Bioethics Discussion Blog: What Can You Say to Mr. B?

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Thursday, April 06, 2006

What Can You Say to Mr. B?

The following is a recent response to the subject of euthanasia on my now inactive "Bioethics Discussion Pages". It is not unusual for a patient to come to the physician's office with a history similar to Mr. B., below. If you were Mr. B.'s new physician what can YOU say to Mr. B.? ..Maurice.




I've been fighting to live for the past 17 years and it hasn't been until the last 3yrs that I've started thinking about how to get it done with.I have periods where I get violently ill the doctors have no clue as to the cause of the spells,nor anything that they can do to help,stop,or treat whatever it is.The only explaination they have is it is a buildup of toxins,or the release of toxins,that are making me so ill.I have just gone through 12-14 weeks of it and more than one nite was spent praying/wishing for the end to come.To get any relief form the nausea,vomiting,aching,and the pain from the tumors/masses from as near as we've been able to determine is some type of bone disease.I've been to Mayo clinic,Johns Hopkins,and the state medical school and every medical facility that thought they might do some good.Not one has been able or willing to do anything to help and several have done more harm than good.I'm no fan of doctors and the games that they play.they should have to live a day in their patients body that are as ill or worse than I have it and then see if they have any doubts about wether they should assist the relief of someone that all they want is relief from the illness they have.I've read the letters from those who think they have any idea of what someone wants that nolonger has any control of themselves,or that is in unbearable pain like I have from the areas of soft bone that the surgeons have described as being like rubber,to areas that have collapsed like the 4 vertabra that partially collapsed 5-6 years ago.I lost 6 inches in height in 30 seconds.I don't dare even discuss the idea of euthansia with any of the doctors for fear that they will take away what little morphine I do get for the bone and tumor pain that I have to deal with 24/7/365.Another problem that I've developed is a resistance to the morphine and every other pain med that I've taken.I may not know what is best for everyone,but from my own positi! on and what I go through every day there needs to be an avenue of some type making availble for those who can't take the pain and sickness they bare some way to get the relief and somekind of end.I would never have let any animal that I've ever had go through the first year of the past 6-8 that I've been through,let alone go this far.We always treat our pets and livestock better than we do our ill family and friends,there is noway that any selfrespecting farmer/stockman would let an animal suffer like we do and those we claim to care about.I'm sick tired and out of any more to say,only that I hope that those who think they know what is best for anyone hasn't likely a clue as to what is best for anyone and sure as hell they've not a clue as what's best for me. B

5 Comments:

At Thursday, April 06, 2006 7:00:00 PM, Anonymous Moof said...

Dr. Bernstein, I'm not in Mr. B's position, and it's hard for me to try to place myself there mentally. Even if I could, I might not react the way he has to the unfortunate situation he finds himself in.

That said, neither am I a physician - forced to deal with the Mr. B's of the world in a definitive way ...

All I can do is make a few observations from my viewing position, which I admit is rather narrow from my lack of experience.

1) From the patient's position: A person who no longer wants to live, as per the impression this fellow has left me with, can make that happen if he really wants to - without spreading blame around to his medical providers for a) "doing no harm," and b) being human, and only being able to do so much to help him.

Someone with a real will to die can make it happen rather easily - without involving other parties. I see this as a guilt trip/blame game.

I'm not saying the fellow isn't very ill, or that he's not in extreme pain. I don't know that I would deal with ongoing pain of that magnitude any better than he would - but I would not blame my lack of courage in the face of a desire to suicide on other people.

2) From the physician's position: I would probably think a lot differently if I had gone to medical school, and had been dealing with very ill, and dying people for 20 years or more ... but I can't come from that position, because I haven't.

From my inexperience, I would say that this man is issuing a cry for help - and that somehow, even more needs to be done to help him improve his quality of living. Different medication? More medication? Perhaps a different thrust in counseling? A different approach to treating various facets of his illnesses?

Others who are just as ill as Mr. B react completely differently ... has he been encouraged to spend time with fellow patients in similar (or even worse) situations? Sometimes amazing attitude changes come from that sort of interaction.

Life is precious. A person who says he wants to die - isn't really saying that he wants his life to end for the sake of no longer being. What he wants is for the situation which is making his life so painful to end. If the pain stopped ... he would no longer want to die.

There's always something that hasn't been tried ... one more thing that has a chance of making a person more comfortable, better able to deal with the situation he's in.

So ... if I were Mr. B's new physician, I would reassure him that, wherever he ended up, he wouldn't be going there alone; that I may not succeed, but that I would do my utmost to improve his quality of living. I would promise him that I would not give up on him, and that I needed a promise from him to not give up on me, as he and I explore ways to bring some "living" back into his life.

 
At Friday, April 07, 2006 11:18:00 AM, Blogger Hans G. Engel, M.D. said...

I feel terribly sorry for Mr. B. I am a physician and have had patients who suffered equally and I felt limited in helping patients. I believe, however, that pain can be controlled. We have been cautious for safety and legal reasons in the past to limit narcotic prescriptions. We need to learn today that we can increase doses to whatever point it takes to control pain, even, wish the patient's wish, the dose may risk coma or even death.
A law was passed in Oregon to help such patients and other states are in progress to do so. In California AB 651 has been proposed (Compassion and Choices: support of physicians for aid in dying). I support AB 651, knowing that many fellow physicians oppose it, but I feel that under very specific and limited circumstances (such as Mr. B.) euthanasia assistance is a responsibility for ethical physicians.
I must disagree with "Moof" on one point: to succeed in choice to die is extremely rare and most difficult to attain (I am aware of this due to family experiences).

 
At Sunday, April 09, 2006 6:09:00 AM, Anonymous Moof said...

Dr. Engel, I must respectfully disagree with you, and for the same reasons - family and friends. People I have been close to.

Of them all, and there were several, only one failed. She shot herself in the head, in the right temple, point blank - and survived. Today, she is blind, aware, but has totally forgotten the reason behind her previous agony, and is as happy and simple as a small child.

A person who truly wants to die can make it happen with any number of items which are customarily found around the home, and are unregulated and easily available. All it takes is a strong desire, and careful planning in order to not be interrupted in mid-course.

Those who truly do want to die seldom issue a cry for help - they just accomplish the feat.

 
At Sunday, April 09, 2006 7:10:00 PM, Blogger Bardiac said...

It seems to me, that I was able to do better by my dog (by putting him to sleep) than we can by people in pain in most states. I could only use my best judgment in that matter, but with humans, so long as they can communicate, we can do better.

I'm no md, but I've seen a couple people in some pretty horrible pain, and if they had asked me to help them, I would. (And then I'd face the consequences; sometimes ethics requires that.) (I'm not sure that I think physicians have that ethical responsibility towards patients where assisting suicide is illegal, but I would have felt it towards the two people I'm remembering.)

I guess I respect people enough to respect their choices. I would respect Mr. B's choice.

The Oregon law seems pretty sane: it's fairly conservative about how one can get the appropriate drugs, doesn't force physicians to act if they feel it's inappropriate. And if you look at the statistics, it's interesting that some people have gotten the prescription and chosen either not to fill it or not to use it. Just having the power may be of some comfort?

I disagree with Moof: I remember childhood as neither necessarily happy or simple. If someone has been left without any sense of understanding, choice, or decision making, that seems to me worse than death. I hope if I lost brain function like that, someone would kill me as painlessly and quickly as possible.

Suicide and attempted suicide statistics seem to indicate that men succeed more often, at least in part because they choose more violent means. But, I don't think it's physically easy for most people to commit suicide, especially for someone very ill, and even more for someone hospitalized or being cared for carefully by someone else.

Further, I think a limiting factor for some people in pain is that they don't want to cause further emotional pain to others, especially by leaving a, for lack of a better word, mess.

 
At Friday, April 14, 2006 3:56:00 PM, Blogger slmare said...

I am the director of a palliative medicine servive. I feel Mr. B. would be greatly served by a referral to such a service. Palliative Medicine is NOT HOSPICE. It is a service that is utilized along with curative treatments but offers services that releives pain, symptoms, psychosocial and spiritual issues. The first line of order would be getting Mr. B's pain under control As pain is a "subjective" finding Mr. B is the "expert" on his level of pain. Once his pain is under control, then move forward with helping with any psychosocial issues and spiritual issues this gentleman may have and need assistance with. A palliative medicine service helps patients acheive the best quality of life possible for their disease state and helps the patient and THEIR FAMILY adapt to the limitations and changes in their lifes.

Regarding the comment "Those who truly do want to die seldom issue a cry for help - they just accomplish the feat" I feel has some validity. But, studies have shown that these individuals are medically depressed. There is a difference between wanting to exit the world as you know it in a dignified manner when you have a terminal disease (again, dignity is uniquely identified), than being depressed and feeling life as you know it is hopeless.

I feel that physician assisted suicide should be acknowledged more as physician assisted death. Of interest, in Oregon, since the Death with Dignity Act was passed (physician assisted suicide), their hospice census dramatically increased. Studies have shown the reason for this was that patient's who request physician assisted suicide in the State of Oregon had to be presented other options, which hospice is one of the options. Oregonians were not aware of such services, their fear was dying alone, in pain, being a burden on their families, etc. Once they were made aware of hospice care, that addresses all those issues and provides care for the family as well, may opted not to end their lives and enrolled in hospice. Those people had their fears addressed, hospice provided them with the support system they needed, and lived until they died.

On the flip side of that coin, some people chose to end their lives at that time and not wait. Again, the uniqueness of each individual is the driving factor.

Another important factor, is that physician assisted suicide is an option only for people who have a "terminal" illness. Terminal being defined as so long to live within weeks or months. (Basically follows the hospice admission criteria). Two physicians have to certify the terminal illness. The patient has to undergo a psychiatric evaluation to verify the patient is not DEPRESSED. So there are checks and balances (lack of a better term) in place.

My personal feelings is I do not agree with physician assisted suicide but I do feel strongly that everyone should have as much control as possible on how they exit their life.

I do feel Mr. B is at the point he feels death would be better than living the life he is now leading due to his illnesses. But, it does not seem like he has given up all hope and he does not seem depressed. It sounds to me by the narriative that he is angry that he has yet been able to find a way to cope and adapt to his changed life and no one was listening to him or helping him.

On a more "ethical" grounds with Mr. B. I feel that the physicians have grossly failed this gentleman almost to the point of abandoment. The gentleman could have been referred to a pain management specialist or if he was willing, be referred to a Palliative Medicine Service. Both of these services work hand in hand with the primary physician to develop a care plan for the patient.

 

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