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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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