust dosing or respond to any pain or suffering that arise.

 

[Mass Effect]

See, I've still never totally understood this. We're talking about depression. Not psychosis. I'm not saying you aren't correct - no ethics committee I know of would let a person with clinically diagnosed depression decide to end their life. However, there seems to be a disconnect. Either a person has medical decision making capacity or they don't. So if a depressed person doesn't have capacity, based on lack of "sound mind", then do they have a right to refuse any care? Example: A person w/ hx depression on zoloft (but acting appropriately and mentating well) comes to my ED for abdominal pain. I think they need an IV and abd labs. They decide they don't want a needle and refuse. Do I now have the right to have them tied to the bed and forced to receive and IV and blood draw? Because seriously like 1 in 5 of my patients is on an antidepressant, and I'm going to be forcing a whole lot of refused care on people if we're going to define depression as being mentally incapacitating

You'll notice I said refractory depression. The patient in your example is on Zoloft, presumably because it helps him/her and therefore, their depression might not be an active concern. A person with refractory depression is actively depressed. A symptom of depression is suicidal ideation, so they are not of sound mind to be asking for a medication to kill themselves.

Secondly, your example is about someone refusing care, which a person who is assessed favorably for capacity is allowed to do. You can't force a procedure on anyone. In the case discussed in this thread, the patient in question wants care. There's a difference.

 

[Guillemot]

I think planning ones death in anticipation of suffering is not the best option. She should be able to end her own life, but wait until she feels she reaches a threshold of suffering that she feels intolerable. Her choice though. I support her right to make this choice. I do not feel that I could participate in physician assisted suicide personally, but would support a colleague trained in something like palliative care being part of it if they flt comfortable doing so.

 

[Jabbed]

You'll notice I said refractory depression. The patient in your example is on Zoloft, presumably because it helps him/her and therefore, their depression might not be an active concern. A person with refractory depression is actively depressed. A symptom of depression is suicidal ideation, so they are not of sound mind to be asking for a medication to kill themselves.

I fully agree with you. Something to consider though is that most of our valuations of what constitutes sound vs unsound mind ultimately has to do with DSM-V criteria. So theoretically anyone whose mental state can't be pigeon-holed into a DSM listed pathology is technically of sound mind. When considering that these criteria are updated periodically, it's perfectly conceivable that we could participate in a physician assisted suicide of a patient with 'sound mind' who may later be categorized as being of 'unsound mind'. Seems sketch.

Also, many patients with terminal illnesses are clinically depressed. Doesn't this disqualify them for PAS by the same logic?

 

[GUH]

I guess I see it differently than many: euthanasia is one of the most valuable tools we have in veterinary medicine. We can peacefully, humanely end the life of an animal, often ending or preventing suffering. I don't see what greater gift you can give a patient with terminal illness or unmanageable suffering. (FWIW...cattle sent for food are not euthanized by veterinarians but by trained plant personnel, although vets are present on the floor.)

@GUH, I find it interesting that you perceive the role of a physician to only be healing. You mention your oath, so I imagine you think, "First, do no harm" is the leading principle... but isn't allowing a person to suffer doing them harm? And what about the harm you do by prescribing certain drugs (such as chemotherapeutic agents) or performing invasive surgeries, for example? Attempting to heal a patient is always the goal, I certainly agree. But when it becomes clear that the person is suffering and will continue to do so for any length of time, the option to end that suffering is a form of healing, too, both for that person and for their families left behind.

Do you really think that killing a human carries the same moral weight as killing a cow? Perhaps many share your opinion but I'm willing to bet that many patients would be uncomfortable seeing a doctor who told them that.

And I'm pretty sure that administering poison for the sole purpose of killing a person, especially a person without a terminal illness as suggested by many on this thread, is the most basic definition of doing harm. If not even deliberate killing of a patient is "doing harm", then "Do no harm" loses all objective meaning. "Do no harm" is not interchangeable with "minimize pain" or else the way we prescribed pain medication, for example, would be quite different.

 

[Mad Jack]

Do you really think that killing a human carries the same moral weight as killing a cow? Perhaps many share your opinion but I'm willing to bet that many patients would be uncomfortable seeing a doctor who told them that.

And I'm pretty sure that administering poison for the sole purpose of killing a person, especially a person without a terminal illness as suggested by many on this thread, is the most basic definition of doing harm. If not even deliberate killing of a patient is "doing harm", then "Do no harm" loses all objective meaning. "Do no harm" is not interchangeable with "minimize pain" or else the way we prescribed pain medication, for example, would be quite different.

"Do no harm" is actually subjective, not objective, as what one person perceives to be harm another might believe to be helping. I think the greatest harm one can cause is perpetual suffering, personally, and that aiding someone in relief from that suffering is doing good, not harm.

 

[GUH]

"Do no harm" is actually subjective, not objective, as what one person perceives to be harm another might believe to be helping. I think the greatest harm one can cause is perpetual suffering, personally, and that aiding someone in relief from that suffering is doing good, not harm.

Are you willing to not mince words and say "administering or prescribing poison/overdose to a patient for the purpose of killing her"? Because that is what you're talking about.

 

[Mad Jack]

Are you willing to not mince words and say "administering or prescribing poison/overdose to a patient for the purpose of killing her"? Because that is what you're talking about.

You prefer to call it that, I prefer to say, "providing a patient with a prescription by which they can make the choice as to whether or not to end their own suffering in a way that is as humane and painless as possible."

 

[GUH]

You prefer to call it that, I prefer to say, "providing a patient with a prescription by which they can make the choice as to whether or not to end their own suffering in a way that is as humane and painless as possible."

Is that what you would tell your patient before giving the lethal injection?

 

[Mad Jack]

Is that what you would tell your patient before giving the lethal injection?

I wouldn't tell them anything, I would ask for a clarification of their wishes using neutral language. Generally patients administer the doses to themselves, but if there were physically unable to do so and clearly communicated that this were their wish, I would administer the dose myself if it were legal.

"Are you aware of what you are consenting to? Could you please state your wishes and intent?" or something to that effect would suffice, followed by a second confirmation that what they have stated is, indeed, what they want, as well as confirmation of their reason for seeking euthanasia.

 

[dpmd]

Are you willing to not mince words and say "administering or prescribing poison/overdose to a patient for the purpose of killing her"? Because that is what you're talking about.

I am willing to. I maintain that even direct action to kill a patient can be in compliance with the principle of do no harm as long as it is done in a setting where the patient requests it because they consider continued life a harm.

 

[Mad Jack]

Let me also say that I've had to place a great number of patients (hundreds) on comfort measures in my past career as a respiratory therapist. Because of the way current laws stand, I would have to watch some of them slowly suffer for hours to days until they suffocated to death, aspirated so much that they were unable to breathe, or what have you. I feel pretty intensely about this because we should have been able to give these people medication to make their final moments with their family more peaceful and less agonizing.

I've seen the downward spirals that some people suffer through, for months or sometimes even years. If they wanted to be spared that nightmare, I'd be more than happy to aid them were it legal, because it is very often the most humane care a physician could provide, so long as it is in line with the wishes of the patient.

 

[GUH]

I am willing to. I maintain that even direct action to kill a patient can be in compliance with the principle of do no harm as long as it is done in a setting where the patient requests it because they consider continued life a harm.

Well at least you're willing to come out and say it. Some folks here want to kill their patients while avoiding telling their patients that they are killing them.

 

[D4C]

Well at least you're willing to come out and say it. Some folks here want to kill their patients while avoiding telling their patients that they are killing them.

Call me crazy, but might you have misinterpreted something, somewhere?

 

[GUH]

Call me crazy, but might you have misinterpreted something, somewhere?

Decide for yourself:

I wouldn't tell them anything, I would ask for a clarification of their wishes using neutral language. Generally patients administer the doses to themselves, but if there were physically unable to do so and clearly communicated that this were their wish, I would administer the dose myself if it were legal.

"Are you aware of what you are consenting to? Could you please state your wishes and intent?" or something to that effect would suffice, followed by a second confirmation that what they have stated is, indeed, what they want, as well as confirmation of their reason for seeking euthanasia.

 

[Mad Jack]

Well at least you're willing to come out and say it. Some folks here want to kill their patients while avoiding telling their patients that they are killing them.

They're pretty well aware of what is happening lol. You have to sign a lot of paperwork, undergo a lot of evaluations where you are assessed as to whether you both understand what is going to happen (informed) and that you are capable of making a sound decision (consent). You obviously know that they would have had the procedure explained ad-nauseum, and that they would have to repeat, after already having signed consent, that they consent to have a medication administered that will end their life because they no longer believe they have a quality of life that makes theirs worth living. The informed consent is already there. You have them repeat their understanding of their informed consent prior to the procedure.

My bet is you've got some religious value system that leaves your view of this sort of thing biased. To those of us that don't believe we're meat suits inhabited by immortal ghosts, this issue is much less black-and-white than you make it appear to be.

 

[GUH]

They're pretty well aware of what is happening lol. You have to sign a lot of paperwork, undergo a lot of evaluations where you are assessed as to whether you both understand what is going to happen (informed) and that you are capable of making a sound decision (consent). You obviously know that they would have had the procedure explained ad-nauseum, and that they would have to repeat, after already having signed consent, that they consent to have a medication administered that will end their life because they no longer believe they have a quality of life that makes theirs worth living. The informed consent is already there. You have them repeat their understanding of their informed consent prior to the procedure.

My bet is you've got some religious value system that leaves your view of this sort of thing biased. To those of us that don't believe we're meat suits inhabited by immortal ghosts, this issue is much less black-and-white than you make it appear to be.

With rare exceptions, death is pretty black and white. Religion or not.

What baffles me is that you are so staunchly in favor of active euthanasia but seem to be afraid of calling a spade a spade.

 

[Mad Jack]

Death is pretty black and white. Religion or not.

A death that alleviates profound suffering is a gift, not a tragedy. That's my point.

 

[tmn]

Well at least you're willing to come out and say it. Some folks here want to kill their patients while avoiding telling their patients that they are killing them.

Are you never going to terminally wean a patient off a ventilator? Or stop tube feedings? A prescription for PAS is functionally the same, and a hell of a lot more humane.

 

[GUH]

Are you never going to terminally wean a patient off a ventilator? Or stop tube feedings? A prescription for PAS is functionally the same, and a hell of a lot more humane.

Allowing a patient to die rather than prolonging his suffering with futile care is not the same as injecting him with poison for the purpose of killing him. Most state laws recognize this.

I would certainly consider taking a patient off the ventilator or stop tube feedings in accordance with current guidelines in whatever jurisdiction I was working in, particularly if the patient had expressed his wishes not to undergo such treatment in advance.

 

[sinombre]

What baffles me is that you are so staunchly in favor of active euthanasia but seem to be afraid of calling a spade a spade.

I must have missed where anyone arguing against your position has appeared afraid of "calling a spade a spade." In fact everything stated has been pretty clear.

 

[Geekchick921]

I just want to add that there's a documentary about the Death with Dignity act called How to Die in Oregon. It's available to stream on Netflix and it's actually really interesting. Hard to watch, obviously (I wept during the last scene) but it was really engaging. I would recommend it.

What I got from it is that Oregon is one of the states where the person must be able to take the medication themselves. The physician writes the prescription but doesn't administer it.

 

[dpmd]

Allowing a patient to die rather than prolonging his suffering with futile care is not the same as injecting him with poison for the purpose of killing him. Most state laws recognize this.

I would certainly consider taking a patient off the ventilator or stop tube feedings in accordance with current guidelines in whatever jurisdiction I was working in, particularly if the patient had expressed his wishes not to undergo such treatment in advance.

We actually do this often when it is not really futile but just prolongs a life with unacceptable quality. I don't think you recognize this, because in a very real sense we are activly killing them when we do so. This is why many of us do not see a fundamental difference with the exception of the length of time and suffering following the killing action we take.

Mad jack's comment about not telling them anything I believe was intended to point out that we do not tell a patient that their quality of life sucks so we are going to kill you. Rather, the patient tells the doctor that they no longer wish to prolong their life and the doctor then discusses the various methods that their suffering can be helped (including the wonderful things hospice can try for symptom control) and the patient TELLS US which they wish to pursue. But unless you work in certain states one very humane method is illegal to let your patient have directly (although making sure they have plenty of pain meds and that they understand what could happen if they took more than the prescription says could be a way to get around that and I am certain that has been done before)

 

[GUH]

I just want to add that there's a documentary about the Death with Dignity act called How to Die in Oregon. It's available to stream on Netflix and it's actually really interesting. Hard to watch, obviously (I wept during the last scene) but it was really engaging. I would recommend it.

What I got from it is that Oregon is one of the states where the person must be able to take the medication themselves. The physician writes the prescription but doesn't administer it.

I agree that it's a pretty interesting documentary and worth watching.

We actually do this often when it is not really futile but just prolongs a life with unacceptable quality. I don't think you recognize this, because in a very real sense we are activly killing them when we do so. This is why many of us do not see a fundamental difference with the exception of the length of time and suffering following the killing action we take.

Mad jack's comment about not telling them anything I believe was intended to point out that we do not tell a patient that their quality of life sucks so we are going to kill you. Rather, the patient tells the doctor that they no longer wish to prolong their life and the doctor then discusses the various methods that their suffering can be helped (including the wonderful things hospice can try for symptom control) and the patient TELLS US which they wish to pursue. But unless you work in certain states one very humane method is illegal to let your patient have directly (although making sure they have plenty of pain meds and that they understand what could happen if they took more than the prescription says could be a way to get around that and I am certain that has been done before)

How is allowing a person to die of his disease in due course the same as prescribing a lethal dose in order to kill him? I admit that as a student maybe there is an aspect to withdrawal of care that I had not thought about which makes it the same as poisoning the patient.

 

[GUH]

I must have missed where anyone arguing against your position has appeared afraid of "calling a spade a spade." In fact everything stated has been pretty clear.

When you refuse to admit that you are killing the patient when you are killing the patient, that is not calling a spade a spade.

 

[dpmd]

I agree that it's a pretty interesting documentary and worth watching.

How is allowing a person to die of his disease in due course the same as prescribing a lethal dose in order to kill him? I admit that as a student maybe there is an aspect to withdrawal of care that I had not thought about which makes it the same as poisoning the patient.

I always give some morphine and versed prior to terminal extubation. For a patient with a weak respiratory drive this is often enough to ensure they will not breathe. So instead of dying slowly "in due course" I speed it up. When I withdraw pressors from a hypotensive patient I speed up their death. When I don't perform a surgery for a patient with a gastric volvulus (such as the one this morning) who has some potential for surviving the operation but only after a protracted icu course and likely requiring a rehab or skilled nursing home stay, I have killed that patient (by removing the one shot they had at survival). These are actions that are perfectly reasonable because they comply with the patient's wishes (as voiced by the family because they aren't able to tell me themselves at that point). You can tell yourself they are fundamentally different if it helps to ease your conscience (which is much better than admitting they are basically the same just not as sped up as a single lethal dose is, and therefore never withdrawing support even if that is what the family wants which I have had the misfortune to know a doc that functions as if this is what she believes ) but I recognize what is actually going on and it does not hurt my conscience.

 

[GUH]

I always give some morphine and versed prior to terminal extubation. For a patient with a weak respiratory drive this is often enough to ensure they will not breathe.

This one in particular is pretty interesting. I still think that there is a difference between administering medication with the main goal being pain reduction in a dying patient and administering an overdose with the main goal being to kill the patient, but your scenario is worth considering as approaching the grey area.

 

[Mad Jack]

When you refuse to admit that you are killing the patient when you are killing the patient, that is not calling a spade a spade.

I'm not saying that isn't what's happening, I'm saying that it isn't a bad thing.

 

[that redhead]

Do you really think that killing a human carries the same moral weight as killing a cow? Perhaps many share your opinion but I'm willing to bet that many patients would be uncomfortable seeing a doctor who told them that.

I remarked on cows as Doctor Bob brought up veterinarians as a possible alternate source to performing human euthanasia. If you can point out where I equate humans to cows, please direct me so that I may correct myself.

And I'm pretty sure that administering poison for the sole purpose of killing a person, especially a person without a terminal illness as suggested by many on this thread, is the most basic definition of doing harm. If not even deliberate killing of a patient is "doing harm", then "Do no harm" loses all objective meaning. "Do no harm" is not interchangeable with "minimize pain" or else the way we prescribed pain medication, for example, would be quite different.

If you see death as harmful, I can see where you draw your conclusions. Those of us in favor of this practice are arguing that death is not always harmful in the strictest sense of the word. Death can end suffering, which is quite the opposite of doing harm.

You do not address the fact that physicians knowingly do harm to patients by prescribing things like chemotherapy. That is certainly harmful to the body but you as a doctor prescribe that medication and see it administered to your patient. If you allow a patient to make the decision to let a doctor "do harm" but for the patient's own good, how does that idea not parallel to allowing them to choose a dignified, humane death?

Allowing a patient to die rather than prolonging his suffering with futile care is not the same as injecting him with poison for the purpose of killing him. Most state laws recognize this.

I would certainly consider taking a patient off the ventilator or stop tube feedings in accordance with current guidelines in whatever jurisdiction I was working in, particularly if the patient had expressed his wishes not to undergo such treatment in advance.

So you allow them to die a slow, painful, traumatizing death instead of a quick, peaceful end on their own terms. If that's something you're okay with, I don't really see how any of us can continue this argument.

 

[Mad Jack]

This one in particular is pretty interesting. I still think that there is a difference between administering medication with the main goal being pain reduction in a dying patient and administering an overdose with the main goal being to kill the patient, but your scenario is worth considering as approaching the grey area.

You clearly haven't seen most terminal withdrawals. The patient gets large enough morphine doses that what would have killed them over the course of sometimes days kills them in minutes. We basically shut their respiratory drives down- we say it is to make them comfortable by eliminating the feeling of suffocation as they fail to compensate for respiratory failure, which is true. But more often than not it is the morphine itself, not the disease process, that leads to their rapid expiration.

 

[Jabbed]

You clearly haven't seen most terminal withdrawals. The patient gets large enough morphine doses that what would have killed them over the course of sometimes days kills them in minutes. We basically shut their respiratory drives down- we say it is to male them comfortable by eliminating the feeling of suffocation as they fail to compensate for respiratory failure, which is true. But more often than not it is the morphine itself, not the disease process, that leads to their rapid expiration.

The PC way of phrasing it: 300 mg of morphine should 'keep her comfortable'.

 

[dpmd]

Ok here is a story for you all. 95 year old guy who pulled out his g tube and it got replaced but turns out it wasn't in the stomach. When you put tube feeds in the abdominal cavity peritonitis is a result which can be managed by emergency surgery to clean things out but when sepsis occurs it can be a tough recovery. Family decides to make him comfort care instead. Peritonitis is one of the most painful things and it doesn't usually go away even with powerful pain medications. Often times high doses of morphine are needed in addition to muscle relaxers and anti-inflammatory meds to keep things under control while you wait for things to get better (for patients who have their surgery to deal with the cause). In this patient though the hospitalist is giving 0.25 to 0.5 mg of morphine every hour as needed for pain because she is worried that any more than that (or a continuous drip) will "push him over the edge". So he is getting less pain control than he would be if getting better was the goal because she is afraid of being the one to cause his death. He is demented so his ability to let us know he has pain is diminished but there is no evidence that he does not still feel pain. This is the expected result of thinking that causing death is wrong for doctors to do and I think that is a horrific consequence.