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Ed Hartouni
Trad climber
Livermore, CA
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Dec 28, 2014 - 10:04pm PT
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thanks for the link, Ken, the piece approaches a very important issue
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nah000
climber
no/w/here
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Dec 28, 2014 - 11:06pm PT
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thanks for both the post and the original piece.
i appreciate your systematically dealing with difficult questions but then more importantly providing practical ways of moving beyond the status quo.
tough questions, that require thoughtful solutions... thanks for providing yours to the public discourse.
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BMcC
Trad climber
Livermore
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Dec 28, 2014 - 11:14pm PT
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Thanks for the link to your thoughtful and well written op/ed.
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Clint Cummins
Trad climber
SF Bay area, CA
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Dec 29, 2014 - 01:41am PT
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Good stuff.
I agree the original Hippocratic Oath refers to old technology.
And the "do no harm" version sounds good at first but doesn't hit the right spot.
It seems like the right replacement should somehow state that the doctor should act as the agent of the patient (using an economist's terminology).
I.e. try to act in the best interest of the patient. Using knowledge of treatment efficacy that the patient probably doesn't know and may not be able to understand very well.
This allows for euthanasia and non-treatment.
It can be in conflict with a "preserve life at all costs" type principle,
when the patient is near the end of their life, if the patient does not
believe in that principle (perhaps the patient believes in something like "preserve [expected] quality of life if possible").
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High Fructose Corn Spirit
Gym climber
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Dec 29, 2014 - 07:43am PT
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+1 for the death doula.
Another excellent article, Ken.
After watching the 60 Minutes piece a couple months ago on the issue, I tweeted to the profiled anti-assist physician in the piece (his similar to Kass') perhaps it was time then for more than one type of physician?
But I like the idea of a "doula" - that works! Maybe "doula" to start and eventually in addition a more sympathetic physician type as well. Hope.
(Dr. Ira Byock was the anti-assist physician in the 60 Minutes piece.)
http://www.youtube.com/watch?v=MAHey2LjA6c
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Crimpergirl
Sport climber
Boulder, Colorado!
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Dec 29, 2014 - 07:50am PT
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Great piece (as usual). I hope our culture changes to allow and provide the means to death with dignity for all.
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Gary
Social climber
Desolation Basin, Calif.
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Dec 29, 2014 - 07:51am PT
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That was a good one. This was also interesting reading:
http://www.latimes.com/opinion/op-ed/la-oe-zamichow-cancer-treatment-20141026-story.html
Physicians often decline treatment in cases of terminal illness, wrote Dr. Ken Murray in “How Doctors Die,” an essay for the Zocalo Public Square website.
“What's unusual about [doctors],” Murray wrote, “is not how much treatment they get compared to most Americans, but how little.”
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NutAgain!
Trad climber
South Pasadena, CA
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Dec 29, 2014 - 08:34am PT
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Compassionate and rational and well-reasoned.
I have a few questions/considerations though:
1. While in some cases the line may be clear, I suspect that in many cases the line is very messy and blurry, between an unchanging and uncomprising desire to end life now, versus a deeper willingness to hang in a few more days/weeks/months. This involves calling on a well of inner strength or a fear of death that may exceed what the patient was previously aware of. How is the "death doula" to know which version of the patient to honor? "Oh nonsense, you're just getting the pre-death jitters, just let me put this needle in and it will get better...." Or maybe the patient later laments that the "death doula" didn't have the fortitude to follow through? Seems like a very personal thing and hard to know a priori which intention to follow.
2. Similar case when a patient is not terminally ill yet becomes potentially so while in a hospital or as a result on an accident. Sometimes a person may state what they want as an advance medical directive according to a romantic or philosophical ideal, but when perched on the edge of finality, may recognize an error or lack of conviction in their decision. By not having a strong bias toward the sanctity of life, the medical profession or "death doulas" would not give an opportunity to reconcile the new situation and patient's discovery of their intention to live. This intention may arise at the last moment, long after legal paperwork and confirmations have been made.
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MisterE
Gym climber
Bishop, CA
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Dec 29, 2014 - 08:40am PT
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Great article - thanks for the link and your thoughtful contributions, Ken.
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crankster
Trad climber
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Dec 29, 2014 - 08:53am PT
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Nicely done, Ken.
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MikeL
Social climber
Seattle, WA
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Dec 29, 2014 - 09:12am PT
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Interesting issue. At least physicians have a code of conduct or oath of office, even if a bit out-dated or in need of amendment. Most careers and jobs don’t, and hence we see all sorts of self-interested behavior that we’d rather not witness from folks. I have high regard for those “professions” that put clients and customers before themselves.
I also liked very much the article pointed to at the same URL that Gary noted and quoted. I’ve gone through one of those radiation and chemo cancer treatments that was very difficult. At the high point, I told my wife that if I had to go through it again, I might not do so. She said, “. . . like hell you won’t.” (Cancer treatments can leave challenging lingering effects. When people ask about the cancer, all I think of is the effects of the treatment.)
It seems to me that issues about quality of life is something that climbers would perhaps understand better than most groups of people.
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SC seagoat
Trad climber
In What Time Zone Am I?
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Dec 29, 2014 - 09:24am PT
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A profoundly important subject.
When I was undergoing chemo I met a number of women who had exhausted just about all the treatment options. They were down to options that may have prolonged their lives by a few weeks to months but with ugly side effects.
Most of them said "nope, I'm over it" As they declined they were given all the pain meds they needed. However, prior to that stage, they got to live the remainder of their days with a level of robustness that they would have been robbed of otherwise.
We have incredible medical technology to continue the beating of the heart and rising of the lungs. Is that life? Especially when a patient wants something else and is horribly suffering.
Thank goodness for Oregon and Washington state. May more follow.
Susan
Ken, your article was very moving and provocative. Excellent read!
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BrassNuts
Trad climber
Save your a_s, reach for the brass...
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Dec 29, 2014 - 09:51am PT
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Nice piece on a tough topic that I think about frequently. I like the concept of a doula or agent, this makes good sense to me.
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rgold
Trad climber
Poughkeepsie, NY
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Dec 29, 2014 - 10:20am PT
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Thanks for an interesting and relevant discussion Ken.
I find myself able to sympathize with multiple positions on both sides of the issue. On the one hand, the Hippocratic oath stands as a bulwark against a potentially chaotic patchwork of ad hoc decisions, with potentially as many "wrong" ones as we get now from an abundance of caution.
On the other hand, modern society with its miraculous medical interventions now holds out a possibility never existed and seems to me to be quite novel, namely that, having lost the physical control we have when relatively healthy, we might still be able to control how we die. That's what it's about: our ability to control the circumstances of our death after we have lost control of our life.
I and almost everyone I know want to have this control; we fill out living wills and sign DNR's, much of which, in my experience, is to no avail. The combination of inertia, bureaucracy, good intentions, yes, the Hippocratic oath, and I think in some cases institutionalized greed, together conspire, much of the time, to prolong life in spite any of the expressed wishes of the now-helpless patient.
My suspicion is that the death doulas (OMG, don't let Sarah Palin get a hold of that notion) are almost a cute trick to circumvent the Hippocratic Oath obstruction; there are many other obstacles, and maybe there should be.
Relatively undaddressed in your piece are the quality of life issues that many people worry about. What if your condition is not terminal so much as vegetative, what if you are not faced with imminent pain, but rather a long cognitive and physical decline?
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Ken M
Mountain climber
Los Angeles, Ca
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Topic Author's Reply - Dec 29, 2014 - 10:51am PT
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Thanks for all the thoughtful comments. I really appreciate it.
As you might imagine, the Op/Ed format is very limiting in terms of length, and is a major constraint in limiting the development of associated ideas. I suppose that is what books are for?? :)
The main goal of the article was to get people thinking about the issues involved with this, not really a specific prescription for system construction.
For most on this forum, the issues involved have had more to do with our parents, and what we've seen happen to them. Hopefully, we can think about how that has gone wrong, and what we can to to right that when it comes time for our own generation, or those approaching the brink.
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Gorgeous George
Trad climber
Los Angeles, California
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Dec 29, 2014 - 11:17am PT
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Your piece was both thoughtful and provocative.
But I would like to see the discussion amplified to include a discussion of how much harm Doctors actually cause by unduly resorting to prescribed medication, including anti-biotics, for everything that ails their patients.
Yes, assisted suicide for terminally ill people is an important societal question, but I believe part of the reason the costs of medical care have skyrocketed out control (and out of reach for most people) is because Doctors are prone to needlessly prescribing too much medicine, and thereby doing the bidding of the pharmaceutical industry.
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Ken M
Mountain climber
Los Angeles, Ca
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Topic Author's Reply - Dec 29, 2014 - 11:25am PT
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George,
I totally agree with you that overuse is a huge problem, and needs wide discussion.
One of the lead organizations taking this on is the Lown Institute:
http://lowninstitute.org/
One of their directors, Shannon Brownlee, has written several books on the subject, findable on Amazon.
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rottingjohnny
Sport climber
mammoth lakes ca
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Dec 29, 2014 - 11:35am PT
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I believe assisted dying is a practical and compassionate procedure...I wonder if this discussion is taboo for a regressive society that thinks prolonged suffering , as long as someone else is doing the suffering , is a noble pursuit... ?
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BLUEBLOCR
Social climber
joshua tree
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Dec 29, 2014 - 11:37am PT
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Congrates on a respectable write!!
This is the original version of the Hippocratic Oath:
I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.
I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else.
With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.
Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will get no sort of medicine to any pregnant woman, with a view to destroy the child.
Further, I will comport myself and use my knowledge in a godly manner.
I will not cut for the stone, but will commit that affair entirely to the surgeons.
Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether mistress or servant, bond or free.
Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.
If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the estimation of posterity; or on breach thereof, may the reverse be my fate![4]
wiki
What part did you want to change?
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murcy
Gym climber
sanfrancisco
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Dec 29, 2014 - 12:03pm PT
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Nice piece! I have a hunch that a couple of my passed relatives benefited from compassionate accelerations of their deaths in hospice care. It would be much better for everyone for the decisions to be made in the open, but it might be fine for that to be under the umbrella of hospice care.
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Marlow
Sport climber
OSLO
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Dec 29, 2014 - 12:07pm PT
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An important discussion. Though the first issue is to give people the early knowledge and health care they need.
And the death system is well worth thinking through. A market model with a death business is not without deep concerns...
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Reilly
Mountain climber
The Other Monrovia- CA
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Dec 29, 2014 - 12:09pm PT
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Well written but I wonder how many of those retards in Sacramento will read it,
let alone bring it up for discussion? But thanks for keeping the flame going or,
more accurately, for blowing on the tinder.
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BLUEBLOCR
Social climber
joshua tree
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Dec 29, 2014 - 01:56pm PT
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from the times article;
Most of the Hippocratic oath has been revised over centuries. Today, it is most often cited as a single phrase, "First do no harm," though those words were not contained in the oath as written by Hippocrates. The closest he gets: "With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage."
But even if we accept the oath in its modern terminology, how do we define "harm"?
The history of medicine is littered with examples of doctors inadvertently doing harm. In the medical profession's attempts to ward off morning sickness, for instance, doctors administered thalidomide to pregnant women, causing countless deformities among babies. So do we revise our oath to say, "Do no intentional harm?"
Funny!, the "old language" knew how to cure morning sickness. Everyone knows to eat lots of parsley.
how do we define "harm"?
"With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage."
Isn't the intent of this sentence to dissolve the idea of "intentional harm" when the doctor introduces foreign objects(here administered orally) as a cure?
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Happiegrrrl2
Trad climber
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Dec 29, 2014 - 03:19pm PT
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Great read! I thought the suggestion of a doula-like assistant for those who seek ending-of-life care was a very good point.
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Sierra Ledge Rat
Mountain climber
Old and Broken Down in Appalachia
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Dec 29, 2014 - 03:20pm PT
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Lots of good questions Ken, would have liked to see more discussion of the answers!
"Do no harm."
If I prescribe penicillin so many times, I will surely kill one of the patients from a drug or allergic reaction, statistically speaking.
If I treat a patient, I am human and make errors and will eventually kill someone.
"Do no harm" - means do not treat?
Sick patients have trouble advocating for themselves, and family members are often too timid to speak up in front a man in a white coat. How does that fit in with all of your questions?
Harry
E.R. physician
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MH2
Boulder climber
Andy Cairns
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Dec 29, 2014 - 04:08pm PT
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There may be more to it than this:
Most people are aware of of death and dying. There is a third possibility, though. You may lose the capacity to make decisions while still alive because of brain injury. This can have bad financial consequences. Consider arranging for your spouse to have power of attorney if you become unable to speak for yourself.
http://en.wikipedia.org/wiki/Lasting_power_of_attorney
"Dying with dignity" is vexed phrase but the option for an individual to say, "This is enough for me," should be available. Try to make your feelings known in advance of the need, but your feelings may change.
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BLUEBLOCR
Social climber
joshua tree
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Dec 29, 2014 - 06:55pm PT
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Times article;
As many doctors point out, since medicine has already discarded the vast majority of the Hippocratic oath, why adhere to the sentence about poisoning, which probably was aimed at reminding physicians not to allow themselves to be enlisted in murder plots?
Hippocratic Oath;
Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the child.
Those Geeks 2500 yrs ago! Thinking that thing in the woman's belly was a child. Science tells us it's merely a Fetus.. and goes not against my Oath to destroy/murder it. But let's go ahead and get rid of that sentence anyway!
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Urizen
Ice climber
Berkeley, CA
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Dec 29, 2014 - 07:58pm PT
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A washboard is no more archaic than a jug band.
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MikeL
Social climber
Seattle, WA
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Dec 29, 2014 - 09:09pm PT
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DMT: I suspect that for many on this forum the topic has transitioned from parents to siblings to, well, thoughts of a more personal nature?
Well played.
Not too long ago, my mother went into emergency complaining of indigestion (she’s 84), in two days found herself in an intensive care ward with pulmonary fibrosis, in two weeks found herself in a hospice with 6 children around her. In 4 weeks, she somehow rebounded, and now lives in her own apartment associated with an assisted living complex. Things can turn around so quickly; one hesitates to follow through on anything.
When I have found myself facing the issue a couple of times, I did two things. One, I balked. Two, some weird chemistry goes through me that makes me relax. I didn’t feel dignified or courageous. I just took what naturally came my way. (So much for plans.)
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Ken M
Mountain climber
Los Angeles, Ca
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Topic Author's Reply - Dec 29, 2014 - 09:25pm PT
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Lots of good questions Ken, would have liked to see more discussion of the answers!
"Do no harm."
If I prescribe penicillin so many times, I will surely kill one of the patients from a drug or allergic reaction, statistically speaking.
If I treat a patient, I am human and make errors and will eventually kill someone.
"Do no harm" - means do not treat?
Sick patients have trouble advocating for themselves, and family members are often too timid to speak up in front a man in a white coat. How does that fit in with all of your questions?
Harry, as a former ER physician, I empathize with the more difficult situations faced in the ER.
As for answers, I have found that as I've moved into the ethics community, oft times the best we can do is to identify the right questions.
Your example, of Pen, happened to me.
As I've spoken to ethicists, the phrase "Do no harm" does not refer to unintentional unexpected outcomes, but rather to intentional harm. It also covers a lot of ground in terms of experimentation or using things with which we have no guidance as to effect.
your EXCELLENT question about advocacy is at the heart of primary care. I have always taught that it is one of the most important issues that we face, facilitating those conversations. Of course, in primary care we have MANY advantages----a prior (hopefully) trusting relationship, prior knowledge of the patient and their wishes, prior relationship with family (at least heard of each other), hopefully a long time to develop that relationship. Also, I never wore a white coat. :)
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Ken M
Mountain climber
Los Angeles, Ca
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Topic Author's Reply - Dec 29, 2014 - 09:38pm PT
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BLUE,
I would not change a word of the original H. oath. That said, it is because it is a historical document. I do not believe that it is used any longer in any medical school ceremony. It was not used in mine, 30-odd years ago.
Some use none. The Wikipedia page describes the situation well.
Would you foreswear piety to Jesus, in favor of a long-dead Greek God? I think not. There is nothing holy about the HO, it was not passed down by God in the Bible.
Ethics change with time. However, it should be done with great care and consideration, particularly on the part of those who will be charged with following it.
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rick sumner
Trad climber
reno, nevada/ wasilla alaska
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Dec 29, 2014 - 10:12pm PT
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I acted as the doula for both my parents. They both made their definition of end of life and cessation of treatment clear to me, my mom in a directive mailed once a year, my father verbally in numerous conversations. Their ends both came in 1998, one in Florida, one in eastern Washington.
My siblings seemed satisfied to leave the decisions to the medical establishment. I had no problem, and encountered no resistance, In person ordering withdrawal of all treatment and allowing the natural progression. It wasn't fast, it wasn't easy, but it was the right course. I never questioned my decision, or felt the slightest regret. It was the right thing to do.
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k-man
Gym climber
SCruz
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Jun 10, 2015 - 08:24am PT
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IMO, Dr. Jack Kevorkian will be exonerated and found to be the spear head of the idea that people have a right to terminate their own lives to save themselves and their families from pain and suffering (let alone economic hardship).
Most people remember Soylent Green for the infamous line, "It's People!!!" But few talked about the forward-thinking idea in the flick, being that folks could choose to terminate their lives when they wanted. The world was so overpopulated, it became the obvious course of society.
{Edit - removed thread drift ramble...]
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thebravecowboy
climber
liberated libertine
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Jun 10, 2015 - 08:25am PT
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cool piece, thanks for sharing! my folks just ordered their own little bottles of Nembutol yesterday.
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darkmagus
Mountain climber
San Diego, CA
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Jun 10, 2015 - 01:01pm PT
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Thanks for posting, Doc!
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Clint Cummins
Trad climber
SF Bay area, CA
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Jun 10, 2015 - 01:12pm PT
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Cool - some people likely missed this great article the first time around.
Here's a link to Ken's original point of publication
(since reprinted on Saturday Evening Post, etc.):
http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/
I just shared this a week ago with my daughter and her friend who is just starting her residency at UCSF (in peds, though!).
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Tobia
Social climber
Denial
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A well written, thought provoking piece. As the son of a doctor, it seems to me that changes in in the field of medicine, both technical and ethical, as well as the influence of insurance companies, have altered the field at a much higher rate that would allow for philosophical changes. The the mission has somewhat remained steadfast.
I have often asked my doctors, why a patient, (me) cannot have their life terminated? I have yet, to receive an answer that is logical. If the mission is to heal or comfort and pain and suffering are the overwhelming aspects of one's life, why does it have to be continued?
When all efforts have been unsuccessful, the continued, the endless variety of pharmaceutical cocktails are relentlessly forced on the patient. The only effect is a lower quality of life. Uncomfortably numb is the usual result.
Unrelated to the subject of the article directly is the vast influence of the pharmaceutical companies and the judiciary system's altering of the physician's mindset. Diagnosing an illness does not resemble the process that was the standard 60 years ago. From my perspective, a trip to the doctor is comparable to drive thru car wash compared to an old fashioned hand job.
I don't believe this is the will of the doctors; but the cumulative effect of the realities of modern day medicine mentioned above.
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Rick A
climber
Boulder, Colorado
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Ken,
Excellent article, thanks for writing it.
A recent New Yorker article discussed the effect of the doctor-assisted euthanasia, which is permitted by law in the Netherlands and Belgium.
http://www.newyorker.com/magazine/2015/06/22/the-death-treatment
This law apparently allows doctor-assisted suicide even for psychological distress and this is causing some to reconsider the effects of the law. The article focuses on a son who was angry that a doctor agreed to assist his mother in her suicide.
In the past five years, the number of euthanasia and assisted-suicide deaths in the Netherlands has doubled, and in Belgium it has increased by more than a hundred and fifty per cent. Although most of the Belgian patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression...
The laws seem to have created a new conception of suicide as a medical treatment, stripped of its tragic dimensions. Patrick Wyffels, a Belgian family doctor, told me that the process of performing euthanasia, which he does eight to ten times a year, is “very magical.” But he sometimes worries about how his own values might influence a patient’s decision to die or to live. “Depending on communication techniques, I might lead a patient one way or the other,” he said. In the days before and after the procedure, he finds it difficult to sleep. “You spend seven years studying to be a doctor, and all they do is teach you how to get people well—and then you do the opposite,” he told me. “I am afraid of the power that I have in that moment.”
I know this is a completely different issue than what your article deals with: people taking control of the circumstances of their own deaths when faced with a terminal diagnosis, but would love to hear your thoughts on it.
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Ken M
Mountain climber
Los Angeles, Ca
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Topic Author's Reply - Jul 9, 2015 - 10:59am PT
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Rick,
The quote you posted says well what American doctors fear most: the gravitation to "death as therapy" for non-terminal conditions. It is not clear to me the logic of restricting termination to people who have a terminal illness with 6 months or less.....that is quite arbitrary.
Mixing arbitrary with ethics seems to produce chaos such that anything you want to do becomes ethical.
The fact is that there are options available to patients right now, that happen every day.
I've mentioned that patients currently have the legal right in all 50 states to give up eating and drinking to hasten their demise. It is one of the gentlest ways to go. In Oregon, in nursing home settings, twice as many patients make that choice as do Physician Assisted Suicide.
I have often asked my doctors, why a patient, (me) cannot have their life terminated?
In the profession gallows humor, this is referred to as a "38-caliber brain biopsy". But you have to do it yourself.
More seriously, doctors have spent a very long time in the pursuit of helping patients to live. It really goes against the grain to kill people.
Once you have trained doctors to kill people, then the issue becomes "when"?
The reality is that very few problems that people fear while dying cannot be adequately addressed. And even for those very rare situations, we have tools to prevent suffering. For example, one is "terminal sedation", in which we basically provide general anesthesia, where a person will feel no pain, and suffer no indignities of which they are aware.
The problem we have, though, is not enough docs trained in these things, called "Palliative Care" specialists.
In my opinion, if a person has severe pain, we should be using the tools to relieve their pain, not killing them instead.
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MikeL
Social climber
Southern Arizona
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I don’t get it. What stand or position is the author taking? What does he want?
It seems what’s wanted are clear delineations of responsibility and authority.
When it comes to visions, I think delineations can’t be created.
Like language, the law or a code of work / professional ethics changes with the times and place. Language, law, and ethics are all living things that reflect who we think we are. (For a reference, see "Judgement at Nuremburg.)
For me, that’s the question: not how to approach the right to death or life, but who or what makes the request to either.
Doctors, like every other profession and work ethic, serve the collective first.
After saying what the focus / unit of concern is, then the question seems to be about how best to serve.
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Jon Beck
Trad climber
Oceanside
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Doctors, like every other profession and work ethic, serve the collective first.
Not a doctor, but I suspect that doctors have a singular duty to patients. Taking the good of society into account when advising a patient is a slippery slope.
Does a CPA have a duty to society to see that people pay more taxes?
Lawyers have a duty to their clients, society be damned. A lawyers duty to advocate ends when the client wants to lie in court or is engaging in criminal conduct. However a lawyer can not disclose a clients past lies or criminal activity. The disclosure of planned or possible future criminal activity becomes an ethical quagmire.
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