Terminal sedation not an answer

Hey there, time traveller!
This article was published 02/03/2015 (3882 days ago), so information in it may no longer be current.

In Dying badly in Canada (Feb. 24), my respected colleague, Dr. Harvey Chochinov, expressed dismay in response to the Supreme Court’s overturning the prohibition of doctor-assisted suicide. I welcome the court’s decision. His concern is the need for more support for palliative care. Firstly, palliative care, as helpful as it can be for a dying person, does not respond to the full range of dying badly. Secondly, we should think through what we mean by “need.”

Chochinov says palliative care is not available for 70 to 80 per cent of Canadians. In fact, palliative care is not relevant for many deaths. There are sudden deaths. There are deaths in the course of “a courageous battle against…” many different diseases. Acceptance that a person is in the process of dying (with palliative care as the choice approach to treatment) is not the front-running choice or recommendation when a person is faced with serious illness. Finally, palliative care, like any other form of help, is not always effective. Pain is not always relieved. Loss of energy and of independence are irretrievable losses. Depression does not always respond to drugs or counseling or spiritual solace.

Once I carefully reviewed the outcome of the service we were providing. (In palliative care, unlike other health care services, death is not an outcome; reduction of dying badly is the objective). The results were very satisfactory on the whole. However, I came to realize that my enthusiasm for what we were achieving and my hope and expectation with each new patient and family were blinding me to the failures.

An alternative, when the usual palliative approaches fail, is palliative sedation, sometimes called terminal sedation (drug induced coma using doses which do not kill). One of my patients, when offered palliative sedation, said, “You mean I’d be there, but I wouldn’t be there.” Then, after a moment’s thought, said, “No.” When used, palliative sedation puts the dying individual out of distress but it can feel terrible for the family, “living with a corpse.” Palliative sedation avoids illegal assisting of suicide but it doesn’t always avoid dying badly. In my eyes, palliative sedation is a failure of care; palliative care typically offers living until natural death. Is coma living?

A personal friend was dying while receiving excellent palliative care, but he wished for death. He was comfortable. He had strong social supports. Looking back, he saw his life as fulfilled. His goodbyes had been spoken. His personal affairs were in order. His wish for death was the only “unfinished business” he still had. Life was a black hole, forced to wait impatiently, hoping for completion. A fundamental theme of palliative care is that death is part of life; the means exist to comfortably enable completion. I feel reinforced by a report from Oregon, where assisted suicide/dying is legal, that the majority of suicides were completed because the dying person did not want an empty life to drag on pointlessly.

When there is reference to a need for palliative care, does it mean that more palliative care is a pressing service issue? The media often report the public cry for more family doctors, ambulances, reduced waiting in emergency departments, rapid access for diagnostic tests, shorter waits for specialist consultation etc. How often is palliative care a headline need? When a need for palliative is identified it seems to be voiced by promoters of palliative care (including me). Are we really recommending what we see as a sometimes more appropriate response to life-threatening illness than our culture’s fight to the death, never-give-up, reaction?

Let me take this opportunity to insert a word about the doctor’s role. Suicide is already a non-criminal act. However, the readily available means are quite ugly: bullet, knife, drowning, jumping… my imagination abhors going on. The means of gently hastening death, that is, with drugs, all need medical prescription and are very closely controlled.

To change that system would require even more changes to our laws, beyond laying down a process for doctor-assisted suicide.

I spent 15 very rewarding years as a palliative care doctor, rewarding, but within limits. Hastening death will be legal in Canada. There will be an additional option for avoiding dying badly. It is now up to our country to legislate a compassionate and safe process.

Dear reader, we both find ourselves tangled in words; assisted suicide, assisted dying, hastened dying etc. None of these terms suit everyone. When new laws are established there will be one term; it will still not suit everyone, but it will be standardized by law. That part of the heated discussion will be put to rest.

Requiat in pace.

 

Dr. Paul Henteleff is first medical director of palliative care at St. Boniface General Hospital. He is the founding president Canadian Hospice Palliative Care Association.