Abstract
Because I am a physician practicing in Oregon and specializing in end-of-life care, I am periodically asked “Have you helped patients die?” I know what the question really means. I know that I am being asked if I have hastened a patient's death through the Oregon Death with Dignity Act, if I have prescribed a lethal dose of medication with the understanding that my terminally ill patient could use it to end their life, legal in Oregon since 1997. In times past, I might have evaded giving a specific answer, worried about stigma and controversy. But lately, I have been responding with a simple “yes.” The law has become such an accepted part of the landscape here that I no longer worry about judgment. It is akin to disclosing that I smoke marijuana once in a while, recreationally, legal in Oregon since 2015. That news has lost its power to startle.
Many of my colleagues make the justifiable decision to not participate in the Oregon Death with Dignity Act. Their personal ethical beliefs will not allow them to intentionally hasten a patient's death. What is not justifiable are the misguided aggressive medical interventions that often paradoxically hasten death when misapplied to the terminally ill. Equally problematic are the myriad other ways doctors fail to “help” their dying patients, with errors of commission and omission, such as failing to refer patients for hospice care until the last days of life. We know that hospice care, contrary to common prejudice, often prolongs life, rather than hastens death.
I recently cared for an elderly man, who I will call Walter, whose treatment at a neighboring hospital epitomized these myriad failings and the potential for paradoxical hastening of death.
Walter had been admitted with shortness of breath. His doctors diagnosed congestive heart failure, new-onset atrial fibrillation and advanced valvular heart disease. They implemented an aggressive course of treatment, a complex regimen of diuretics, lisinopril inhibitors, digoxin, and warfarin, all in concordance with published guidelines. I imagine his doctors expected their treatment would benefit Walter, although their discharge instructions included this caveat: “If this doesn't work, then probably you should call hospice, because then there will be nothing else to do and we can't help you here.”
Walter was discharged home only 48 hours after admission. A few nights later, Walter experienced a precipitous decline, suffering severe respiratory distress. He became agitated and confused. Walter's family had no idea what to do. There was no one to call. No hospice team was in place to come to the house. So they drove Walter some distance across town to my hospital, having been told quite clearly that their local hospital could not help them.
When I saw Walter in the emergency room he appeared cadaveric, mottled and gray, gasping for breath, pulse thready, heart beating fast, and erratically. I set about helping Walter die peacefully, providing him with the death with dignity he deserved. I administered morphine injections, which eased his respiratory distress. This took some stress off his heart, which further eased his breathing, taking further stress of his heart, creating a progressively virtuous cycle. I administered an injection of metoprolol to slow his rapid heart rate, and a judicious amount of intravenous fluids to counter the acute kidney injury and iatrogenic dehydration caused by the ACE and overaggressive diuresis. I administered vitamin K to reverse his dangerously overanticoagulated blood.
His heart regained a fragile equilibrium. By the next day, when I came to the bedside, Walter was rosy cheeked and smiling broadly, entertaining his grandchildren.
I recognized that this was a temporary victory. I knew that his underlying heart condition would not improve. I convened a family meeting. I shared my belief that Walter was at the end of his life, that in all likelihood his survival was measured in weeks. I advised that any further treatment should be directed at Walter's comfort, that attempts to prolong his life might only increase his suffering, and even shorten his life, as almost happened the previous evening. All present agreed, and expressed gratitude for the compassionate care provided.
I did not discharge Walter for another couple of days, so that his family could properly prepare his home, and their lives, for this last chapter of his life. The delay also gave the hospice team a chance to mobilize their support. The only medication I prescribed was morphine, to be given when needed for pain and respiratory distress, and some low-dose metoprolol to prevent symptomatic excessive ventricular rate from his atrial fibrillation.
The hospice team was there to greet them when he arrived home, and provided wise counsel as to what they could expect in the days to come. Two weeks later Walter had another sudden bout of respiratory distress. The hospice nurse was summoned to the house and arrived promptly. The nurse helped administer morphine under Walter's tongue. His symptoms eased. This time, however, he did not regain his rosy cheeks. This time the heart's fragile equilibrium would not be regained. He died peacefully, several hours later, grandchildren at his bedside. The family again expressed gratitude for the compassionate care provided.
The hospice team and I “helped” Walter die. We provided Walter the “death with dignity” he deserved.
It is time to reclaim those words, “death with dignity,” “helping a patient die” from the fraught realm of politics and ethical controversy. That other thing, the prescribing of a lethal dose of medication for terminally ill patients to self-administer at a time of their choosing as a means of controlling the ultimate moment of dying, that thing deserves a complex ongoing public debate, not a battle of sound bites. That controversy should not carry the price of poisoning those words that best describe what we in end-of-life care accomplish for our patients every day.