Keith Olbermann opened his emotional Special Comment on health care Wednesday with the story of his father’s six-month-long hospitalization suffering through a colon removal, pneumonia, kidney failure, liver failure, and many infections.  

After a particularly difficult week, Olbermann said he went into his father’s hospital room to find him “thrashing his head back and forth” and mouthing the word “Help.”  “It was just too much for my father,” Olbermann said. “‘Stop this,’ he mouths. ‘Stop, stop, stop.’”

Olbermann said he resorted to gallows humor, asking his father, “What, you want me to smother you with a pillow?” And his father responded, mouthing, “Yes, kill me.”

“And as I left the hospital that night, the full impact of the last six months washed over me,” Olbermann said. “That conversation, that one, was what these ghouls who are walking into Blair House tomorrow morning called death panels. Your right to have that conversation with a doctor. Not the government, but a doctor. And your right to have insurance pay for his expertise on what your options are when dad says ‘Kill me’ or what your options are when dad is in a coma and can’t tell you a damn thing.”

Olbermann then laid into those who spread fear about death panels.

“That, right now, is the legacy of the protests of these subhumans who get paid by the insurance companies, who say these things for their own political gain, or like that one fiend, for money,” Olbermann said. “Betsy McCaughey told people tht this conversation about life and death and relief and release…she told people that’s a death panel and she did that for money! It’s a life panel. A life panel. It can save the pain of the patient and the family. It’s the difference between you guessing what happens next and you being informed about what probably will. And that’s the difference between you sleeping at night or second-guessing and third-guessing and thirtieth-guessing yourself.”

“It’s a life panel, and damn those who call it otherwise to hell!” he said.

Olbermann closed the comment with news that his father has not awoken since Friday, and that it’s now possible he never recovers.

“So considering that if he does not recover you will not see me here for a while, I have some requests,” he said. “Please, have this conversation with your loved ones. Don’t wait. Do it now. It’s tough. It acknowledges death, and it also narrows the gray area you and they will face from infinity to a foot wide. It is my greatest comfort right now and I want it to be yours. And to the politicians who go into Blair House tomorrow, for that summit, I have some requests as well. Leave your egos at the door. I want, I demand that you give everybody in this country a chance at the care my father has gotten. And I demand that you enact this most generous and kind aspect of the reform proposed, the right to bill the damned insurance company for the conversation about what to do when the time comes. The life panel.”

Ray Gosling was arrested on Tuesday after he told a BBC documentary that he smothered the man. The admission and investigation has added to an already heated public debate in Britain on the issue of assisted suicide or euthanasia.

Dr Evan Harris is a UK parliamentarian and a member of the British Medical Association’s Medical Ethics Committee. Dr Peter Saunders is General Secretary of pressure group ‘Care Not Killing’. The BBC’s Roger Hearing brought them together and began by asking Dr Saunders why the issue was so prominent now.

Listen to BBC broadcast here which explains the case and the differences between murder, euthanasia, and assisted suicide.

People in a persistent vegetative state, the bishops say, must be given food and water indefinitely by natural or artificial means as long as they are otherwise healthy. The new directive, which is more definitive than previous church teachings, also appears to apply broadly to any patient with a chronic illness who has lost the ability to eat or drink, including victims of strokes and people with advanced dementia.

Catholic medical institutions — including 46 hospitals and 49 nursing homes in Illinois — are bound to honor the bishops’ directive, issued late last year, as they do church teachings on abortion and birth control. Officials are weighing how to interpret the guideline in various circumstances.   What happens, for example, if a patient’s advance directive, which expresses that individual’s end-of-life wishes, conflicts with a Catholic medical center’s religious obligations?

Gaetjens, 65, said she did not know of the bishops’ position until recently and finds it difficult to accept.

“It seems very authoritarian,” said the Evanston resident. “I believe people’s autonomy to make decisions about their own health care should be respected.”

The guideline addresses the cases of people like Terri Schiavo, a Catholic woman who lived in a persistent vegetative state for 15 years, without consciousness of her surroundings. In a case that inspired a national uproar, Schiavo died five years ago, after her husband won a court battle to have her feeding tube removed, over the objections of her parents.

The directive’s goal is to respect human life, but some bioethicists are skeptical.

“I think many (people) will have difficulty understanding how prolonging the life of someone in a persistent or permanent vegetative state respects the patient’s dignity,” said Dr. Joel Frader, head of academic pediatrics at Children’s Memorial Hospital in Chicago and professor of medical humanities at Northwestern University’s Feinberg School of Medicine.

Gaetjens, a hospice volunteer and instructor at Northwestern University, has thought long and hard about illness and the meaning of life after struggling with multiple sclerosis for 40 years.

She said she has told her sister and a close friend that she does not want “heroic measures” undertaken on her behalf at the end of life. But she acknowledged that she has not studied Catholic teachings on the subject or thought through all the implications of her position.

“My pleasure is in being part of the human race,” she said. “If that’s gone, if I can’t interact with other people, even if they could give me nutrition and keep me hydrated, I’m not interested in being preserved.”

Some experts are advising that a similar stance is no longer tenable for devout Catholics. Church members should steer away from advance directives that make blanket statements such as “I don’t want any tubes or lifesaving measures,” said the Rev. Tadeusz Pacholczyk, director of education for the National Catholic Bioethics Center in Philadelphia.

The church’s view is that giving food and water to a person through a feeding tube is not a medical intervention but basic care, akin to keeping the patient clean and turning him to prevent bedsores, Pacholczyk said.

Pope John Paul II articulated the principle in a 2004 speech, and the Congregation for the Doctrine of the Faith, an arm of the Vatican, expanded on it in a 2007 statement. The new guideline incorporates those positions in Directive 58 of the U.S. bishops’ Ethical and Religious Directives for Catholic Health Care Services.

There are several important exceptions. For one, if a person is actively dying of an underlying medical condition, such as advanced diabetes or cancer, inserting a feeding tube is not required.

“When a patient is drawing close to death from an underlying progressive and fatal condition, sometimes measures that provide artificial nutrition and hydration become excessively burdensome,” said Erica Laethem, a director of clinical ethics at Resurrection Health Care, Chicago’s largest Catholic health care system.

Some ethicists are interpreting that exception strictly. The Rev. William Grogan, a key health care adviser to Cardinal Francis George and an ethicist at Provena Health, based in Mokena, said death must be expected in no more than two weeks — about the time it would take someone deprived of food and water to die.

But Joseph Piccione, senior vice president of mission and ethics at OSF Health Care in Peoria, said that if a patient knows she is dying of, say, incurable metastasized ovarian cancer but is several months from death, she can decline to have a feeding tube inserted if she anticipates significant physical or emotional distress from doing so.

A second exception has to do with bodily discomfort. If infection develops repeatedly at the site of the feeding tube, for instance, artificial nutrition and hydration can be refused or discontinued, Catholic ethicists agree.

A third exception is allowed when inserting or maintaining a feeding tube becomes “excessively burdensome” for a patient. That would apply, for instance, if a person regurgitates the food and develops pneumonia when it enters the lungs, Grogan said.

Under traditional Catholic teachings, patients may refuse medical interventions when anticipated burdens outweigh potential benefits.

“Decisions are made case by case,” and that will continue, said Ron Hamel, senior director of ethics at the Catholic Health Association of the United States.

Of particular concern is whether Catholic medical centers will honor an advance directive stating broadly that a person does not want a feeding tube inserted.

Compassion & Choices, a group that supports the right of dying people to end their lives, suggested the potential for conflict is significant.

“Now, (Catholic) hospitals and nursing homes have no choice but to enforce Catholic doctrine universally over patient wishes,” the group’s president, Barbara Coombs Lee, wrote on her blog.

But most ethicists said they do not see a significant problem. Disagreements, they say, usually can be resolved by discussing people’s end-of-life concerns, such as fear of being abandoned, fear of living in pain or fear of becoming entirely dependent on others.

It is rare for people to be very specific about their wishes.

“I have never seen an advance directive that says, ‘If I am in a persistent vegetative state, I ask that you withdraw food and water,’” Laethem said.

“We will be very attentive to patients’ advance-care planning,” Piccione said.

That offers some solace to people like Jim Lindholm, 69, who is struggling with a recurrence of non- Hodgkin’s lymphoma and attends St. Nicholas Catholic Church in Evanston.

“If there is no hope of recovery for me, if I’ve lost my active mental life, I don’t see any reason to keep my body alive,” he said. “I would prefer to die a peaceful death.”

Lindholm speaks from deep personal experience. A dozen years ago, his father suffered a stroke and lost the ability to feed himself and speak for himself. Attempts to feed him by hand did not succeed. His advance directive was clear: no extraordinary measures.

The doctors offered a feeding tube; Lindholm’s mother said, “My husband wouldn’t want that,” so Lindholm’s dad died of lack of food and water.

Lindholm still struggles with it. Did his father really want to starve to death? If his mother had agreed to the feeding tube, how long might he have lived?

“We owe it to those who survive us to make it very, very clear what we mean by ‘do not resuscitate,’” Lindholm said.

Although medical institutions are legally bound to respect patients’ advance directives, exceptions exist for providers who object by reason of conscience or religious belief, said Charles Sabatino, head of the American Bar Association’s Commission on Law and Aging.

The bishops’ guidelines specify that “advance directives are to be followed, so long as they do not contradict Catholic teachings,” said John Haas, president of the National Catholic Bioethics Center. How those teachings will be interpreted has yet to be resolved.

jegraham@tribune.com

—————

Questions and answers about Directive 58

Q. What did the bishops actually say?

A. This quote from Directive 58 gives the gist: “In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or (would) cause significant physical discomfort.’”

Q. Is this an entirely new position?

A. An earlier version of the directive, published in 2001, spoke of a “presumption” in favor of giving food and water to patients in a vegetative state; the new version speaks of an “obligation” to do so and appears to extend to patients with other chronic conditions. Precedent for the position comes from a 2004 statement from Pope John Paul II and a 2007 statement from an important advisory group at the Vatican.

Q. What inspired the change?

A. Church leaders oppose assisted suicide and euthanasia and wanted to affirm strongly that the lives of severely disabled people have value.

Q. Does it apply to Catholics only?

A. The guideline affects all patients who seek care at Catholic medical centers, regardless of their religion, said Stan Kedzior, director of mission integration at Alexian Brothers Health System.

Q. Who decides if a feeding tube is “excessively burdensome” and therefore not warranted?

A. That’s up to the patient, but it isn’t as simple as, “I don’t like it and I don’t want it.” There have to be discernible physical, emotional or financial hardships for the patient, according to Joseph Piccione of OSF Health Care. Those hardships must outweigh the potential benefits.

Q. Does this mean Catholics must pursue all medical interventions at the end of life?

A. “No. We mustn’t all die with tubes,” said John Haas of the National Catholic Bioethics Center. “The Catholic Church has never taken that position.” Church members may refuse interventions they deem excessively burdensome.

For instance, someone with advanced kidney failure is not obligated to pursue dialysis, said the Rev. William Grogan, a health care adviser to Cardinal Francis George. Someone who has lost the ability to breathe is not required to use a ventilator.

Copyright © 2010, Chicago Tribune

Rom Houben, trapped in his paralysed body after a car crash, described his real-life nightmare as he screamed to doctors that he could hear them – but could make no sound.

‘I screamed, but there was nothing to hear,’ said Mr Houben, now 46, who doctors thought was in a persistent vegatative state. ‘I dreamed myself away,’ he added, tapping his tale out with the aid of a computer.

Doctors used a range of coma tests before reluctantly concluding that his consciousness was ‘extinct’.

But three years ago, new hi-tech scans showed his brain was still functioning almost completely normally. Mr Houben described the moment as ‘my second birth’. Therapy has since allowed him to tap out messages on a computer screen.

Mr Houben said: ‘All that time I just literally dreamed of a better life. Frustration is too small a word to describe what I felt.’ His case has only just been revealed in a scientific paper released by the man who ’saved’ him, top neurological expert Dr Steven Laureys.

‘Medical advances caught up with him,’ said Dr Laureys, who believes there may be many similar cases of false comas around the world. The disclosure will also renew the right-to-die debate over whether people in comas are truly unconscious.

Mr Houben, a former martial arts enthusiast, was paralysed in 1983. Doctors in Zolder, Belgium, used the internationally accepted Glasgow Coma Scale to assess his eye, verbal and motor responses. But each time he was graded incorrectly.

Only a re-evaluation of his case at the University of Liege discovered that he had lost control of his body but was still fully aware of what was happening.

He is never likely to leave hospital, but as well as his computer he now has a special device above his bed which lets him read books while lying down.

Mr Houben said: ‘I shall never forget the day when they discovered what was truly wrong with me – it was my second birth.

‘I want to read, talk with my friends via the computer and enjoy my life now that people know I am not dead.’

Dr Laureys’s new study claims that patients classed as in a vegetative state are often misdiagnosed.

‘Anyone who bears the stamp of “unconscious” just one time hardly ever gets rid of it again,’ he said.

The doctor, who leads the Coma Science Group and Department of Neurology at Liege University Hospital, found Mr Houben’s brain was still working by using state-of-the-art imaging.

He plans to use the case to highlight what he considers may be similar examples around the world.

Dr Laureys said: ‘In Germany alone each year some 100,000 people suffer from severe traumatic brain injury.

‘About 20,000 are followed by a coma of three weeks or longer. Some of them die, others regain health.

‘But an estimated 3,000 to 5,000 people a year remain trapped in an intermediate stage – they go on living without ever coming back again.’

Supporters of euthanasia and assisted suicide argue that people who have lain in persistent vegetative states for years should be given the opportunity to have crucial medical support withdrawn because of the ‘indignity’ of their condition.

But there have been several cases in which people judged to be in vegetative states or deep comas have recovered.

Twenty years ago, Carrie Coons, an 86-year-old from New York, regained consciousness after a year, took small amounts of food by mouth and engaged in conversation.

Only days before her recovery, a judge had granted her family’s request for the removal of the feeding tube which had been keeping her alive.

In the UK in 1993, doctors switched off the life support system keeping alive Tony Bland, a 22-year- old who had been in a coma for three years following the Hillsborough disaster.

Dr Laureys was not available for comment yesterday and it is not clear why he thought Mr Houben should have the hi-tech screening when so many years had passed.

“Dad’s not doing very well,” he said. “If you want to see him before he dies, you’d better fly up here.”

I didn’t believe him. At age 88, my dad had weathered crises before, and he had told me many times that he didn’t want to die and wasn’t ready to die. For a decade, my saintly mother had nursed him as he progressively declined. But always before, during his crises, he had rallied.

My father was the son of a lawyer. After one brief year in the undergraduate medical curriculum at Washington and Lee University, he switched to law, where he earned his degree. After a stint in the U.S. Army in World War II, he ended up in the Patent and Trademark Office, serving 30 years as a trademark examiner. He and my mother grew up in the small farming town of Woodstock in the Shenandoah Valley, where their grandparents were farmers. After the war, they moved to Montgomery County, Md., a suburb of Washington, D.C., and began a new, big-city life, having five children.

To my regret, my dad and I hadn’t talked about his dying. My father had always feared death, but had met this fear abstractly. From the age of 5, I remember Victor Frankel’s “Man’s Search for Meaning” and Ernest Becker’s “The Denial of Death” near his reading chair. Over the next decades, he accumulated more books like these.

So after his 50 years of pondering death, I expected some wisdom from him about how he would face his own death. I hoped it would, in turn, help me face my own. Maybe every adult child hopes for this, but Dad and I never had that conversation.

On the other hand, his obsession and those books surely had something to do with my decision to get a Ph.D. in philosophy. And so with my ending up in bioethics, whose primordial issue is death and dying.  After I had taught in a medical school for 25 years, my father’s last illness occurred. It also came to pass that my father’s dying taught me wisdom about dying, but of a different sort than I’d expected.

In bioethics, philosophers for decades had argued the distinction between killing and letting die. James Rachels famously attacked this distinction in a 1975 article in the New England Journal of Medicine.

Whereas legally, it matters in most states whether physicians cause someone’s death or fail to aid a patient in distress, bioethicists criticize the distinction, claiming the difference carries no moral weight. For if physicians intend to kill a patient and the result is death, does it matter if physicians did something active or merely omitted normal treatment in life-or-death contexts? Either way, death was intended and death occurred.

But I oversimplify. Not all bioethicists thought this way. Indeed, I searched the literature once and turned up hundreds of articles, graduate theses and books about the distinction. (Thanks to Rachels for creating a small, cottage industry in academe.)

But I believed the distinction didn’t matter until that singular day when my father’s doctor called from the Hebrew National Home in Washington, D.C., where my father spent his last days. The doctor said dad’s condition had worsened and the only stopgap was a feeding tube; otherwise, Dad would soon die.

Because I was a medical ethicist, my family had — perhaps incorrectly — left this decision to me. I talked to my father by phone: He could barely talk, but said he did not want to die, was not ready to die. Patel said my father would soon be too sedated to talk. And indeed, short as it was, that was my last conversation with my father.

So I allowed the feeding tube. After all, it was my father, and he didn’t want to die.

About an hour after I made that decision, a nurse called: “Aren’t you the medical ethicist? Are you sure you want to put your father on a feeding tube? Do you realize what that means for him and your family?”

And, of course, I had forgotten what it meant, because the issue was no longer the abstract one, but the death of my father. I agonized that afternoon. I talked to my relatives and then, reluctantly, called to rescind my decision. Don’t put in a feeding tube; let him die. I said I was packing and on my way.

My father’s death was philosophically a hard death. He didn’t want to die, and he wasn’t ready to die. Yet, he was getting worse and worse.

The next morning, I was still feeling ambivalent about my decision when the doctor called to say my father had just died.

In that moment in Alabama, 1,000 miles away, enormous guilt wracked me: I had killed my father. I had made a decision resulting in the death of a man I loved who didn’t want to die, and my dad’s consciousness had ceased to exist. No conversation between us would ever occur again.

For the first time, I felt why some physicians find it so hard to remove patients from respirators and why decisions to remove feeding tubes cause such guilt in families.

Intellectually, lest terminal patients suffer in dying in hideous ways, I know someone must make these decisions. One study says 80 percent of deaths in America involve a decision to limit some kind of medical care.

Looking back, I understand I made the right decision, but I am also now wiser. Perhaps, as my wife, Pat, says, my emphasis on withdrawing or not withdrawing the feeding tube merely intellectualized my real feelings of helplessness and loss (after all, I am my father’s son). Looking back, too, I understand that ending the life of one you love tears you apart. Nothing prepares you for it — not even 25 years in bioethics. And you always want one more conversation with your dad.

Gregory Pence, Ph.D., is a professor of philosophy and director of the Early Medical Student Acceptance Program at UAB. Web site: www.uab.edu/philosophy/faculty/pence/

By Special to The Birmingham News  November 15, 2009, 5:39AM  By GREGORY PENCE

The federal agency also found that during this period:

• The proportion of people age 45 to 64 who incurred medical expenses did not change (about 89%), but average annual health care expenses for those with expenses increased from $3,849 (after adjusting for inflation) to $5,455.

• Prescribed medicines were a substantially higher proportion of total expenses in 2006 compared to 1996 (25% and 15%, respectively).

• The proportion of total expenses for hospital inpatient care decreased (from 36% to 26%).

• The average expense per service rendered also increased significantly (in 2006 dollars):

• Physician office visit $128 to $207
• Inpatient hospital day $3,005 to $3,491
• Emergency room visit $563 to $947
• Dental visit $195 to $265
• Prescription medicines $103 to $199

[Newswise] AHRQ, which is part of the U.S. Department of Health and Human Services, improves the quality, safety, efficiency, and effectiveness of health care for all Americans. The data in this AHRQ News and Numbers summary are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on the health services used by Americans, the frequency with which they are used, the cost of those services, and how they are paid. For more information, go to Trends in Health Care Expenditures for Adults Ages 45-64: 2006 versus 1996 at http://www.meps.ahrq.gov/mepsweb/data_files/publications/st255/stat255.pdf

Ten years after the notorious Michigan doctor was ultimately jailed for killing a patient — one of 130 he helped die through lethal injection — Philip Nitschke, a new renegade physician, is spreading the gospel of assisted suicide — and he’s coming to the United States next month.

Nitschke is the 61-year-old Australian founder and director of the pro-assisted-suicide organization, Exit International. (Motto: “A Peaceful Death Is Everybody’s Right.”)

Based in Melbourne, Australia, the vocal advocacy group has gone beyond the legislative projects of other right-to-die organizations, who want to decriminalize euthanasia, to develop an array of educational tools for people considering ending their lives on their own terms.

These include public meetings (”free and open to all”), “ExiTutorials” (formerly called “Workshops”), private home visits, and, most recently, an “Exit kit,” which is best described as a do-it-yourself lab test for people who wish to commit suicide but want to make sure they do it right.

The battle over health care reform may be raging too intensely for Americans to notice right now. But while end-of-life questions are distorted into wild and ominous claims that “death panels” will “pull the plug on Grandma,” elsewhere in the world, from Australia to Canada, the right-to-die debate is heating up.

It’s not the same debate it used to be. Reuters reported this spring: “It used to be an issue just for the terminally ill. Now, as populations around the world age, governments are increasingly being confronted with the taboo idea of dying as something people can volunteer to do.”

Foolproofing Sucide?

At $50 a pop, the Exit kit was developed to help people who have already procured lethal drugs — specifically, the barbituate Nembutal, which is sold over the counter in Mexico — to ensure that they are still potent enough to kill after spending time in storage.

Time magazine explained earlier this year: “When someone with a terminal illness decides to end his or her life by overdosing on barbiturates, they may hope the drugs will lull them into a peaceful and permanent sleep. But if the drugs have passed their expiration date or lack a sufficiently lethal concentration, the would-be suicide victim may actually survive — risking an array of complications, including coma, reduced physical functioning and the opprobrium of disapproving friends and family.”

“Now, in an effort to provide certainty to those contemplating suicide, one of the world’s leading euthanasia advocates plans to sell barbiturate-testing kits to confirm that deadly drug cocktails are, in fact, deadly.”

Exit International also sells a book ($35) called The Peaceful Pill Handbook, a sort of suicide tutorial that, in addition to defending suicide as a legitimate choice that can be made by lucid people (whether they are terminally ill or simply “tired of life”), provides readers with eight ways to kill themselves. (The group boasts a research-and-development arm, which is focused on coming up with “various end-of-life approaches that are reliable, peaceful and dignified.”)

Some of these methods are spotlighted on Exit International’s Web site through an assortment of (admittedly weird and, really, pretty creepy) instructional videos featuring a grandmotherly “nurse educator” named Betty, who gives short, cheerful lessons on the finer points of suicide, all to a jaunty instrumental soundtrack.

(In one, titled “Doing It With Betty,” she shows you how to make an “Exit Bag,” which consists of a plastic oven bag with a drawstring. “What I usually do is just reinforce with two piece of tape …” she says, as if death by self-asphyxiation is a hobby of hers.)

The videos carry the disclaimer: “This Material Is Not Suitable for Children or Anybody Suffering From Depression or Mental Illness.”

In March, the Australian government, which has banned The Peaceful Pill Handbook, also banned two of the “Betty” videos, prompting an angry response from Betty.

“My generation has lived through a lot, including WW II,” said 78-year-old Betty Peters, an Exit International volunteer. “We, more than most people, know about death, and many of us don’t want to suffer the pain and indignity of illness or a prolonged period as a vegetable in a nursing home.”

A former physician, Philip Nitschke has been working on end-of-life tools for years. In 1996, he achieved fame by helping four people kill themselves through a computerized lethal-injection system he called the Deliverance Machine. At the time, it was legal under Australia’s short-lived Rights of the Terminally Ill Act.

As he described in the introduction to The Peaceful Pill Handbook, “the computer presented a short series of questions” before administering the lethal injection:

1. Are you aware that if you go ahead to the last screen and press the “yes” button you will be given a lethal dose of medication and die?

2. Are you certain you understand that if you proceed and press the “yes” button on the next screen you will die?

3. In 15 seconds you will be given a lethal injection … press “yes” to proceed.

“After pressing the button for the third time, the machine started up and delivered to each patient a lethal dose of the barbiturate Nembutal,” he wrote. “At the time of their choosing, the Deliverance machine enabled those four people to die, peacefully and with dignity.”

Nitschke recalls the inevitable aftermath of these physician-assisted deaths as the end of a promising era when people had the option of “dying with dignity.”

But the Rights of the Terminally Ill Act was repealed and replaced within nine months of its passage, at which point Nitschke gave up medicine and devoted himself full time to the fight for assisted suicide.

Like other assisted-suicide proponents, Nitschke considers the “right to choose” a human-rights issue, as well as one of free speech. “It is because of … deliberate attempts by the State to further restrict, control and censor end-of-life information that The Peaceful Pill Handbook has been written,” he said.

‘Death With Dignity’ vs. U.S. Healthcare?

It’s difficult to untangle the layers of controversy surrounding the topic of physician-assisted euthanasia in the U.S., from alarm at “playing God” to a more general fear of confronting death, to the very real question of how it would work logistically to decriminalize it.

As a recent Reuters report put it, the issue is “littered with ethical red flags.” But it’s a topic that is not going away. As aging Americans face the prospect of making difficult end-of-life decisions, two states (Washington and Oregon) have already passed “Death With Dignity” legislation to allow doctors to prescribe lethal doses of barbiturates to patients who are terminally ill.

Although the measures have not led to a spike in suicides as some predicted, they have nonetheless been controversial. In Oregon, the Death with Dignity Act has its own Web site that takes pains to distinguish between its law and still-existing laws that ban euthanasia. (”Euthanasia is a different procedure for hastening death,” according to the FAQ section. “In euthanasia, a doctor injects a patient with a lethal dosage of medication. In the Act, a physician prescribes a lethal dose of medication to a patient, but the patient — not the doctor — administers the medication. Euthanasia is illegal in every state in the U.S., including Oregon.”)

Some might argue that it is a distinction without a difference; and no doubt the debate will heat up when Nitschke comes to North America to peddle Exit International’s philosophies and products, which he’s scheduled to do in November.

A visit to Canada scheduled at the same time is already generating controversy; a planned workshop at the Vancouver Public Library was recently canceled over concerns that it would violate Canadian law, which prohibits the encouragement of suicide. (Nitschke disputes that the workshops actually encourage suicide.)

Proponents of assisted euthanasia often point to religion and all its moral strictures as the root behind this kind of controversy — and in one sense they’re right. Their real foes are the doctors and nurses who provide hospice care — a movement with a strong religious tradition.

Dr. Helen Watt, director at Linacre Center for Healthcare Ethics in London, told Retuers, “It is good holistic palliative care, not medical killing which is the answer to the real distresses of so many people when contemplating natural death.”

This echoes the belief of Cicely Saunders, the pioneering British doctor who founded the modern-day hospice movement. Saunders, who was deeply religious, died in 2005, but her firm opposition to laws allowing physician-assisted suicide lives on.

“Freedom to take one’s life as a private matter is very different from a legalized ‘right to die,’ which all too easily can lead to a presumed duty to die,” Saunders argued in a letter to the London Times in 1991. “All those who work in palliative medicine know well how most requests for a speedy end to life fade away once good care has been instituted. … To suggest killing before we have done all we can in caring would, to me, be the wrong answer to the present question.”

That present question, more than 15 years later, is as relevant as ever. Yet, as we have seen all too clearly in the past several weeks, in the United States, even the most superficial changes in our for-profit health care system have proved polarizing beyond reason; a meaningful attempt to address the fraught topic of end-of-life care seems nearly impossible.

With another round of controversy over the “right to die” on the horizon, hysteria over so-called death panels must be abandoned in favor of a less distorted, more empathetic discussion over the right to health care — in all its forms.

Liliana Segura is an AlterNet staff writer and editor of Rights & Liberties and World Special Coverage. http://twitter.com/LilianaSegura

© 2009 Independent Media Institute. All rights reserved.
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A study published in the September 2009 issue of the Journal of General Internal Medicine found that one in five doctors are not comfortable working with a surrogate decision maker. The doctors surveyed reported ineffective communication, lack of satisfaction with the outcome of the decision, and an increase in stress level as a result of the surrogate decision making process.

“We have come to consensus in our society that people should have a lot of input into their own medical decisions. But when the patient can’t made decisions we have much less consensus on how to proceed. For example, we aren’t as certain if the family should have as much discretion as patients would if they could make their own decisions or if the physicians should assume some of the responsibility,” said Alexia Torke, M.D., senior author of the study. Dr. Torke is assistant professor of medicine at the Indiana University School of Medicine and a Regenstrief Institute investigator.

A surrogate decision maker often becomes involved in the care process only after the patient is critically ill and concerns are being raised about the futility of continued medical care and the value of life. These are very difficult issues for both physician and surrogates and often ones which neither party discussed with the patient when that individual was still competent to make decisions about care preferences.

The study surveyed 281 doctors, primarily internists, family practice doctors, intensive care unit physicians and hospitalists, about half of whom were in private practice. Slightly over half were male. Three-quarters of the physicians reported having made a major decision with a surrogate during the past month. Most of these surrogate decisions involved some aspect of life sustaining care for older adults. A quarter of the doctors stated that surrogate decision making caused them a great deal of distress.

“A significant percentage of decisions faced by surrogates involve changing aggressive care to comfort care, when medical options have been exhausted. Making a decision to change the focus of therapy is often a very difficult one for the surrogate, who may be a close family member and under a great deal of stress due to the patient’s illness. Often, neither the physician nor the family knows what course of treatment the patient would have elected. Physicians reported that they also feel significant distress when make these decisions,” said Dr. Torke, who is also with the Fairbanks Center for Medical Ethics at Clarian Health.

She notes that although only a small percent of patients lacked an identified surrogate, physicians often had trouble reaching the surrogate to make critical decisions. Additionally, few patients had ever expressed prior written or oral preferences for care.

Asian physicians, who comprised 28 percent of the doctors surveyed, were less likely to report agreement with surrogates than white or African American physicians. The study did not differentiate between American born and foreign born Asian physicians who may have experience language difficulties in communicating with surrogate decision makers. Dr. Torke says further research is needed to explore why Asian doctors reached lower levels of agreement with surrogate decision makers.

The JGIM study was funded by the Department of Health and Human Services’ Health Resources Services Administration. Co-authors are Mark Siegler, M.D., Rachael M. Moloney, B.A., and G. Caleb Alexander, M.D., of the University of Chicago, and Anna Abalos, M.D., of West Suburban Hospital, Oak Park, Ill.

[BBC] The advice allows food and fluids to be withdrawn from patients, who are then continuously sedated, if they are judged to be close to death.

In a letter to the Daily Telegraph the six doctors and campaigners criticise a “tick-box approach” to care. The government says the guidance helps deliver high quality care for people.

Among the signatories on the letter are PH Millard, Emeritus Professor of Geriatrics at the University of London and Dr Anthony Cole, chairman of the Medical Ethics Committee.

Dr Peter Hargreaves, a consultant in palliative medicine, Dr David Hill, fellow of the Faculty of Anaesthetists of the Royal College of Surgeons, Dr Elizabeth Negus, a lecturer at Barking University, and Dowager Lady Salisbury, chairman of Choose Life, were the other signatories.

Their letter says the new treatment pattern of palliative care, based on experience at a Liverpool hospice is being rolled out into hospitals and nursing homes.

“If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death,” they write.

“As a result, a nationwide wave of discontent is building up, as family and friends witness the denial of fluids and food to patients.”

A Department of Health spokesman said they are investing £286 million over the two years to help improve end of life care.

He added: “The Liverpool Care Pathway is an established and recommended tool that provides clinicians with an evidence-based framework to help delivery of high quality care for people at the end of their lives.

“It has been recommended in the Supportive and Palliative Care Guidance issued by the National Institute for Health and Clinical Excellence.”