Care For And Comfort The Dying To Their Last Moment

It is difficult to overstate the importance of pending Supreme Court deliberations on physician-assisted suicide. The issue touches us all - patients and physicians. It drives to the heart of the physician-patient relationship.

As fundamental as it is, it also reflects a much deeper and broader social issue of how we, as a society in the late 20th century, approach the issue of caring for the dying.

Regardless of how the Supreme Court rules next summer, we must come to terms with how we treat thedying and work to improve the care provided to our loved ones as death approaches.

Many of us - physicians included - fail to appreciate how natural and inevitable a part of life dying is.

Too many physicians seem to regard death as a failure and our inability to “save” a patient as a reflection on our skills. In this we reflect a larger societal view of dying and society’s expectations that somehow science and technology can turn back an inevitable life process.

Too often lost in our care of the patient is the realization that quality of life must be paramount. The 8,000 members of the Washington State Medical Association encompass very strongly held views on both sides of the physician-assisted suicide issue. At our recent annual meeting, a group comprised of physicians opposed to and supportive of assisted suicide issued a special report.

While physicians’ opinions on assisted suicide mirror those of the public, all members of our association were united in concluding that:

We must work on laws and regulations to protect the vulnerable, should physician-assisted suicide become legal.

We must actively encourage physicians to advocate for their patients’ optimum care, recognizing that physicians must take the leadership role in shifting medical attitudes and traditions in the direction of delivering quality palliative care for their dying patients.

We must confront the widespread perception that if a cure is not possible the physician’s role is minimal. Too often, we fail to provide optimum care to our dying patients because the only recognized outcome is death. We must be persuaded to shift conceptually - and then in fact- from treating the patient’s disease to recognizing that dying is a personal experience of the patient. End-of-life treatment, done or not done, must be driven by the needs and desires of the patient in consultation with the physician.

As physicians, we need to play a critical role in easing a patient’s inevitable transition from life to death for both the patient and his or her loved ones. We must not only treat illnesses, but also promote mental and spiritual well-being for the patient and his or her family, physical comfort for the patient, and a sense of peace in the individual’s last days.

Assisted suicide is a subject few people will ever agree upon and upon which compromise seems next to impossible. There are, however, alternatives.

Patients need to be made comfortable. Physicians must respect a patient’s dignity, needs and wishes, while also seeking to alleviate pain and suffering when the prospect of recovery does not exist.

The hospice movement has given patients a place of rest and comfort, offering support to both patients and their families during their grieving. Hospice care puts the emphasis on accepting and dealing with death when it is inevitable, rather than spending a patient’s last energies on fighting a futile battle.

Patients should plan ahead. For years physicians have strongly endorsed advance directives and living wills, which allow the patient to dictate, in advance, under what conditions he/she would have life support maintained, and what kind of medical care he/she wishes to receive in an extreme situation. Planning ahead for the worst may seem unnerving to some,, but it does guarantee a measure of peace of mind for family members and loved ones, should the worst-case scenario occur.

Assisted suicide propositions have been defeated in several states, partly due to fear that the vulnerable, the elderly and those rendered by illness or injury unable to speak for themselves would be easy targets. Since the 9th Circuit Court of Appeals overturned Washington’s law banning assisted suicide, the WSMA has commissioned a medical assessment of existing guidelines and an appraisal of the related issues they raise.

By appointing an End of Life Task Force to evaluate these guidelines and examine the issue in all its complexity, the WSMA is taking steps to ensure adequate and humane care for all dying and critically ill patients, regardless of the outcome of legal rulings on assisted suicide in the future.

The Supreme Court is likely to make a decision on assisted suicide next year and the 1997 Legislature may also address the issue. While lawmakers and the courts wrangle over the issue, the WSMA will continue to study the quality, satisfaction and processes of end-of-life care delivered by Washington state physicians in order to help improve such care, using the opinions of patients, families, communities, physicians and other health care providers.

Working with other organizations, the WSMA will support programs that promote greater public awareness of end-of-life care options in our society, including optimal palliative care and hospice.

Death is natural and inevitable. No matter how advanced our life-saving technology and mastery over disease becomes, there still remains the certainty that at some point, life as we know it ends. What we as physicians and members of society ought to look at now is not the length of a patient’s life, but the quality.

As Henry Miller wrote: “In the attempt to defeat death, man has been inevitably obliged to defeat life, for the two are inextricably related. Life moves on to death, and to deny one is to deny the other.”

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The following fields overflowed: CREDIT = Nancy L. Purcell, M.D. Special to Roundtable