WHAT CAUGHT MY EYE

ADVANCE DIRECTIVE REGISTRIES

Lawyer and law professor Thaddeus Pope, whose own blog is an invaluable source for this one, recently made this interesting distinction between what a patient might reasonably or rightfully expect. Jane Brody wrote in the NY Times about the state’s Palliative Care Information Act, which Pope describes as “ basically a specialized informed consent obligation like that earlier enacted in California and more recently considered in Maryland and Arizona.”

Brody wrote: "Even knowing these facts [about palliative options], some patients are likely to choose to take advantage of anything and everything in the medical armamentarium that could conceivably grant them extra days, weeks or months of life. And such a choice is the prerogative of every terminally ill patient; the new law does not in any way deny that choice."

Pope’s distinction: “Well, the PCIA does not deny that choice. But it is hardly clear that patients have that right under New York law.”

KEVORKIAN'S LEGACY

NY Times columnist Ross Douthat on the death of Jack Kevorkian: “Fortunately, the revolution Kevorkian envisioned hasn’t yet succeeded. Despite decades of agitation, only three states allow some form of physician-assisted suicide. The Supreme Court, in a unanimous 1997 decision, declined to invent a constitutional right to die. There is no American equivalent of the kind of suicide clinics that have sprung up in Switzerland, providing painless poisons to a steady flow of people from around the globe.”

ADVANCE DIRECTIONS

The Department of Health and Human Services makes the astounding estimate of "between 65% and 76% of physicians whose patients had an (advance directive) were unaware of its existence." What might raise physician awareness of their patients’ written wishes? Pope points to an idea proposed in “The Advance Directive Registry or Lockbox: A Model Proposal and Call to Legislative Action.”in the Journal of Legislation, by Joseph Karl Grant. See Grant’s abstract at: http://bit.ly/l0OJ2C

AAMC: Palliative Care's Rising Role

Compelling vision from Dr. Darrell G. Kirch, president/CEO of the Association of American Medical Colleges”:

“Palliative care and related fields, like geriatrics, are a microcosm of the larger health care system. Everything is amplified when the patient in front of us is managing multiple chronic conditions, from the need for us to work seamlessly with other health professions to placing the patient and their family’s needs truly at the center of our efforts. For all these reasons, palliative care is a high-impact specialty that will see increased demand moving forward and will require some of medicine’s brightest minds to choose it as their career path.”

See the full text at: http://bit.ly/iNa3eG

The End-of-Life Care-toon

Thanks to http://www.pallimed.org for the tip on this animated view of end-of-life care, through the eyes of the Happy Hospitalist. After you watch, share your thoughts!

http://thehappyhospitalist.blogspot.com/2011/06/hospitalist-vs-icu-end-of-life.html

Kevorkian's Legacy

I don't pretend to know that much about Kevorkian - I have not seen the movies or documentaries and I have not spent alot of time reading about his methods or actions in "helping" people die. But, even so, I am emboldened to share some thoughts on his passing.

My first impression was curiosity at the fact that he did not choose to end his life in the way that he had chosen for others. He died in a hospital, apparently with plans for surgery to remove lesions from his lungs. He did not hasten his death, rather he was actively planning for life. That reminded me of a physician friend whose father had been an advocate for the Netherlands' laws for assisted suicide but who, when terminally ill, fought "tooth and nail" for every chance at life. Everyone approaches death in their own unique way and Kevorkian was no different, I suppose. But it is a curiosity . . .

My second impression was that, although his death-administering practices were rightly and highly questionable - he did not require second medical opinions or psychological counseling of his "patients" - he did us all the service of bringing to the fore what many in our society have been thinking but unable to say. If we work so hard to control the quality of our lives, can we not also work to control the quality of our deaths? What does it mean to "let go and let God" have control in this critical last moment of our life story? My grandmother stockpiled medicines in order to "end it" when she was ready. The stockpile was discovered in a bedside table and she was whisked away to spend her last two years in a nursing home, slowly but inexorably declining toward a death that was not particularly "good".

And my third impression was that Kevorkian's legacy will be one of advancing the necessary discussion in halls of government, corporate board rooms, and family rooms - and that is definitely a good thing. A Huffington Post blog entry speaks in the same breath of Palliative Sedation and Physician-Assisted Suicide . . . the Community Ethics Committee has submitted a report encouraging access to Palliative Sedation for those who are terminally ill in intractable pain - we called it Continuous Sedation to Unconsciousness as Comfort Care until Death. We viewed it as a merciful and appropriate treatment option. The sedation does not kill, it treats pain; it is the underlying terminal disease that brings about the patient's eventual death. In contrast, Physician-Assisted Suicide's primary focus is to treat pain by killing the patient - something different and troubling. The Committee has written an article that will be coming out soon in the American Journal of Bioethics - the heading is "Palliative Sedation is to caring as Physician-Assisted Suicide is to killing". When it is published, we will share the citation.

In the end, we probably die as we live. Kevorkian died as a doctor - in a hospital, trusting in yet more medical interventions. I hope as the dialogue about death continues in our society, we will find ways to ensure we die in the ways we choose - most of us desire to be at home, free of pain and fear, surrounded by loved ones. A "good" death. I hope that is what Kevorkian had.

Also see
http://www.huffingtonpost.com/janice-van-dyck/assisted-suicide-kevorkian_b_871287.html

DEATH'S RORSCHACH

The bidding for Jack Kevorkian’s ’68 VW van was up to $3,400 last year when eBay pulled the plug on an episode of morbid capitalism timed to coincide with HBO’s Kevorkian movie.

Thirty years earlier, in that reconstructed van, Kevorkian had assisted in the suicide of the first of his approximately 130 ... patients? victims?

Which were they, patients or victims? In life, or as portrayed by Al Pacino on HBO, was Kevorkian closer to Marcus Welby or Hannibal Lecter? He became known as Doctor Death, but he was also Death’s Rorschach.

Even as a subject for thoughtful consideration, we put off death as long as possible. Kevorkian, who died on Friday at age 83, made it unavoidable, and even people who considered his actions those of a murderer would concede that fact.

“His critics were as impassioned as his supporters,” Keith Schneider wrote in today’s New York Times, “but all generally agreed that his stubborn and often intemperate advocacy of assisted suicide helped spur the growth of hospice care in the United States and made many doctors more sympathetic to those in severe pain and more willing to prescribe medication to relieve it.”

Kevorkian’s van was equipped with the Thanatron and later the Mercitron, his homemade “death” and “mercy” machines. Kevorkian stopped using the Thanatron when he lost his medical license and could no longer prescribe the necessary ingredients. He served eight years in prison for the last of his assisted suicides, judged to be second-degree murder.

Nicholas Jackson began writing about Kevorkian in high school, and described his infamous work in The Atlantic (http://bit.ly/mxjQsI):

“Kevorkian outfitted the patient with an intravenous drip of a saline solution. When the patient pressed a button, the saline would switch to thiopental for sixty seconds. After that strong dose of thiopental, the patient would slip into a deep coma, at which point the Thanatron would inject a lethal dose of potassium chloride, a solution that stops the heart. Potassium chloride, a mix of potassium and chlorine, is the same solution that is delivered in the final step of most lethal injection procedures.

“The key component of Kevorkian's Mercitron (“mercy machine"), which was used far more often than the Thanatron, was not potassium chloride, but carbon monoxide. A deadly gas, the carbon monoxide was stored in a cylinder in the back of the van and connected to a mask that Kevorkian would fit over his patients' nose and mouth.

“Because he always required patients to make the final move, Kevorkian built a makeshift handle. Attached to the valve of the carbon monoxide canister, even the most disabled of Kevorkian's patients was able to turn the handle and release the gas.

“But carbon monoxide can take a little while to finish the job. Sometimes as many as ten minutes were required. Kevorkian, though, would often encourage his patients to ingest muscle relaxants or sedatives before the procedure so that they would stay calm while taking their last gasps of air. He never wanted them to experience any pain. As a doctor, he cared.”