There has been a profound change in my practice since I left Texas, hospice and palliative care have become a very significant portion of my practice. This change has left me with deep questions regarding the practice of medicine, and has left me considering the obligation to ‘Do the right thing’.
When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.
How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.
When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.
How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?
Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?
When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.
How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.
When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.
How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?
Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?
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3 comments:
Gil, Those are very good questions, but I do not think that anyone can answer them for you. Truly your answer can only come through prayer. God gives life and takes it away. We are called to treat each of those lives with dignity, respect and care. How can you do that in your work? I am sure you already do it, but if you need further guidance, ask God and he will guide you.
Gil, I agree with Maria. I don't even think the patient has the right to determine when they die; therefore, I am opposed to euthanasia. However, if s/he looks you in the eye and requests comfort over pain, I believe you should try to accommodate that. The consequences of shortening their lives more is just one of those consequences. In my opinion, if they tell you do what you think is best, find out if they have made all their final arrangements, then relieve their pain. Frankly, I would choose comfort over a few more days of life. Either way, it's in God's hands. You are a great physician, Gil. I love that you care about your patients. God bless.
Gil,
When I was a medical student, Dr Thompson (former chairman of surgery at UT Galveston), who was half retired at the time, called out a resident during a controversial morbidity and mortality presentation--asking her what her purpose was as a surgeon. Annoyed, she muttered some nonsense about being a skilled operator curing cancer. He quickly jumped on her and said "its simple, two things, you relieve suffering and prolong meaningful life." Nothing more or less than that? Seemingly simple, this concept, for me anyhow, clarifies the muddy waters. Did I give someone the cancer or shoot them in the chest? No. Living in a state of pain is hell, morphine is the cure. Treat pain like a disease, one that must be cured. Prolong life only if it is meaningful, if not, relieve suffering at all cost--as that is our greatest responsibility to our patients as physicians. Medicine is just like gardening. We don't choose which plants live, die or make seed; however, we do choose whether or not to water them after the wilt has already set in.
Leigh
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