Caring Advocates Blog & News

The Associated Press carried a story on November 29, 2006 entitled, "Bedridden woman with muscular dystrophy prompts euthanasia debate in Spain."

The victim of severe muscular dystrophy was quoted as saying, “I don’t want to die with pain, like Ramon Sampredo" (the person who died from drinking cyanide -- the story of movie “El Mar Adentro/The Sea Inside,” which won an Oscar for best foreign film in 2005).

She has ignited the debate of euthanasia in Spain.

But what she wants is for a machine to be unhooked, not an assertive act that would actually cause her death, such as a lethal injection.

The controversy is probably due to her being in a Catholic hospital. Even though her request to discontinue the ventilator is legal, it is problematic for her religious caregivers to comply with her request. To make her dying peaceful, she would need her doctors to prescribe sedatives so she does not suffer from air hunger anxiety.

Ramon Sampredro had no ventilator that could have been discontinued. But he did not have to die in pain -- eleven people helped, each with a small part. He could have instead exercised his right to refuse all food & fluid.

The New York Times of November 28, 2006, has a "Personal Health" article by Jane E. Brody entitled, "Medical Due Diligence: A Living Will Should Spell Out the Specifics." The article points out how physicians may interpret written instructions for specific treatments differently, and that they should do so, depending on the other circumstances of the patient. Instructions not to intervene aggressively could lead to death when the intervention might lead to resumption of life nearly as functional as before.

The article suggests a more detailed "code status," but we at Caring Advocates disagree. The better way to make end of life decisions is to use a Proxy Directive. That is the more prudent document. Authorize a person you trust to speak to your doctors and make the decision based on what is going on at the time.

British judge over-ruled the family's wishes to let a relative die by insisting that a drug that might allow consciousness to return (briefly) first be administered. One solicitor was quoted as saying, "there are incredibly sensitive issues that need to be addressed with this family... no stone should be left unturned in trying to save life."

British Medical Journal, 2006;333:1089 (25 November), doi:10.1136/bmj.39041.664433.DB

...Stay tuned.

Since the death penalty was reinstated by the Supreme Court in 1976, over 1000 people have been executed. Thirty-seven States and the Federal government now have capital statutes. In 2005 in sixteen States, fifty-nine men and one woman died—all by lethal injection, according to the U. S. Bureau of Justice Statistics.

Some prisoners have sued that death by lethal injection is cruel and unusual punishment. Meanwhile, physicians and nurses have shown increasing reluctance to participate. Hence the debate continues at many levels.

Just how peaceful is death by lethal injection? Actually, by three lethal injections? The order and purpose of each injection is: The first medication, a barbiturate, puts the condemned person to sleep. The second medication paralyzes the skeletal muscles so no signs of suffering are apparent to on-lookers. Finally a potassium salt stops the heart from beating to cause death.

This three-drug method was designed by a forensic pathologist named Dr. Jay Chapman in Oklahoma in 1977. Yet in 2006, Dr. Chapman told the New York Times that he now prefers an overdose of just one of these medications—the barbiturate—which is the method veterinarians use to end the lives of sick animals. He said that using just the one drug would painlessly cause prisoners to lose consciousness, stop breathing, and die. The only downsides are that it would take longer and on-lookers might see some jerking movements. But the prisoners would not be aware of either.

The three-drug method remains “popular” because it is fast and appears peaceful to those who watch. Yet a recent article in the British journal The Lancet, “Inadequate anaesthesia in lethal injection for execution,” presented these key results: 88% had blood barbiturate concentrations lower than that required for surgery, and 43% inmates had concentrations consistent with awareness. The authors' conclusion: “some inmates might experience awareness and suffering during execution.”

If there is awareness, the paralytic agent would produce extreme anxiety from the feeling of suffocation, and the potassium salt would cause extreme chest pain. In February 2006, a federal judge in California ruled that either a doctor must be present to ensure the prisoner was unconscious before injecting the second and third drugs, or only the barbiturate could be used for execution.

While debate continues among scientists about the results of the findings reported in The Lancet, there is little substantive scientific debate regarding whether barbiturates alone are peaceful… for executions, that is. Yet Dr. Bill Toffler, an opponent of Physician-Assisted Suicide offered his opinion: Using barbiturates to end the suffering of terminal patients did not appear peaceful since breathing “becomes irregular… for hours and hours.”

The question comes down to this: Do we want a method that appears peaceful or is peaceful? Perhaps because the argument is indirectly convincing, it is more compelling: The way terminal patients can choose to end their suffering under the present terms of Oregon’s Death With Dignity Act, now in its eighth year, and the similar proposed law that California legislators are considering, the Compassionate Choices Act (AB 651), by ingesting a lethal dose of barbiturates, is definitely a peaceful way to die.

Proxies can help end-of-life decisions

By: STANLEY A. TERMAN - Commentary

How can a patient with Alzheimer's disease say: "It's time"?Robert Hammerman was the longest-serving judge on Maryland's Supreme Court. He ended his own life by a gunshot to his chest. He died across the street from the nursing home where he feared unbearable confinement. He suffered from early dementia and feared prolonged indignity and total dependency. His mother and two close friends were institutionalized, one for 10 years.

Advanced dementia is our greatest end-of-life fear. Very few of us want to exist at a cost approaching $100,000 a year if we have no potential for meaningful human interaction, if we must be strapped down to "accept" medical treatment and to prevent us pulling out feeding tubes, or if we eat and drink only when orderlies force puree through clenched teeth as we try to turn away.

Unnecessary end-of-life pain and suffering is our second greatest fear. For Californians, a potential solution seems distant. Recently, state Sen. Joe Dunn cast the deciding committee vote to prevent California legislators from considering a law to decriminalize physician aid in dying for terminally ill patients. Just announced: He was selected to head the California Medical Association. Although two out of three Californians want to legalize physician aid in dying, strong opposition to changing the law lies ahead.For patients with Alzheimer's and related dementias, changing the law is neither necessary nor sufficient. Oregon's Death With Dignity Act "helps" only about three dozen people a year because patients must be terminally ill and competent when they decide to die. In contrast, thousands suffer from end-stage dementia in that state. In the U.S., they number in the millions and will increase threefold in the next three decades.Yet there is a legal alternative: Voluntary Refusal of Food and Fluid. Although often mischaracterized as "starvation," people really die from "dehydration," which is peaceful. Good mouth care reduces thirst, and ketones from metabolism prevent hunger during the few days to two weeks of the dying process.Those worried about suffering from dementia someday could consider Refusal of Food and Fluid by Proxy. They can legally authorize a surrogate decision-maker to refuse food and fluid on their behalf. For success, their proxy directive must be strategic, to prevent others' challenges. (Proxy directives are generally stronger than living wills.)When Voluntary Refusal of Food and Fluid is not considered, the consequences can be severe: Loved ones may be imprisoned for attempted murder, professionals may lose their licenses, and people in early dementia (like Judge Hammerman) may decide not to risk living longer.

Fearing dementia will worsen so they no can longer act, their premature dying is the greatest tragedy of all. That's why education about Refusal of Food and Fluid ---- for both competent patients and to plan for possible dementia ---- is so important.ÝBut who will be your proxy? Close relatives sometimes find it hard to make the decisions you want or are not able or available when that time comes. People could form groups and agree to serve as each other's proxies if their reluctance to assume the awesome role of making life-or-death decisions was lessened by the ability to turn to professionals for advice and support.

Stanley A. Terman, Ph.D., M.D., is a Carlsbad psychiatrist who leads Caring Advocates, a nonprofit organization that organizes Trusting Circles -- groups whose members consider serving as each other's proxies. He will lead a free two-hour workshop on this subject on Monday, at the Carlsbad City Library on Dove Lane. He will discuss proxy directives, Voluntary Refusal of Food and Fluid and forming Trusting Circles. For more information, call (800) 64 PEACE, or visit www.CaringAdvocates.org.

North County Times/The Californian - Community Forums

http://www.nctimes.com/articles/2006/11/04/opinion/commentary/19_17_5111_3_06.txt

Friday November 3, 2006

Grappling with final questions that have no easy answers

by Janet Silver Ghent

During my father’s protracted battle with cancer, my mother made her own wishes clear. When her time came she didn’t want to suffer. She didn’t want her family inconvenienced. In a New York minute, she wanted Jack Kevorkian.

But when her time did come, the death doctor was out of commission, in a Coldwater, Mich., correctional facility, and my mother was confined to a hospital bed in her New York apartment. Neither I nor my brother nor the hospice workers would comply when she asked us to toss her out the window or give her a shot to end it all. The best we could say was that we would make her as comfortable as we could, keeping her out of pain.

But that wasn’t good enough. Administering morphine every few hours didn’t quell my mother’s anxiety attacks. Those last days were grueling. By the time the hospice nurse put my mother on Ativan, it was a bit late in the game.

There was another alternative, but my brother and I didn’t know about it. After my April column describing my mother’s last days, I received an email from Dr. Stanley Terman, a San Diego psychiatrist:
“I am sorry for your mother’s prolonged final ordeal,” he wrote. “What I do not understand is why no physician offered palliative sedation (sometimes called terminal sedation). That is what she wanted, and needed, and would NOT have hastened her dying, so it would not have broken any religious or secular laws. Can you explain why this was not offered?”

The explanation was that I didn’t know about it.

Terman referred me to his Web sites — www.caringadvocates.org and www.thebestgoodbye.com — which discuss legal end-of-life choices. Among them: Palliative sedation, which involves alleviating extreme suffering and agitation through medication that makes the patient unconscious. It is not lethal. In addition, those who are terminally ill can opt to refuse food and fluids. Ironically, my mother, who wanted to die, was calling out for ice chips and sherbet at all hours.

Months later, I attended a Palo Alto symposium on assisted suicide and personal choices at Congregation Etz Chayim. I listened to social psychologist and medical ethicist Stephen Jamison, California director for Compassion and Choices, address the right to die. I also heard Dr. Ellen Brown, medical director of Pathways Hospice, and Dr. Bruce Feldstein, director of The Jewish Chaplaincy at Stanford University Medical Center, address some alternatives.

I learned that in Oregon, only one in 1,000 who sign assisted-suicide directives actually implement them, according to Jamison. But filling out those directives gives patients “the right to talk” when they really need to be heard, he said.

Brown said she has those conversations all the time. When a patient says, “Help me die,” one needs to look at what’s behind the request, including fear. The answer may be better hospice care. She also discussed the possibility of palliative sedation, which is legal in California. Unlike assisted suicide, it doesn’t violate Jewish law, Feldstein added.

Addressing the Jewish perspective, Feldstein said while many Americans feel they have the right to commit suicide, “Jewish tradition has a different set of assumptions.” Among them: “The body does not belong to us, but to God or to life itself.” Because the body is “on loan to us … we’re caretakers.” Suicide is “murder of oneself” and it is prohibited, he said, as is assisted suicide.

However, he added, placing impediments to dying also violates Jewish tradition: “We can and should do everything to relieve suffering, including giving medication that may hasten death.”

Looking back at that dark February, I thought of what my brother and I did and did not do. Do I wish we had used palliative sedation? Yes, but my brother reminded me that because my mother was conscious, we were able to be present with her until she slipped away.

Could I have administered a lethal injection, which was what my mother would have wanted? The answer is still no. But then again, there are no easy answers.

Janet Silver Ghent, former senior editor of j., is a freelance writer/editor living in Palo Alto. She can be reached at ghentwriter@gmail.com.

J. The Jewish news weekly

http://www.jewishsf.com/content/2-0-/module/displaystory/story_id/30781/format/html/displaystory.html