Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, April 26, 1993 TAG: 9304260369
SECTION: EDITORIAL PAGE: A5 EDITION: METRO
SOURCE: TIMOTHY E. QUILL, M.D.
DATELINE: LENGTH: Long
In its headlong rush to stop Dr. Kevorkian from assisting in another suicide, the Legislature didn't fully evaluate the law's effect on the vast majority of dying people - the ones who do not seek the assistance of Kevorkian - or their physicians.
It is profoundly disturbing that 15 severely ill, desperate people have chosen to die, using suicide machines, in a van, motel rooms, a cabin or a house in the presence of a stranger, and that many others are hoping they will get the same opportunity.
In publishing the story of "Diane" in the New England Journal of Medicine in March 1991, I attempted to articulate a more personal approach to helping patients die with dignity. Diane had been my patient for eight years. As she was dying of acute leukemia, she spent three months in a home-hospice program before choosing to end her life with my assistance, by taking an overdose of medication.
I believe that helping terminally ill, suffering patients die - as much as possible on their own terms - is one of our central roles as physicians.
There is a humane and poorly understood alternative to the kind of high-tech death in a hospital intensive-care unit that many Americans fear, or a physician-assisted death in a stark, anonymous setting. The solution is hospice care, where treatment is devoted to alleviating physical, psychological, social and spiritual suffering.
Potent, effective treatments are available so that patients do not have to spend their last days racked with pain. When advanced palliative measures are used with skill and care, and without fear of legal or professional repercussion, they can almost always ensure a dignified and relatively pain-free death.
If such treatment is available, why is there widespread fear of an intolerable, undignified death?
First, our health-care system is highly fragmented and often impersonal. It devalues and undermines long-term relationships between doctors and patients.
Changing insurers often requires changing doctors. Primary-care doctors are in short supply and have low status relative to the oversupply of high-priced specialists in almost every other medical field. Primary-care doctors are more likely than specialists to talk honestly with patients about dying and commit to working with them.
If we are to revamp the health-care system so that it better serves the needs of patients, it must include a commitment to training, encouraging and rewarding primary-care physicians.
Second, hospice care is grossly underfunded, under-reimbursed and underused. Formal hospice programs often are restricted to patients who have enough money to pay for them. Hospitals and physicians are almost always well-reimbursed by insurers for treating dying patients with invasive and ineffective medical technology, and poorly reimbursed for comforting and caring for the dying.
If you believe money drives the actions of many physicians and hospitals, it should be no surprise that hospice care is offered late in the process, if at all, and that physicians are relatively ignorant of and unskilled in palliative measures.
Third, we must better educate physicians about how to talk with their patients about death, and about how to use advanced palliative measures. Medical schools would never graduate a physician who is unskilled in technical procedures such as cardiopulmonary resuscitation. Yet we produce physicians who are uninformed about advanced pain-relief methods and who have never talked openly to a patient about dying.
In addition to developing palliative skills, physicians must be reassured that there will be no legal or professional repercussions if they treat dying patients with medications that indirectly hasten death. The Michigan law prohibiting physician-assisted suicide increased already exaggerated physician fears that they are legally vulnerable if they aggressively and compassionately treat dying patients' pain.
Fourth, we must consider how we want doctors and patients to proceed when a dying patient's suffering becomes intolerable despite advanced palliative measures. With broader, more skilled application of hospice care, I hope such instances will become less frequent.
Yet we cannot ignore those few, very troubling dying patients whose lives become intolerable despite extensive caring efforts by physicians, nurses and families. Such people don't have good or easy choices, yet we must continue to work with them to find acceptable options. We cannot abandon those whose need is greatest.
Helping people die with dignity is one of our highest callings as a profession and as a society. We must demand that health-care reformers, legislatures and the medical and legal professions focus on and respond to the struggles of dying patients and their families.
It is simply not adequate to create legislation or health policy that responds to provocation by one physician, but further restricts the options available to the vast majority of doctors and patients.
Promoting education about, and better reimbursement for, primary care and hospice care would be a good start. Another would be to give the medical community a clear message that fully treating a dying patient's pain, even if that inadvertently hastens death, is medically, ethically and legally the standard of care for the dying.
We also must define what options we want to make available to those rare patients for whom advanced palliative measures stop working, and death is all they look forward to. There must be better options than the stark images of abandonment and isolation conjured by suicide machines and death at the hand of a pathologist.
Death is not always the enemy. Sometimes our duty as caring professionals is to help our patients find it in the most humane way possible.
Timothy Quill, M.D. associate professor of medicine and psychiatry at the University of Rochester and associate chief of medicine at Genesee Hospital in Rochester, N.Y., is the author of "Death and Dignity; Making Choices and Taking Charge." He wrote this for the Detroit Free Press. Knight-Ridder/Tribune
by CNB