Euthanasia - On Terry Pratchett's 'Choosing to Die'

[animist]

Latest post of the previous page:

Animist,
You have slightly misunderstood the Liverpool care path way. It is not a pathway that gives permission to assist in someones death. It is a pathway implemented when someones condition is such that they are likely to die within the next few days. At this point crisis drugs are prescribed to relieve discomfort and pain usually given through a syringe driver. In this case the priority is symptom relief and in general some one will usually die from the condition that they have. On occassions the balance between symptom relief and side effects of certain drugs may steer someone towards death but this is only when the analgesic need dictates. It is in no way related to euthanasia
or assisted dying. In this case Tony Nicholson would have been a completely unsuitable candidate for LCP. The life threatening problems he had were reversible and thus not indicative really of palliative care or the LCP unless of course the co morbidities that might occur such as septicaemia from pressure sores ala Christopher Reeve caused irreversible damage likely to cause imminent death

OK, thanks. I knew of the practice but not the LCP label, and I did not know that patients were asked in advance. I suppose the practice is a form of "double action": since the ostensible and justifiable reason in giving heavy doses of painkillers is to ease pain rather than to kill, it cannot indeed be called voluntary euthansia or assisted suicide

[jaywhat]

I suppose the practice is a form of "double action": since the ostensible and justifiable reason in giving heavy doses of painkillers is to ease pain rather than to kill, it cannot indeed be called voluntary euthansia or assisted suicide

Yes this practice is many years old, without a name as far as I know. Large doses of painkillers do result in shortening life and many doctors have used this 'method' as a kindness; but it has always been hushed up and, in fact not known to many people including the patient or the relatives. It is the desire to have it in the open that is what is argued about in many cases.

[Alan C.]

jaywhat.
Yes this practice is many years old, without a name as far as I know.

Compassion?

Large doses of painkillers do result in shortening life and many doctors have used this 'method' as a kindness; but it has always been hushed up and, in fact not known to many people including the patient or the relatives.

My father in law and Mary' cousin were both helped on their way in that fashion, it was no secret to us and ethically the right thing to do.

Mary' mother suffered from severe senile dementia for 11 years, never leaving her bedroom in all that time, but because she lived with one of Mary' brothers (not bed blocking in hospital) she got no such help.

[Woody Duck]

In practice the recognition by Drs and nurses that analgesic drugs may cause respiratory failure in order to relieve intense pain is never hushed up. To not be transparent with patient or relatives would be just criminal and at best very bad practice. This is partly why we have the palliative care teams. To manage these decisions and loads with all teams and family and patients in order to maintain absolute transparency. End of life care is no dark, subversive art.

[Fia]

There is also a difference between what is required in a 'living will' (or 'Advanced directive') and euthanasia. The living will clearly contains intructions for one not to be resuscitated if certain conditions prevail. Euthansia is what we do to cats and dogs as well - we 'put them to death'.

I wrote this in June 2011 and should have made another and clear distinction between 'not to be resuscitated' and 'assisted suicide'. They are clearly different and IMO are both something which should be legal and readily available. 'Euthanasia' is a different ball game and the word itself scares the shit out of many people.

I agree jaywhat. Shades of Nazism. It's not a good cultural word. I'm sloppy with the term having been involved with EXIT in the 80s. Although in my mind I always prefix euthanasia with voluntary, a better term is probably assisted dying.

Personally I have made the conditions crystal and abundantly clear in my advance directive, even though, at present, it cannot be fulfilled.

I'd add that although we put cats and dogs to death I've lost count of the number of folk I've cared for who would wish that dignity upon themselves...

[Fia]

After all those with dementia are still capable of making decisions and putting forward their preferences.

early stage of course. But at end stage dementia? Where the only communication is behaviour? I don't think so. Which is another reason why living wills and talking to one's family is so important.

Mary' mother suffered from severe senile dementia for 11 years, never leaving her bedroom in all that time...

That's an awful situation Alan. I'd like to think it wouldn't happen now...

End of life care is no dark, subversive art.

Absolutely. Times have certainly changed, and I'm honoured to be part of a team who can provide a good dying. It's just not changed enough yet..

[Woody Duck]

Fia, perhaps I was a little too hasty with my choice of words. Of course I wasn't suggesting the ability to make decisions or communicate needs on the level of moat of us who do not suffer from dementia. What I am suggesting however is that someone with diminished functionality can still decide that they are not enjoying life and they can still decide that they no longer need to eat. I would go even further to say I believe that many people with severe dementia are able to think abstractly about their existential situation whether they are able to articulate it or not to themselves or to others.

I refer to one piece of research recently which considers the dynamic of communication using the three process procsss of the patient, close relative and their cater. Of course this has no bearing n someone asking for assisted suicide or euthanasia but it certainly would have a relevance to a patient who has become apathetic towards basic care and nutritional needs. I by no means wish to generalise and each person of course should be considered on their own needs.
I am also aware that you probably have a lot more experience than myself in this area so am happy to be corrected.

[Alan H]

In today's Telegraph: Doctors to launch investigation into Liverpool Care Pathway

Doctors are to investigate whether the controversial Liverpool Care Pathway, which is supposed to alleviate suffering, is actually being used to deliberately hasten death.

[Alan H]

This looked interesting:

The real truth about the Liverpool Care Pathway

October 27, 2012

There has been a lot of misguidedly adverse publicity about the use of the Liverpool Care Pathway in end-of-life care over the last couple of weeks, and the effect of this has certainly being felt at times where I work.

The BGS are one of a number of interested organisations to have signed a joint consensus statement that concisely outlines the benefits and appropriateness of this framework when used correctly. It also point to more detailed GMC guidance about the ethical issues to consider when providing end-of-life care, specifically with regards to clinically-assisted nutrition and hydration.

My position on the subject mirrors what is written in the consensus statement, so rather than re-invent what has already been expressed so thoughtfully, I’ll echo a quote used in the statement itself:

We support the appropriate use of the Liverpool Care Pathway and make clear that it is not in any way about ending life, but rather about supporting the delivery of excellent end of life care.

The Concensus Statement can be found here

The GMC Guidance can be found here
Written by: Mark Garside on October 27, 2012.

[Alan H]

There's been a lot in the media recently about the Liverpool Care Pathway, most of it completely wrong. Now we have a Government review: Government launches independent review into use of Liverpool Care Pathway

[Woody Duck]

I think such a review can only serve to educate the public more appropriately and enable health professionals to use the LCP more appropriately and openly with patients and their relatives. I personally have only ever seen the LCP used in full consent and understanding of the patient or their relatives but can understand how it occurs that some relatives are alarmed when they no longer see their loved one receiving food. The truth is that to give fluid when someone is in advanced renal failure is worse than denying them fluid and it is also recognised that hunger is often not a factor in patients at the end of life. This often gets lost in translation though when dealing with relatives who are desperate to see an improvement in their loved one.

[Fia]

The LCP is not used in the community here, I think it is mostly a nursing home protocol. A person in their last stages of life under my teams care are offered tasty morsels of favourite food and as much fluids as they wish. When all are refused we regularly swab the mouth with pineapple juice (something to do with enzymes, don't have the science to hand), ensure adequate pain relief, cleanliness and bed sore avoidance is provided, and listen if they talk. But TBH much of the care at this stage is with the family.

I can't imagine a community situation where the family are not fully aware that their loved one is dying. We have the deniers in clients and family right enough. Although we can't be direct -which sometimes I'd love to be- if there is time to ease all to acceptance then the process can be a loving, supportive, dignified and gentle one for all.

[lewist]

Maureen had LCP in her last days. It was how our little GP run hospital worked. I was told and I accepted the advice of the professionals that this was the way to go. It was made very clear to me when there were only days left.

I think LCP made things easier for the staff. They knew Maureen well and she received tender care throughout.

[Dave B]

Latest survey shows majority in favour of euthanasia.

[Alan H]

Latest survey shows majority in favour of euthanasia.

Careful! Words are important:

The survey found that a large majority (75%) of the British population think that legislation on euthanasia should be amended to allow some degree of assisted suicide. Just over two thirds (67%) think that doctors in particular should have the legal power to end the life of a terminally ill patient who has personally given a clear indication of wanting to die.

I would hope that no one would be in favour of euthanasia!

[Dave B]

Latest survey shows majority in favour of euthanasia.

Careful! Words are important:

The survey found that a large majority (75%) of the British population think that legislation on euthanasia should be amended to allow some degree of assisted suicide. Just over two thirds (67%) think that doctors in particular should have the legal power to end the life of a terminally ill patient who has personally given a clear indication of wanting to die.

I would hope that no one would be in favour of euthanasia!

Ooops

[Dave B]

I caught part of the Moral Maze this evening on assisted dying.

There are unusually some good discussions but this evening I wondered who picked the "witnesses". I don't think I have heard so many instances of the misuse of language to create, mostly negative, effect than in this program.

Some of the "jury" were not so great either, especially the "Christian humanist" who seemed to be anti-assisted dying (due to his "humanism"). Some much of the argument seemed to concentrate on nasty people pushing the patients into taking their lives, presumably for selfish or cynical reasons, rather than the morality and ethics of being allowed to decide, for oneself, that life had reached a point of personal unsustainability.

[animist]

I caught part of the Moral Maze this evening on assisted dying.

There are unusually some good discussions but this evening I wondered who picked the "witnesses". I don't think I have heard so many instances of the misuse of language to create, mostly negative, effect than in this program.

Some of the "jury" were not so great either, especially the "Christian humanist" who seemed to be anti-assisted dying (due to his "humanism"). Some much of the argument seemed to concentrate on nasty people pushing the patients into taking their lives, presumably for selfish or cynical reasons, rather than the morality and ethics of being allowed to decide, for oneself, that life had reached a point of personal unsustainability.

many Xians are humane people but I do find it annoying when people try to get the best of both worlds by calling themselves "Christian humanists" - another reason IMO for preferring "ethical atheism" to "humanism". Anyway, at this very moment I am watching a programme about a severely disabled woman who is the centre of an attempt to say "what is needed is support for living, not support for dying" - as though the two were incompatible - grrr!

[Dave B]

I caught part of the Moral Maze this evening on assisted dying.

There are unusually some good discussions but this evening I wondered who picked the "witnesses". I don't think I have heard so many instances of the misuse of language to create, mostly negative, effect than in this program.

Some of the "jury" were not so great either, especially the "Christian humanist" who seemed to be anti-assisted dying (due to his "humanism"). Some much of the argument seemed to concentrate on nasty people pushing the patients into taking their lives, presumably for selfish or cynical reasons, rather than the morality and ethics of being allowed to decide, for oneself, that life had reached a point of personal unsustainability.

many Xians are humane people but I do find it annoying when people try to get the best of both worlds by calling themselves "Christian humanists" - another reason IMO for preferring "ethical atheism" to "humanism". Anyway, at this very moment I am watching a programme about a severely disabled woman who is the centre of an attempt to say "what is needed is support for living, not support for dying" - as though the two were incompatible - grrr!

That was part of what I got from the Maze program, the lack of realisation that is there is no possible cure and no effective palliative treatment to relieve extreme pain or a deep set sense of help/worthlessness, if the patient genuinely wishes an end to torment, then prolonging life is a cruel thing.

I heard of some priest saying that god gave life and it is up to god to take it. Who is this shit-head god who likes to hold people in a start of incredible suffering before it decides the time is right? I could easily lose my humanism and wish that such pratts could suffer years of pain and helplessness themselves.

[Stosh]

Any person should be in control of what happens to their own body to the greatest extent a society can not only allow, but ensure as well.

Each of us would want this (even if that guardianship was something we wanted to be in the hands of someone we trusted to make a better decision than we would rather than ourselves, it should still be our own call to make.
Which one might prefer if they had various disorders etc..)

Folks make 'bad' choices for themselves all the time, if every 'bad' decision we made could be superceded - then we would have no rights left.

This same responsibility for ones welfare needs to remain with the individual rather than with folks who have interests of their own to take into account.
In situations of incapacity to make clear decisions for themselves, society would be acting with compassion , to assure the rights of an individual to end misery or to go out with dignity.

I do not feel that Doctors should be burdened with this directive, nor do I think that family members should. Both of those groups are far too embroiled with the patient,
nor should it go to a court decision which ensures delays and again is slave to the whims of the participants, rather than the rights of the individual in question.

There would need to be a institutional guardian to protect the right of a person to die, make sure there are no nefarious reasons for the request, affirm the compassionate need for the discontinuance, and actually conclude the issue.

I really wouldnt expect this to happen in my lifetime though, so Im just whistlin' dixie.

[Alan H]

We can all make our treatment wishes known through an Advanced Decision. This covers how we want to be treated when we become unable to make our wishes now. Properly done, this is a legally binding document (but you don't need a lawyer), but it can't demand that your life be ended.

There is the option currently - if we meet the criteria, are able and can afford it - travel to Dignitas in Switzerland and end our life there. The Bill currently before the House of Lords, introduced by Lord Falconer, would allow something similar to happen here, with many safeguards. There is a similar - but far from identical - Bill in Scotland Assisted Suicide Bill (Scotland). There are safeguards in both Bills to ensure it is not abused.

I do not feel that Doctors should be burdened with this directive, nor do I think that family members should. Both of those groups are far too embroiled with the patient, nor should it go to a court decision which ensures delays and again is slave to the whims of the participants, rather than the rights of the individual in question.

I don't see doctors as being embroiled at all: they may know the patient, but the signature of a completely different doctor could be sought. You're right about family members though, but I don't think anyone is suggesting they would have a say in any decision.

I think both Bills require the agreement of two doctors at different times with appropriate safeguards, so a court isn't currently being considered. However, courts already make decisions about safeguarding children, making them wards of court, deciding custody, etc as well as sometimes making life or death treatment decisions where people or hospitals can't agree. So, even if courts were involved, I can't see that there would necessarily be any specific issues with them making a decision, but remember that under current proposals, the person requesting assistance with suicide has to have clearly made their wished known before hand.

You might be interested in Friends at the End, Dignity in Dying or Compassion in Dying.