End of LifeOctober 18, 2013

Thoughts on suicide

By James Salwitz, MD

New Jersey is considering following four other states in legalizing physician-assisted suicide. The Death with Dignity Act would allow people with less than six months to live to receive a prescription for a fatal cocktail and then to commit suicide at the time of their choosing in the privacy of home. This weekend I had the opportunity to participate in a debate on the merits of the proposed law.  While I appose this act, the wisest comments were not from the panel, but from the “audience” who carried on a vocal and revealing discussion and taught me a great deal.

While many people spoke, and all were interesting and articulate, there were two stories that, at least for me, paraphrased the core ideas. These comments placed physician-assisted suicide in the context of modern society.

The first was a woman who described her life over the past few years and the future that she seeks.  She is a nurse with a long experience working in hospitals, nursing homes and even in hospice care. She is now dealing with her second cancer, which has metastasized and from which she will eventually die.  She is receiving excellent care, including chemotherapy, and for now the disease is in control, and she is living a “great” life.

She reflected that she loves each day, and fights for every quality moment.  She plans to continue to do whatever it takes to live well for as long as she can, however, she knows that the cancer will eventually end her life.  She does not plan to commit suicide, but absolutely refuses to live a life without quality.  Therefore, just in case her condition deteriorates to the point that it is leached of all beauty and meaning, she wants to have the option of suicide.  As she has a long attachment to the medical profession, she trusts doctors to provide that gentle end.

The second illuminating comments came from the family of a man who recently died of lung cancer. The daughters of this patient detailed a long chain of atrocious medical care. They described physician neglect, poor communication, and refusal to answer questions or return phone calls.  At the end of his life, as he lay dying, hospice workers did not follow-up, did not show-up and did not replace faulty vital medical equipment. It was a horrible story of suffering through a painful end and the failure of multiple caregivers to address pressing need.  Desperate, on his dying bed, their father begged his daughter to write a book about “why people must suffer.”

In both cases, the nurse and the surviving family, support suicide.  The first, because she wishes to maintain control.  The second, because they believe patients cannot depend on doctors and even hospice may fail to give comfort and hope.  I understand their points of view and cannot help but empathize with their pain. Nonetheless, after listening carefully and further thought, I conclude that the contrast between these two experiences is the strongest testimony against the Death in Dignity Act and physician-assisted suicide.

If end-of-life for most patients were like that of the nurse, the “freedom” of suicide might make sense.  That is, if everyone planned for dying, everyone had the best support and everyone received optimal medical care to achieve quality at the end of life, then perhaps elective death should be an option.  If even with perfect, compassionate and complete treatment, there was uncontrollable suffering, perhaps taking one’s life might be a way to find peace.  Presumably, this would be a very rare event (in Oregon where suicide is legal, only 1 out of 750 use it), but dying would comfort some and many would welcome having the choice of suicide as giving them control.

However, tragically, the experience of the medically sophisticated nurse is the exception, not the rule. Most patients and families do not plan for end of life events. Often, doctors do not communicate regarding these vital issues and rarely do patients hear the precious words, “we do not have to treat the disease; we can just keep you comfortable.”  Very often, even with a terminal illness, patients do not understand what is going on and therefore descend into pain, fear, and isolation. Many die in institutions, on machines, with chemotherapy infusing even as the code team performs CPR.  Although many people try and as a society we have the best of intentions, quality of life at the end of life is not guaranteed and perhaps not even likely.

If we ratify suicide we may be helping a very few, but we neglect many.  We fail to emphasize quality life, at the end of life, by good communication, good planning and good care.  We fail to demand of doctors and the medical system what is possible.  We discard the potential to live, learn and love in the last days, weeks, or months, and instead say, “Your life is worthless, make it easier on all of us, take this pill and die.”

While I appreciate the freedom to choose suicide in a perfect world, for the average patient and family, we have a long way to go.  We are allowing ourselves to be distracted and neglect life’s potential by focusing on an inadequate, controversial, and ethically questionable alternative, instead of demanding of ourselves and our society improved life at its end.  That is the vital conversation and we all have much to learn.  Quality at the end of life must be our destination, and we must not stray from that path.

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20 Comments

  • red pear puppets
    Assisted dying only applies to terminally ill, mentally competent adults and requires the dying patient, after meeting strict legal safeguards, to self administer life-ending medication. Assisted suicide allows assistance to die to chronically ill and disabled people who are not dying but are suffering. Assisted suicide is permitted in Switzerland Voluntary euthanasia allows a doctor to administer life ending medication directly to the patient. Voluntary euthanasia is permitted in the Netherlands and Belgium Euthanasia is a term often used to describe life ending medication being administered by a third party, perhaps without the consent of the patient. In England we are campaigning to change the law to allow.assisted dying only. No one at any point is saying life is worthless..it is precious beyond measure however not one of us has the right to condemn another to an existence full of misery and the shame of suffering. You are obviously an exceptional and infinitely caring doctor however..we must allow the individual to take their own lives into their hands. To support them in this we need to create strict terms of engagement but this is not beyond the wit of man and we should work together to find a way to make this law..so that families do not have to travel at a time of great pain and stress to find a strangers hand willing to give ease.
    Reply
    • Liz
      I agree. I wish I had read your comment before I wrote my mine. I would have used your language as it is more precise in meaning.
      Reply
  • Mary
    Dear Dr. S, I cannot agree with your conclusions on death with dignity. I have witnessed two deaths from cancer and both were horrific beyond belief. The first was well within our " standard of care" and was anything BUT caring. The second was beyond incompetent with no medical professionals communicating with the patient, the family, or each other in any meaningful way. Both of these people suffered a truly undignified end that was soul crushing to witness. I would not wish any of this unnecessary suffering on another.
    Reply
  • Liz
    So where do you draw the line between a patient choosing to have the respirator pulled and then dying the same day and the patient choosing to ask for an overdose of a medication (whether administered by the medical profession or by the individual) and dying the same day when in both cases they will die anyway? In both cases the patient will die the same day. In both cases the patient is making a conscious decision to do this. In both cases they don't have much life expectancy left. In my mind both are committing suicide - in one case legal as you choose to stop care/treatment in the other case illegal in all but a few states and countries... Either way you are dead, faster than generally otherwise would be the case. Here is how family and extended family members have died, many of them by conscious choice... assisted by physicians: 1) post polio syndrome coupled with hospital caused infections that will also kill him - pulled respirator (had respirator assisted breathing for 4 months) and hospital administered morphine (with only 1/3rd of lung capacity this would, in my mind, qualify as doctor assisted due to the respirator depressing side effect of morphine) to help with the pain - took 7 hours to die in a facility. (my father, a minister). 2) ovarian cancer with multiple relapses- chemo not doing any good, stopped that, choose to stop eating, died 2 months later. She was given the ability to choose to give herself a morphine overdose (was attached to a pain pump) but chose not to (died in her sleep shortly after asking for a glass of water), died at home. (my aunt). 3) ovarian cancer - second relapse - chemo sort of helping with some tumors, cardiac problems that would kill her possibly prior to the cancer, hated quality of life, chose to stop treatment, died 3 months later. Died at home. (my aunt). 4) Died of who knows what (died in her sleep) in nursing home after pleading for 2 years to end her life and had a miserable quality of life (my grandmother). 5) Died in her sleep bedridden, deaf and blind in a nursing home after spending 7 years like this, after telling everyone for years prior if she ever gets like this shoot her like a horse. Would have died much sooner if her children had been willing to stop the medications. They were not ready to have her die. She was unable to communicate, had no written advanced directive. (my grandmother - this was prior to my father dying, I think my mom might have made a different choice if this had happened afterwards because once you allow someone to choose death in situations like this it changes how you think of it). 6) Was diagnosed with advanced prostate cancer, his wife chose not to tell him, brought him home, he died at home 3 weeks later (my grandfather). 7) Had a complication of chemo (colon cancer, had significant lung damage from chemo) that he would not recover from. Decided to stop all treatment after was put on a respirator due to the lung damage, two weeks later he decided he wanted the tube pulled, died 3 hours later (my uncle, he was also a minister). I can tell you from having to go through giving permission for my father to die that this is difficult. I didn't exactly say it was ok with me - what I did say was that I didn't want him to die but I recognized it was his life and his choice and I wouldn't stand in his way, knowing that my dad (my aunt - #2 above and my dad had long conversations about this) were both members of the hemlock society. My aunt, a life long anti gun person, went out and bought a gun to use if she had to (didn't have to as her doctor gave her another way). My father tried to talk to us about this about two years prior. We didn't want to talk about it. It was too hard (my brother had committed suicide - didn't find out until around 10 years later he was murdered by his wife so we had to learn to cope with suicide) to do that... but at least we knew what my dad wanted. I was the one who finally asked him if he wanted me to do the leg work to find out if the facility he was in would allow him to die. He told me yes and died 2 and a half weeks later. He had been a minister. He stated that he no longer knew if there was a heaven or hell, he didn't care, he was ready to die (he wasn't depressed by the way - I happened to be the one with him that day about 2 weeks before he chose to die, when a researcher looking at end of life issues interviewed him - not easy since he would either nod yes or no or struggled to talk). I know that when my brother died, back when we thought it was suicide, it was very difficult to come to terms with this. In order to do so we (my family talked about this and were surprised all of us thought this way) we had to fundamentally change how we thought about suicide - something I think many physicians have not had to do in quite the same way. A side consequence is that now, suicide is a choice, just like any other choice, that has to be consciously rejected. We all resent that. I found the three different counselors I tried to talk with had their own issues with death, suicide, etc, and could not put their own issues aside to help me deal with mine. I would suspect that this is an issue with many doctors when it comes to considering patients who want to die and to do so would involve an active hand of the doctor giving an injection or handing out the meds. I know that had we not thought my brother had committed suicide and I had not finally figured out how to deal with it and in doing so found my thoughts had shifted, I would have really struggled, far more than I did, to even consider asking the facility if my dad could do this and then sort of agreeing to it when he decided he was going to. I think physicians are caught in the same taboos, emotional struggles, etc. that the rest of us are. Physicians have been trained that one is OK (stopping treatment and pulling tubes) and one is not so you have learned how to deal with the one that is OK, because you have had to or drive yourself over the edge since patients die, and not learned how to deal with the other. And it is something you learn on a very fundamental, emotional level. I think that doctors have figured out how to deal with and justify patients refusing treatment, decisions to pull tubes... all of which will end in death -eventually - because the operative word is eventually and not (usually) sometime today. Physicians can distance themselves from the act that started the final cascade of death and the actual death. These are often longer (although often more painful and tortured) deaths. There is distance for the physician though because act and consequence are (usually) further apart. And you have the occasional reversal - the exception to the rule where the patient gets better or hangs on for months/years- that you, as the physician, can hold on to if need be. Our cognitive biases, though, cause us to think these exceptions are more frequent than they really are... but they are useful as they can add an element of insulation from the certainty that your action will cause death. The focus is also on end the suffering, quality of life left...not that what you are doing or the patient is choosing and/and you are helping them do, will end their life at some point in the future. I think it is because it is closer, easier to say this specific action caused their death (eg give a med either themselves or for the patient to self administer) that it is harder for physicians to come to terms with this way to end suffering...not to mention your training is do no harm (and you focus on the harm side - death, not the stop the suffering side)... But while stopping treatment, pulling tubes can be/are doing harm in hastening death... generally the medical profession has decided to call that compassionate, honoring the patient's wishes, stopping the suffering.... how is this different than stopping the suffering by doing something else? Allowing a patient to die sooner by pulling tubes or stopping treatment is doing harm by hastening death... and is more active on the part of a physician...but these are usually deemed acceptable. In all cases the patient is suffering and you are doing no harm with respect to the point of view of stopping the suffering by giving the drug, pulling the tube... I ask again, how is giving a drug to stop the suffering in a terminally ill patient any different than pulling a tube? Give a drug my dad dies today, my uncle dies today. Pull the tube my dad dies today, my uncle dies today. How are you (and other physicians) justifying that somehow, the actions are different - one deserves to be legal and one illegal? In some contexts it is considered a good to hasten death (stop treatment, pull tubes). In other contexts it is considered a bad. In ethics, how someone judges something is ethical can vary. Sometimes something is considered ethical if the outcome is good, even if one has questions about the methods to get to the outcome. You judge by the outcome. Sometimes something is considered ethical by the methods used even if the outcome is not good because how you tried to do it was ethical even if things didn't turn out as you expected. In this situation I think that the doctors who disagree with assisted suicide (whether done by the patient or doctor) are using the "methods" approach of ethics and the doctors who are on board with this, even if reluctantly, are using the "outcomes" method with stopping suffering as the intended outcome. The problem I have is when physicians are using "methods" in some contexts and "outcomes" in another - with the SAME underlying issue. OR perhaps physicians aren't seeing/are denying that the underlying issue is the same? - e.g. the underlying issue is stopping suffering because there is no hope of recovery, quality of life is so compromised...and the patient requests option (c) to stop suffering (patient or doctor administered drugs) as there is no option (a) (stopping treatment) or option (b) pulling tubes... for that particular patient. None of this is easy and doctors are just as human as the rest of us when it comes to struggling with ways people die, being traumatized by some deaths, learning to cope with it, come to terms with how people died, how they justify some actions but not others that have the same outcome for the same underlying cause, only the methods differ... I do think this, along with how an individual approaches the ethics involved in end of life choices- the process/outcome focus difference - is what is responsible for much of the disagreement.
    Reply
    • Mary
      You said it well. I don't understand why it's wrong to end suffering caused by cancer and neglect-even possible malpractice, but it's OK if the patient is in the medical field, and everybody is doing an excellent job. I wouldn't treat a dog the way the second patient was treated. My father was treated well, his doctors and nurses were very caring. This was before hospices. The doctors gave my father extra vials of morphine and told my dad to use them. He didn't want to because of religious convictions. He begged doctors and nurses to hive him all of the morphine. The one thing I knew was that he already reached the point where the morphine didn't work very well. They told him that he only had a few months to live, but that was 3 years earlier, so he had it pretty bad. I was 13. I have a slow moving incurable cancer on my face. The radiation killed the tumors, but it's known to come back with a vengeance. I've been told that it's one of the more painful bone cancers. I asked about pain killer for when it gets bad-I was called a dope addict by everybody. Cancer doesn't make sense. I just find a fallacy of the logic in this article. Both patients should have their wishes respected. I find myself wondering if there is a bias, because one was in the medical field. How much education does a dying person with a recognised painful terminal disease needs to have, before they are treated with respect? I hate to think that the only reason my father was treated well was because he was a math professor @UCLA, and before that an Army medic that did anesthesia in the OR.
      Reply
      • jill
        Bias in directing care is alive and well. Depending on what administering persons agendas are I think. Answer this..why would a 'family general practitioner with 6 counts of sexual harassment/assault on his record be allowed to continue to practice? Why, when I am given a prescription drug for a topical antibiotic , it is over a year and a half out of date, and yet I am hung up on..? Bias against persons of different economical,educational and professional statuses is across the board..we learn that in public schools.
        Reply
        • jill
          PS. There is an SLEP (shelf life extension program) database. uSED BY GOVERNMENT FOR EMERGENCIES .
          Reply
  • joannevalentinesimson
    "quality of life at the end of life is not guaranteed and perhaps not even likely." This is the key to the whole question/problem of assisted suicide. If that phrase is true, then the assisted (or at least permitted) suicide option is a kindness. Insisting that a person continue to suffer a prolonged, painful, and meaningless death is cruelty. We no longer permit torture in our culture - or do we? A valuable resource on this topic is "In Search of Gentle Death" by Richard Cote. http://www.amazon.com/Search-Gentle-Death-Dignity-ebook/dp/B008WPIEPS/ref=sr_1_1?s=books&ie=UTF8&qid=1382114221&sr=1-1&keywords=in+search+of+gentle+death
    Reply
  • jill
    The medical/psychiatric community has made definitions that are not necessarily moral or medical about this issue. How many times I have heard "no guarantee", "we do not always know", everyone responds differently" etc. never a really accurate answer based on science. If every person at the moment of considering this option were given full and equal attention I am sure the 'quality of living and dying' issues would be better served. I think along with the word 'justice' these things are and continue to be intangibles.
    Reply
  • Kathleen Denny
    Dr. Salwitz seems to equate assisted suicide as a substitute for fixing the truly grievous state of medical reality, especially when there is no realistic prospect of improvement. But nobody that visits here would think of doing that. The only people who might do that are shills for insurance companies, policy pundits and the like. You know - in the name of still more "cost-cutting." That said, I think that those who have considered their prospects, and then decided that further life will be a degrading and painful burden to themselves, deserve to end it with dignity and compassion. Sadly, in this society that option is most often reserved for the wealthy and well-connected.
    Reply
  • Mary
    Consider my incurable atypical cancer that eats through bones. It's very slow moving and one of the more caustic cancers. It's by my nose. Because of its type- if it comes back, it will eat through the roof of my mouth til my brains fall out. I had radiation and got a reprieve.The ACS says the best temporary stop is cutting away my facial bones-waiting a year or so and getting a prosthetic face-a million dollar surgery. This type of cancer will only affect my organs by me catching infections. I was told that palliative care is for the last 6 months or so-that I have to meet certain medical criteria-liver-kidney function-my cancer isn't in that part of the body. Then since I'm not rich-my last 2 weeks are supposed to be in a hospice, if I meet the standards. How many years would I have to wait to meet the standards to get palliative care, to be admitted to a hospice? Even if assisted suicide was legal- my brains probably would fall out before I met the standards. I do not understand why I'm supposed to spend years in agony, without help in pain control because I have a rare cancer. The first thing on my EHR is that I refuse to follow ACS standardized treatment. That will impress medical staff in a positive way, won't it? I think that it already negatively impacts me. Some of the doctors think that I'm a hero, some don't treat me so well. But, right now, I'm sneaking some Halloween candy, I'll be able to help cook and eat thanksgiving dinner-and be grateful that I can talk, smile, eat. Hopefully, I'll be sneaking candy and roasting the turkey next year- laughing with my family.
    Reply
    • Kathleen Denny
      Yes, and hopefully that is exactly what you'll still be doing next year. Though your cancer is rare, your example says a lot about the reality of end stage options for most people. But even in a perfect system, each of us should have the option of deciding when enough is enough, and to know that we can end it with dignity and without unnecessary suffering. Your example (and the ACS "standard") also reveals an entirely gratuitous disrespect that is all-too-common in medical relationships.
      Reply
  • D Someya Reed
    I found myself shocked at your reaction to the individual testimonies that you heard. I haven’t made up my own mind on the various forms of euthanasia (collectively) but I am leaning towards supporting the passive form that New Jersey is proposing. I can so closely relate to the experiences and feelings of the family of whom you wrote. I have heard many stories from varied health care professionals in support of suicide or that they would do it anyway. I’m curious…would you have supported the nurse if her situation of good care/quality of life were swapped for that of the man’s with lung cancer? I ask because there seems to me to be a bit of medical bias encroaching (based on your experiences) just as I have a hospice bias based on my own. My wife said several times that she did not want to live this way (as a quadriplegic cancer patient). She never asked me to help her die because she (nor I) would ever put the other in that position. Had she chosen to end her life, I would have understood and supported her no matter how difficult it would have been for me to accept. That is what you do when you truly love and respect another person and their right (in my opinion) to make their own self-autonomous choices. This doesn’t exactly apply to politicians as they don’t “love us” but they absolutely should “respect us” (but don’t, at least not always). As to your post, these are the points that I “heard” (as opposed to your intention for what you actually stated): 1. We are privileged with the gift of life and have a duty to live it regardless of the condition(s) of that life because the end of every individual life must have some positive aspects that we should desire and seek out at any cost. 2. All people are basically good (or well-intentioned) and will care for you appropriately but because you, the patient, have neither planned for your death nor have the knowledge of medicine sufficient to understand what your medical team is telling you, doing to you and/or not telling you then you are most likely going to end up in a poor quality end-of-life situation. 3. If euthanasia (in any form) is allowed, the sick will be perceived as worthless and of having a “duty to die.” 4. If euthanasia (in any form) is allowed, there will neither be pressure placed upon the medical system to improve nor desire to improve amongst those staffing it. 5. If euthanasia (in any form) is allowed, only a few will benefit but many will be neglected because of this “why bother” attitude from number 4. 6. Only the medically savvy can decide on the appropriateness of euthanasia. 7. A medically perfect world is required for euthanasia to work. 8. Until we have a medically perfect world terminal patients should be made to follow number 1 until we force ourselves (and society) to get end-of-life to some, yet unknown, acceptable level of quality. It’s coincidental that you posted this as I am reading a comparative study of euthanasia and hospice. Surprisingly, these groups are incredibly aligned in beliefs and practices except for one thing: Killing vs. Letting Die This then moves to Active vs. Passive Euthanasia (not exactly the same thing). Then ethicists will get into Acts of Commission vs. Acts of Omission. Then people get into Government Intrusion vs. Autonomy and the list goes on and on but ultimately ending in the questions – Do we have the “Right” to Die? and Do we have true Self-Autonomy? My biggest problems arise from the idea of “intent.” We allow many things based upon the “intent” of the person(s) taking the action. For instance: - Double Effect – we know the negative effect can kill and even be equally likely as the positive effect but it’s all OK because our “intent” was for the positive one. (How is that verified?) - Removal from life support – do we absolutely know that in absolutely all cases there is no chance of recovery and there is no financial (or other) competing concern? - Refusal of food/water – pretty much allowed everywhere, even hospice; the “intent” of the patient is obvious and the outcome much slower and painful than a lethal “cocktail” Everyone compares their state’s bill to that of Oregon. Interesting thing about Oregon is that the feared issues have not come to pass. The request for fatal prescriptions has been minor – 1,050 in 15 years (1998-2012, see 2012 annual report at http://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx) and only 673 of those requested were actually used. From 1997 to 2003 it was reported that only 171 patients took this suicide route out of 53,544 with the same disease that died of different causes. That is 1 out of every 313 (more than your 1 in 750 statistic but may not have the same basis). 87% of those who chose this form of suicide said their greatest concern was not from fear of inadequate pain control but fear of losing autonomy. A survey of 35 doctors who received requests for the lethal prescriptions described the requestors as “feisty” and “unwavering” as opposed to being “depressed” as detractors had warned. Even hospice learned from this law (in Oregon) and has adapted its practices. They found that pro-euthanasia groups supported everything just as hospice does including increased palliative care and living life to the fullest. Oregon’s Hospice Association reports that they now work with groups such as Compassion in Dying (involved in 75% of Oregon’s assisted suicides) and have changed their own practices. They claim to fit their treatment to patients seeking assisted suicide and claim that they will honor the patient’s final wishes. A shock for me was that they admitted to learning (from this) that 50% of the people who rejected hospice had done so because they found the hospice staff to be “condescending and arrogant.” I just had a local resident tell me that she and her husband both rejected hospice in my town for the very same reason. Of course, one hopes these changes are being done for the benefit of patients and not just the obvious potential financial returns. Oregon, I’ve read, also leads the nation in overall suicides from all causes. 35% higher than the national average for non-assisted suicides and still rising long after assisted suicide went into effect. It appears that this legislation had no effect on that either good or bad. Finally, I don’t believe that we have either the “right” to live or the “right” to die. Life is just a “privilege” because there are so many ways (legally) it can be taken away. A “right” is a right simply because it cannot be taken away. Since we have the privilege to live, why too can we not have the privilege to die when and where we choose? Is it more dignified to have people meet their end through all the various (illegal) methods used for centuries? When we euthanize our pets are we doing it out of compassion or are we actually saying, “You’re worthless as a dog or cat to me so take this shot and die?”
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    • Kathleen Denny
      Beautifully said and perfectly clear.
      Reply
    • jill
      Excellent!
      Reply
  • red pear puppets
    Surely it is not either/or.....there is an obvious need for excellent hospice care but please allow for compassion to those clear thinking adults who choose to take responsibility for their own, controlled end. 'Bad' deaths are far too common and in the uk we don't have the added worry of paying for treatment...How terrifying that must be. We need good people like you James Salwitz MD to put your experience and understanding to the task of easing this change in the law and not blocking it...with so much appreciation of all you do...Lynne
    Reply
    • Mary
      @Red Pear Puppets. In my case, in my state, it's not a matter of excellent hospice care. It's matter of any hospice care. The hospices here are filled up with Alzheimers. Then, unless I win the lottery, I'll be allowed only 2 weeks of care. I say that I'm not in any pain, but part of my lip, nose and the flesh between was removed during the second biopsy the end of Oct. 2013. I always have a face ache. Heat and cold put my face in agony. I can't bake cookies, because of the blast of a very hot oven about every 15 minutes. This month I started eating food warmer than room temperature. . When I started radiation, my lip was splitting open from the cancer inside. About pain, I'm terrified of it. My first baby was breech-without any meds. That is supposed to be one of the worst levels of pain, but it ended, and ended with life. Another time, I had a dirty break above the wrist, some of the bone was pulled into my hand, and my hand was pulled off. I had to lead my horse for almost 9 miles, and the temp was about 110. I do know what some pain can be like. Then my arm was shoved into the rotator cuff. It took over an hour and 3 techs to X-Ray my elbow.They never did my shoulder.I was unloading bricks from my truck-and it popped out and the grinding stopped. I wasn't given any pain killers for my nose or shoulder. I watched my father die, I watched the daily breakdown of body and mind, but his doctors cared. I'm thinking of how, my arm popped out of the rotator cuff, while I was unloading bricks from the pick up. Where I live, they call me a dope addict because I'm allergic to acetaminophen, and I refuse anything with that in it. I use ice packs and self-hypnotism. Why do I need to become physically ill, besides being in the original pain? What has happened to doctors? Then I read this article where there is such evident bias about the two patients. One is blamed because she didn't have an education, didn't know the technicalities about what was going on, so that was the reason she received poor care. Blame the victim, a common psychological problem. I had to fill out my directives several times, because I didn't give the desired answers of wanting to cling to pain and life at any cost and indignity. I don't want a tube for over 3 days, I want to be doped out of my mind, etc If my life is in order, why do I want to be alert? I didn't think that alertness was part of hospice, I thought that hospice was for easing me and my family into my final days spent in this dimension. My sadness is that doctors bring their prejudices to the tumor boards, and every other part of cancer treatment. That they seem to think that all cancers are alike. I had a god awful oncologist at first. It took me 6 weeks of writing letters, Emails, calling, sitting in the waiting room to get another oncologist. I finally used the 'sue' word. At the end of the visit with my new oncologist, I was told that I wasn't anything like what he expected, because the first oncologist said that I was ignorant, peevish, etc. While doctors are human-- they should be like defense attorneys-and get the best deal they can for a patient from the tumor board, the hospice. Maybe part of this is not to write us off as someone that didn't have a directive, someone that doesn't know what's going on and doesn't understand things.
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  • amy challener
    dear doctor, to say I was appalled at your response is mildly put. I have read your articles for a long time, and turned my friends onto you, never expecting that your are part of the group, that by your opposition is keeping people in unbearable pain. You come on as such a caring, country doc. a marcus welby, and here you are deciding what law should effect our most important decision. our life, of which your are not living, or part of. strangers, religious fanatic's, are in charge, and although, mercy killing for dogs who are in pain are legal, Humans have not a right to make a decision for ourselves of loved one's. Yes a ninety year old man can be put in jail for helping his ailing, hopeless wife to end her misery. You are part of that group. Maybe you should be trying to try to implement laws preventing vets from putting dogs to sleep. I am very, very disappointed in your position and will pass it on. a past reader amy challener and family
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    • James Salwitz, MD
      I am very sorry to read your comment, although I understand your feelings. Having practiced oncology for 30 years and also "felt" the pain of 19 family members struck by the dread disease, I have seen much suffering. As you probably understand from reading both this piece, as well as others, I am deeply concerned and hurt by the suffering of my fellow man. Every single day I see patients that because of poor planning, thought and the absence of empathetic and skilled physician care, suffer needlessly. The experience in Oregon and other areas that have legalized physician assisted suicide is that less than 1 in 750 actually use that choice. On the other hand not a day does not go by in my life that the failure to give basic palliative care, allows unneeded suffering. My focus has to be on the 749 patients we are not reaching adequately. The medical profession must be held accountable and must be expected to give every person the chance to have high quality end-of-life care. Once again, I am saddened that I have disappointed you, yours is a view shared by most in our society, I simply believe there is so much more we must do in order to improve life. jcs
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      • Kathleen Denny
        I think everyone here would agree with you, Dr. S, that there is much, much more to be done to improve quality of life, especially with those who suffer in many different ways. That your focus is to help alleviate that suffering does you credit. That in no way serves as an argument against removing legal obstacles for those who wish to end their lives, though you seem to think it does. I was disappointed to see your column here republished in Kevin M.D., entirely unchanged by this outpouring from people close to severe illness and conditions, and without any reference to that. Though, at least when I looked, it seemed that many of the docs who replied did not share your view either. The grandfather of a friend recently decided to end his life after 97 years. He led a good life and had always been vigorous, intellectually powerful, but the love of his life had already died and he was no longer able to care for himself in basic ways. Faced with evidence that even his mental faculties were failing, he asked my friend and his wife to help him end his life quickly and easily. But to help him they would risk arrest and even imprisonment. So in the end he stopped eating and drinking. That's a long and painful way to go, though certain, and when his docs realized there was no way to dissuade him, they helped ease his suffering. But he was denied faster means that are available. I see no humane reason to place legal and physical obstacles before those who, for whatever reason, no longer want to live, or to endanger those who love them. And please, keep trying to improve people's lives. To the extent that health and medical care are a right, not a profit center, the better off we all will be.
        Reply

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