TREATING TERMINAL PATIENTS an end of year thought

Here is a thoughtful article about dealing the the terminally ill person who is dealing with increasing levels of pain. It is not always as clear what is proper and acceptable pain management. Fr. Ernesto gives those faced with this decision a clear and Christian answer,

There is a tough subject that has been being debated in American medical circles for well over a decade. That subject is palliative sedation for, “a patient who is suffering from a terminal illness and who is experiencing great pain. . . .” The wording is from a 1997 Supreme Court decision. The American Academy of Hospice and Palliative Medicine has endorsed the practice as has the American Medical Association in 2008. The reason this is a tough subject is that it slops over into the area of euthanasia, according to some. And, I used the words “slops over” deliberately because it is a sloppy subject. You see, this is again one of those subjects in which our medical knowledge is insufficient to fully answer all the questions. This, therefore, immediately gives an opening for those seeking to cause political harm to put an oar in and stir vigorously.

Let me first state that there is no major Christian body, of which I know, that is against palliative care for those suffering and in pain. The problem is that as the pain grows greater and greater, the dosages of the drugs given that have to be given grows greater and greater. And, with a greater dosage comes a greater risk that the patient will die. So, it is one thing for you to take one aspirin when you have a headache, but too many aspirins may cause you to bleed spontaneously and maybe even die (aspirin overdose). Now, that is a silly example, but it gives you an idea of the problem. This greater risk that a patient will die is why you sometimes see patients in pain in the hospital and the nurse telling them that it is not time for their next dosage yet. Because of the risk posed by some anti-pain medication, patients are often kept on the minimal dose necessary to keep them comfortable, even if not completely out of pain.  In addition, there is the danger of addiction with some drugs, so they are used sparingly. I will comment that there are many patient advocates who will argue that physicians are too conservative in their pain management and are allowing their patients to suffer unnecessary pain because of the fear of lawsuits and the refusal of insurance companies to reimburse adequately. Now, to this point there is no conflict with the morality of any major Christian group.

Where does the ticklish situation come in? It comes in when two conditions are present: the patient is in great gut-wrenching pain and the patient is terminal. You see, when a patient is in great gut-wrenching pain but NOT terminal, we sometimes knock them out. That is what is called a “medically induced coma.” No major Christian group has a problem with this type of treatment since the purpose is to keep the patient from further damaging himself/herself while the healing process continues. Medically induced partial paralysis is common for people on a ventilator so that they will not gag the tube out, etc. These types of treatments are seen as morally acceptable despite the fact that a rare few never come out of the coma and despite the danger that the drugs used may cause some harm or addiction. Why are they morally acceptable treatments? Because the rate of survival and mental health ratings for patients receiving such treatments is greater than the rate of survival for patients who do not.

But, what happens when a patient is terminal AND in great gut-wrenching pain? Well, if you sedate them strongly, they may go to sleep and may never fully awake before they die.  Sometimes the dose required for severe pain is so strong that it puts them somewhat out of it or fully asleep. And, because their systems are shutting down and debilitated, you run the risk that you may shorten their life by a couple of days. And here are where the arguments come in. Ethically, should you dose someone so highly that they may not be able to be “awake” during their final day or so? How “awake” does a patient need to be in order for the family to feel that they have truly communicated with their dying relative, even if that means that their relative is kept in a state of great pain? Please note that no one is saying that any lives should be ended. No one is even trying to shorten any lives. Among physicians and hospice workers themselves there are arguments over these issues. The issue is how does one balance patient comfort in their final days with the desire of family to spend as much quality time as they can with their dying relative. There is no easy answer.

Nevertheless, some anti-euthanasia people have argued that giving high enough doses of pain management drugs that the patient sleeps through most of their final couple of days is itself a form of euthanasia. That is, the argument has slopped over from active killing into even aggressive pain management. One of the strong modern arguments against euthanasia has been the capability of modern medicine to manage pain. However, it appears that some anti-euthanasia people are trying to move the goal posts to argue that even too much pain management is a form of euthanasia. The problem is that they do not and cannot define what is too much pain management. Even physicians and hospice workers themselves are still trying to work out appropriate pain management protocols that balance out patient comfort with family needs. Many argue that a patient’s comfort is of higher importance than family needs; many argue the reverse. Let me repeat NO ONE is arguing for shortening the patient’s life.

I said at the beginning that this uncertainty about pain management had given the opportunity for some to cause political mayhem. Because of the uncertainty, one of the ways to decide how much to sedate, etc., is in consultation with both the patient and the family. This is often accomplished by a multi-disciplinary team that includes the patient’s physician, a pain-management physician-specialist, a social worker, a hospice worker, etc., in consultation with the patient and the family. The process is sloppy because human beings are sloppy. However, the question is, “who pays for this team consultation process?” The proposed healthcare legislation put in regulations that officially defined the panels so that even private insurance companies would be forced to reimburse for those reviews.

Or, at least, that was until the political fighters stepped in. This type of panel was labeled a “death panel” by the anti-healthcare folk. There was a deliberate and forced twisting of the purpose of these panels into an euthanasia mold, something which goes against the very purpose of the panel. Seeking to cause political harm, they stirred up people into thinking that the government was going to OK killing them in their old age. And, that has never been the case. In fact, to this day, no major Christian denomination has condemned the use of palliative sedation for a terminal patient or the use of a consultation panel to help determine the correct course of patient treatment. And the reason they have not is that every time that the subject is investigated, the Christian denomination finds out that they really do want palliative sedation when they are dying and they really do want multiple people, and themselves, and their relatives consulted about their care at the time of the end of their life. For those of you who are still claiming death panels, you might want to re-read the previous statement. No major Christian denomination has condemned the use of palliative sedation for a terminal patient, particularly when it is in consultation with other healthcare workers and with the family.

Someday you will face your end, unless the Lord returns first. Some of you will die from a disease that will be slow and cause you great pain. Someday you may be the one lying there in great pain. I trust that at that time, you will have available to you the palliative drugs necessary for you to finish out your life in comfort, even if sedated. I hope that there will be people (plural) consulting with you and your family so that you may have some time to say goodbye, even if somewhat sedated. I hope that the insurance company will reimburse you and your family for such consultation. If they will not reimburse, then I hope that ethical healthcare workers will do the right thing by you anyway. That is the most moral approach that I can wish for you.

About Fr. Orthohippo

The blog of a retired Anglican priest (MSJ), his musings, journey, humor, wonderment, and comments on today's scene.
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