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Euthanasia – quiet and easy death

13 Jun

Euthanasia – quiet and easy death

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As many people now know I am partially retired, which for me means I spend half time in London as a GP and the second half enjoying life in the country and following various pursuits.
This why you may find blogs referring to time out of London and in the countryside !!
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/> Yesterday, I was busy gardening surrounded by trees in full leaf,flowers bursting into bloom and my broad beans awaiting harvest. The scent of freshly mown grass and the aroma of surrounding herbs with the steady hum drum sound of a nearby tractor confirmed the arrival of summer. The weather was perfect, the sky a glorious blue, the sun blazing brilliantly, the Golden Oriole singing gracefully as he leapt from tree to tree accompanied by two turtle doves squawking noisily whilst they chased each other playfully. This was amidst a chorus of feathered creatures chatting as the distant sound of the Cuckoo was beginning to change it’s tune before flying south. I felt that I was the nearest I could ever be to Paradise.!
Then the phone rang asking if I could come to lunch, which initially I thought was a good idea until my dear friend said ‘by the way we are having an informal discussion on ‘Euthanasia’ and wondered if you could come along to give a more informed opinion.
When I was working full-time there was very little time to think deeply about such issues and now I was amongst people who felt this is something important to discuss as they were all in retirement and needing to think about end of life. What a day to choose!
” It will only be for about an hour and it will be good to see you……..” I soon found myself driving through beautiful countryside past barley fields swaying in the gentle breeze as if dancing to a Strauss Viennese Waltz and the unmistakable russet coloured leaves of the walnut trees standing alone or in a grove bearing perhaps the healthiest nut in the World. The road followed several hamlets of stone terracotta roofed houses and wooded glades and finally I arrived at my destination .
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In the quiet dining room about a dozen people gathered to discuss this topic – all post retirement and having experienced death an suffering of a near relative(s) and several had emailed their views to be shared.
It was also announced on the day of this discussion that “The French Government are in the throes of tabling a draft legislation on euthanasia or as they want to refer it as ‘assisted death’. ” so a very topical subject.
An older gentleman, a retired naval officer opened the discussion by defining Euthanasia as a deliberate intervention specifically intended to end a person’s life for the purpose of relieving distress.
And went on to elaborate by referring to a reputable Ethics book (1)
Euthanasia can be classified in different ways, including:
active euthanasia – where a person deliberately intervenes to end someone’s life, for example, by injecting them with sedatives
passive euthanasia – where a person causes death by withholding or withdrawing treatment that is necessary to maintain life, such as withholding antibiotics in someone with pneumonia
Euthanasia can also be classified as:
voluntary euthanasia – where a person makes a conscious decision to die and asks for help to do this
non-voluntary euthanasia – where a person is unable to give their consent (for example, because they are in a coma or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances
involuntary euthanasia – where a person is killed against their expressed wishes
Depending on the circumstances, voluntary and non-voluntary euthanasia could be regarded as either voluntary manslaughter (where someone kills another person but circumstances can partly justify their actions) or murder.
Involuntary euthanasia is almost always regarded as murder.
He reminded us that both euthanasia and assisted suicide are illegal under English and French law.
Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by law with a maximum penalty of up to life imprisonment.
Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years’ imprisonment. Attempting to commit suicide is not a criminal act in itself.
However, Active euthanasia is currently legal in Belgium, Holland and Luxembourg. Under the laws in these countries, a person’s life may be deliberately ended by their doctor or other healthcare professional.
The person is usually given an overdose of muscle relaxants or sedatives. This causes a coma and then death.
However, euthanasia is only legal:
*if that person has made an active and voluntary request to end their life, and
*it is thought they have sufficient mental capacity to make an informed decision regarding their care, and
*it is agreed that the person is suffering unbearably and there is no prospect for an improvement in their condition
*Capacity is the ability to use and understand information to make a decision.

In some countries the law is less clear, and some forms of assisted suicide and passive euthanasia are legal but active euthanasia is illegal.
For example, some types of assisted suicide and passive euthanasia are legal in Switzerland, Germany, Mexico and the American state of Oregon.

During the discussion aswell as reading on the subject it appears that there is widespread revulsion at the medicalisation of death and there is a growing fear of long,lingering death . Attempts are made to keep people with irreparable bodies alive by ‘high-tech’ machinery and radical medical treatment when there is no reasonable expectation of returning to normal life for what remains of the ‘person’
The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 80% of the public said they wanted the law changed to give terminally ill patients the right to die with a doctor’s help.
However, this is where the disease is incurable and the person concerned is in coma or on a life support machine or there is significant intractable pain and suffering but at the other end of the spectrum where someone is not ill or close to death but -for example maybe extreme lonely and no longer enjoys life the pro-euthanasia is 12%.
Nowadays, experience of death has changed and suffering is not considered part of human life and expectations are such that there is a demand for a swift and painless, tidily controlled death. Many people desire to keep control and dread losing it. Although despite the Hospice movement and greater expertise in dealing with palliative care there are still those who resist a move towards dependency and loss of self-determination.
All major religions spring from a deep sense of the sanctity of life. It is believed that human life is a very great gift from God ,to be revered ,cherished,and protected from beginning to end .To destroy life is to dishonour the Giver of Life.
But conversely pro euthanasia groups feel that people have an explicit right to die.
A separate right to die is not necessary, because our other human rights imply the right to die.
Death is a private matter and if there is no harm to others, the state and other people have no right to interfere (a libertarian argument)
Practical arguments It is possible to regulate euthanasia-
Allowing people to die may free up scarce health resources (this is a possible argument, but no authority has seriously proposed it)
Euthanasia happens anyway (a utilitarian or consequentialist argument)
Philosophical arguments
Euthanasia satisfies the criterion that moral rules must be universal
Regulating euthanasia
Those in favour of euthanasia think that there is no reason why euthanasia can’t be controlled by proper regulation, but they acknowledge that some problems will remain.
For example, it will be difficult to deal with people who want to implement euthanasia for selfish reasons or pressurise vulnerable patients into dying.
This is little different from the position with any crime. The law prohibits theft, but that doesn’t stop bad people stealing things.
The group were not so concerned about whether they agreed with euthanasia it was more their concerns about how it was done and the act is open to abuse.
Unfortunately, the murder trial of Dr Harold Shipman,who by all accounts was a charming doctor has drawn attention to the enormity of trust which patients have held in their doctors for thousands of years.
As doctors we all take the Hippocratic Oath (2) albeit usually the modern version and this is quite clear what direction we must follow and often people are unaware of our formal commitment.
A 12th Century Byzantine Manuscript of the Oath

    " I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them " Hippocratic Oath


” I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them “
Hippocratic Oath

Hippocratic Oath-classic version-
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
-modern version
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
A guide to the Hippocratic Oath
By Dr Daniel Sokol Medical ethicist
http://news.bbc.co.uk/1/hi/7654432.stm

This Oath sworn when we pass the threshold into the medical profession covers every aspect of our work and is a constant challenge as society makes demands.
I have also been aware of of times when patients have taken to hospital , languished and died on trolleys in corridors. We have all been horrified by the avoidable deaths that have been in the news especially those reported at the Mid – Staffordshire NHS trust.
This inevitably stirs up a desire to have control over end of life to avoid neglect.
The NHS is moving towards more accountability and GP’s are piloting ways of actively working with patients and their families by advanced planning to have wishes and actions on record so that there is some broad outline of how end of life is to be managed.
The concerns of the Liverpool Care Pathway was raised I feel that this it would be useful to explain what this is and how it came about:-

The Liverpool Care Pathway (LCP)
LCP, developed by the RoyalLiver­pool University Hospital and The Marie Curie Hospice in Liverpool, grew out of the hospice movement in the 1990s.
The aim was to spread good, skilled care in the last few days and hours of a patient’s life into other healthcare settings, such as hospitals and care homes, where there was evidence to suggest end-of-life care was poor.
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It had been noted that as a patient was noted to be terminally ill and active intervention was scaled down the end of life care was left to junior doctors and nursing assistants. I clearly recall this when I was a junior doctor and I remember how some of these dying patients took me underwing to tell me what it was like to be dying and what they wanted and I shall be ever grateful to them but this is not an appropriate way to learn: we had to ‘learn on the hoof’
It was often found that symptoms were inadequately controlled, oral hygiene often neglected, thirst remained unquenched and psychosocial needs were ignored.
Looking after a dying patient is challenging. To do it well involves confronting human mortality and accepting death as a normal part of life and therefore is an important part of medical care (which cannot always be curative).
Complicated factors are at play, including the existential worries many of us have about death, a sense of failure (and, increasingly, fears of litigation for not doing enough), and the unhappiness we anticipate among those left behind.
The benefits of the LCP soon became apparent because it offered a simple framework tool that even the least experienced could follow to institute consistent care.
In the hectic, understaffed modern medical world, the LCP ensures the patient is never left for too long. Continuing assessments in four domains (physical, psychological, social and
spiritual) every two hours mean symptoms are regularly considered.
The LCP also provides a scheme for drugs to manage problems such as pain or terminal agitation. Unnecessary drugs can be stopped, but there is no hard and fast rule – the LCP is best used in an advisory, rather than a didactic, way and any treatments deemed
of value can continue to be given. The focus is on comfort and symptom control.

The LCP was clear from the start that it is not an active step to end life.

Although people die after an average of 29 hours on the pathway, the door is never closed to further intervention, and as a result of regular assessment, some patients are taken off the LCP because they improve. (The small number of patients I have seen taken off the LCP have all gone on to die within a few days.)

Hence, in practise a patient is put on the LCP if it is deemed that they seem to have only 48hours to live but if they survive they are taken off it and observed and may be put back on if appropriate but this is all done under close supervision with advise and input from senior staff. It appears that the problem arises when communication fails and the professionals consider a patient having 48hrs to live without a concluding test just simply by experience and the attending relatives don’t understand the patient is dying. Hence, it is very important to communicate with relatives and address their views and concerns. In my experience I have had to hold many a family conference at all times of day and night and it is only when all grievances ,worries and fears are addressed that the end of life can be effectively managed.

Another, big anxiety that people have was that euthanasia would be open to abuse especially from relatives and it is therefore not surprising that The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 45% supported giving patients with non-terminal illnesses the option of euthanasia. “A majority” was opposed to relatives being involved in a patient’s death.

Lack of oral intake is one of the things that particularly disturbs families and this was raised in discussion. The need for fluid is such a basic human drive that even medical staff tend to feel troubled when someone has not taken fluid for days, and better guidance is needed regarding assisted hydration and the use of other interventions.
Research confirms my own experience that at the end of life, people may survive for many days without fluids and without significant discomfort, but this fact is little appreciated.
A survey of patients in Oregon hospice programmes found that as many as 15% of those who chose to discontinue food and fluids survived for more than two weeks, but reported high degree of peace and comfort..
I explained to the group who were not aware of how many doctors work with a palliative care team who holistically look at the circumstances and management of the end of life and that this is not just for cancer but can be any end of life illness including end-stage dementia, heart,kidney, liver failure end -stage neurological conditions including strokes, multiple sclerosis and motor neurone disease and many other diseases at any age. This challenging work is for the most part done by very dedicated health professionals based at local Hospices and who work with GP’s. I have witnessed many deaths which have been ‘quiet and peaceful’ but not involving deliberate actions. All GP’s in England have a Palliative Care register and we are contracted to discuss these patients holistically every 3 months and more often if appropriate .
At present in Britain, the Hospice approach, with its sensitivity to the many dimensions of human distress is gaining ground in all areas of health care so that euthanasia is not gaining further momentum. (3)Cicely Saunders, by inspiring world-wide enthusiasm for hospice philosophy ,has done more than any single individual to provide a positive alternative to euthanasia.
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http://www.meadowhousehospice.org.uk/faq.php
The group generally felt that what they wanted was a quiet and peaceful death in the lines of palliative care and if possible to be part of the process but were not in agreement to support active/deliberate terminal intervention. Even though it seemed not the right day to discuss the end of life perhaps someone in that group felt better informed and less fearful about dying.

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References
(1)Grove Ethics Series ‘Euthanasia’ – a Good Death ? by Margaret Whipp (consultant in Palliative Medicinse and Director of hospice ServicesHartlepool & East Durham)
(2)http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html
(3)http://en.wikipedia.org/wiki/Cicely_Saunders

Posted by Dr Bayer

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