Monday, April 18, 2011

Dignity in dying

When you are studying medicine and particularly if you are an internal medicine specialist, you get drilled a lot about "quality of life". It's not about curing a disease or saving a patient's life. It's about the quality of life the patient will have after a doctor has intervened on him or her.

Being alive is not necessarily a good thing. As medicine and technology progresses, the life expectancy in the developed world is getting higher. The quality of life gradually decreases as you get older for most people, mainly due to age and the deterioration of the bodily functions but also due to the long term medical conditions people have. Society also suffers in the long term. There will be a higher percentage of elderly people living in society. The situation creates a burden on the public health services in recent years, as doctors have to treat their chronic and recurrent illnesses.

I know I have a tunnel vision view of the situation, since most of the elderly people I come in contact with have such medical conditions which require hospitalization. I know there are many elderly people who enjoy their retirement years, looking after their grandchildren or doing leisure activities which they never had time for when they are working. Yet there are a lot of elderly people who lying in beds in old-age homes, unable to feed themselves and requiring a nasogastric tube for nutritional supplements. They are unable to communicate to the outside world their bedsores are hurting or that they need to go to the toilet.

At this stage I would like to bring the people who advocate against euthanasia. Do they really think there is any dignity or quality of life in this kind of person - the bedbound, non-communicable, double incontinent, old-age home resident? I know doctors are there to save lives but we also have a duty to the people under our care to ensure they are comfortable and pain-free. Maybe death is a release for these kinds of people.

There is a whole spectrum of what the doctor can do to "hasten" a patient's departure. It can range from not actively investigating for a condition if you know that the treatment would be futile. Doctors often find some abnormality in blood results or radiological examinations, which will require further tests just to make sure what they mean. Most of the time elderly patients don't want to know or find the investigations too invasive for their liking to proceed any further. One step up from that is knowing what is wrong with them but finding the treatment to gruesome or harsh to endure, rather opting for "palliative" treatment.

Now we head into murky waters with the next phase, when an elderly patient is an acute deteriorating condition. Doctors often say in those conditions, that cardiopulmonary resuscitation (also known as CPR) or intubation is futile due to the patient's advanced age, poor medical history, current condition and grave prognosis. Doctors at this point usually talk to the relatives with these facts in mind and nowadays both parties agreed not to actively resuscitate the patient, issuing a "Do Not Resuscitate" (otherwise commonly known as DNR) order. This is very commonplace, especially for cancer patients and elderly patients.

The extreme of the spectrum will be euthanasia. Most people would have some idea of the policy in the Netherlands or have come across the news of the Dignitas clinic in Switzerland. Naturally some people are appalled we can do this to our fellow human beings but we have no problem putting pets to sleep or killing people in the name of war.

I think in the 21st century, when people are living longer with more chronic disabling conditions, that firm guidelines needed to be laid down for euthanasia. Sooner or later people will opt for this rather than wait for the natural death that will never come. There are those from the religious right who say that life was given by God and only He can take it away. However not all people believe in a religion and the arguments against euthanasia now have to be universal and appropriate for this day and age.

I think most of the rules for euthanasia are pretty self evident. The person has to be coherent enough to give the order that we wants to die and there has to be good evidence he or she gave that order. Often this is difficult for people who are lying on the bed, unable to communicate to the outside world. The problem could be circumnavigated by signing a piece of paper with witnesses or even better a video of them giving explicit instructions that they want to die if they turn into a vegetative state.

The other big rule is that they are either dying with very little time to live or that their quality of life is so severely poor that continuing living is equivalent to Hell on Earth. All of this is very subjective but there are some aspects we can put a rule or number on, like how long the patient has to live or which diseases we can allow the person to have to meet the criteria.

I know some people are appalled that a doctor can write about this subject but we are not making the decisions, the patients (or the patient's relatives) are. We just give the facts and often our opinions and it is the patients or their relatives that decide. I often come across a few relatives who insist on CPR, even though we know it would be futile. And in those situations, we don't say no - we actually respect their wishes and do what they ask.

We have to acknowledge the preciousness of life itself but also that there is some dignity in dying.

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