The following article is both interesting and somewhat disturbing. On the one hand, it discusses the practice in hospital settings of doctors ignoring Advanced directives when patients are no longer able to make decisions. The ignoring of a patient’s wishes is not uncommon, yet, as usual, I wouldn’t draw strict conclusions from just one story. Nevertheless, the loss of patient choice is disturbing.
What is even more disturbing is the perception the piece gives about hospice. Once again the story reads, she came on hospice, they stopped the feedings, she died.
Within a few days, the woman was transferred to a hospice unit, where the IV was removed and she was permitted to die.
There are two main problems with this account. First of all, it plays up to the hype that hospice’s goal is to hasten death. Even if the facts would say different, the wording is simply, they stopped feeding her and allowed her, “helped her” to die. And hence the harsh comment by the doctor’s colleague, referring to him as a Nazi. The second problem is that nowhere does anyone consider the ethical dilemma of even stopping the IV. It is true that in general medical ethics, withdrawal is no different than withholding treatment. Yet, that distinction does exist for many people and would help to explain to the reader why the surgeon was such a harsh critic of what the hospice did, let alone making the unilateral decision to provide IV in the first place. I am looking to justify or legitimize either side. Rather, I want to show you the problems with the whole approach to the situation.
Among Doctors, Fierce Reluctance to Let GoBy PAULA SPANValerie Winckler/Getty Images
The conversation took place two years ago, but Dr. Daniel Matlock still recalls it quite vividly. You tend to remember when a physician colleague essentially brands you a Nazi.
Dr. Matlock, a geriatrician who specializes in palliative care, had been called in to consult when a woman in her 70s arrived at the University of Colorado Hospital, unresponsive after a major stroke.
She’d done what we’re forever chiding people for not doing: She’d drafted a very specific advance directive and had even taken the trouble to have it notarized. It unambiguously said: no life support, no artificial nutrition or hydration, no nursing home.
The ambulance crew had put her on a ventilator — standard procedure. After the palliative team removed it, she was able to breathe on her own, which isn’t uncommon. She even opened her eyes, though she couldn’t track or follow objects and remained unresponsive. That’s when the prominent surgeon directing her care ordered intravenous fluids.
Dr. Matlock, alarmed at this direct contradiction of her preferences, tells the rest of the story in a post on the GeriPal blog, published by geriatricians and palliative care docs at the University of California, San Francisco. After talking with the patient’s sister, who held her medical power of attorney, he called the surgeon to suggest stopping the IV.
“You would have been hung in World War II for doing what you are doing now,” the surgeon said.
Let’s pause to think about that for a moment.
Within a few days, the woman was transferred to a hospice unit, where the IV was removed and she was permitted to die. But Dr. Matlock’s anger at his colleague and his sorrow at the woman’s treatment, or mistreatment, have persisted. “You work so hard to do what’s right for the patient,” he told me.
And he was sure he was right. Administering fluids to a dying patient increases the person’s secretions and makes breathing more difficult, palliative care doctors are taught. “Dehydration is a gentler death, with less agitation,” he said. But quite apart from that, the woman had done everything but stencil “no IV” across her forehead.
A palliative care consultant, however, couldn’t overrule the surgical team whose patient she was. “I went home that night feeling really bad,” Dr. Matlock said.
What prompted his account of this unpleasant exchange, all these months later, was a startling study recently published in The Journal of Palliative Medicine. After surveying nearly 700 physician-members of a national hospice and palliative medicine organization, the authors report that more than half had had at least one experience in the past five years of another physician or health care professional referring to their treatments as “euthanasia,” “killing” or “murder.”
This, despite palliative practices being broadly accepted as legal and ethical, as reducing suffering while honoring patients’ autonomy.
About a quarter of the respondents had heard similar accusations from a personal friend or family member, the study found. And 25 doctors (4 percent of the respondents) had been formally investigated on the question of whether they had hastened a patient’s death.
“It was cathartic for me” to read the study, Dr. Matlock said. “It was helpful to know I wasn’t alone.” But it’s not exactly reassuring news for the rest of us.
We’ve had frequent discussions here of end-of-life care and why the “good death” so many people want proves so elusive. We can, with ample reason, blame physicians who don’t want to talk or think about dying. (A favorite joke among hospice workers, who tend toward a dark sense of humor: Why are coffins nailed shut? To keep oncologists from administering more chemotherapy.)
And physicians have often responded with their own stories of family members who won’t accept that further treatment is futile and urge another operation, another drug, another something.
But here’s another part of the dynamic, apparently: Even when the system works as it’s supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers.
It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that’s intended to reduce suffering, to point out that the patient’s own wishes are paramount. Perhaps they have to be stronger than we know.
“The culture is changing,” Dr. Matlock told me. “But it’s not changed yet.”
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”
In addition, here is the original piece that the above was based upon.
Being Accused of Murder
“You would have been hung in World War II for doing what you are doing now,” I was told by a prominent member of a surgical service at my hospital when I suggested we stop the intravenous hydration.
The patient had suffered a devastating stroke. Her advance directive (notarized no less) stated that she did not want any artificial means of life support specifically mentioning artificial nutrition or hydration. Further, she also clearly stated that she would never want to be in a nursing home. The palliative care service on which I was attending was consulted to assist in removing the ventilator. We did. The next day, she was breathing on her own, showing no signs of decline, and even opening her eyes so the prominent doctor on this surgical service started intravenous hydration. I was immediately uncomfortable with this value discordant move so I called her sister who was listed as the medical power of attorney to clarify what the patient meant in her advance directive (because apparently it wasn’t clear enough for the primary team). She told me a story about her sister hunting deer outside her house and dragging them down the mountain all by herself at the age of 70. She used this story to explain how her sister would never want to be in a nursing home and if the best that she could hope for after this stroke, then she would definitely rather be dead. She agreed that we should stop the hydration. There was no ambiguity here.
I called this prominent member of this surgical service and explained what the MDPOA had told me about stopping the hydration. That’s when he said, “You would have been hung in World War II for doing what you are doing now.” It is a good thing that we were on the phone because this was one of the few times in my life where I remember having that rageful sensation of my blood “boiling” – I could feel my face turn red. I remember making some comment about “modern ethical theory evolving from the time of WWII” and hung up the phone before I got into any trouble.
This is actually one of the most disturbing interactions I have ever had in the hospital. I’ve asked several of my mentors what I could have done differently and I get the feedback that perhaps I could have explored his perspective (typical palliative care response!). I honestly don’t think I was capable. Sometimes it is frankly unfair that we in palliative care always have to be the bigger people educating these dinosaurs about modern ethics. Frankly, I wanted to just drop the gloves and go at it with fists. I still do…I’m not over it. When I see this doctor on the elevator, I cannot even look at him.
I found some comfort today though! A beautiful and important survey by Goldstein et al. showed that a large percentage of clinicians who care for dying patients have been accused of murder. The authors argue that “further efforts are needed to explain to the health care community and the public that treatments often used to relieve patient suffering at the end of life are ethical and legal.” This is indeed one implication of this study but the other important implication is that people like me who are victims of this kind of verbal onslaught have clear evidence that they are not alone.
by: Dan Maltock, MD, MPH
Disappointing, but not surprising. Ethical considerations in medicine are currently a subconscious process.