Medical Ethics Musings: On Caring

April 12, 2010 • Posted in End of Life

By R. Henry Williams, M.D., M.A.
Tennessee CBC
Board of Directors

Photo:  “Time of Life” by L. Ian Riley

Recently an elderly, long-time patient was brought to my office by his two daughters, who were upset after a visit with his oncologist.  His multiple myeloma and general condition were such that chemotherapy was no longer being recommended.  The oncologist had suggested that they consider hospice care.  The daughters were shocked.  From their perspective, Dad was not in a state of obvious decline, and he was not in any pain.  They expressed to me a feeling of abandonment, and they were turning to me, his primary care physician, for guidance.

End-of-life care is a delicate thing, fraught with cultural underpinnings that sometimes strike fear in patients and their families.  Dr. Timothy Quill underscored this fact recently in the New England Journal of Medicine, commenting that “legalization of physician-assisted suicide has resulted in more open conversation and careful evaluation of end-of-life care.”  Quill attempts to reassure us that there is no “slippery slope” in this matter, even in the Netherlands, where a 2005 study showed a small decrease in the number of cases of euthanasia and physician-assisted suicide since legalization.  However, there has been an increase in a procedure called terminal sedation.  In this the intent of the physician is supposedly to relieve intractable pain and other symptoms, but not to cause death.  One might wonder if it is really procedures that are changing, or just terminology.

The hospice movement is a good thing.  If anything is lessening the inclination to use euthanasia or physician-assisted suicide, it is the growth of hospice and what it has taught us about pain management, dying in the context of home and family, and palliative care in general.  Yet it is also disturbing that part of what has driven the ascendancy of hospice and palliative care is the legalization of euthanasia in the Netherlands and of physician-assisted suicide in Oregon.  Now, state after state is considering similar legislation (recently defeated after intense debate in Vermont, soon to be on the ballot in California).  How should we engage this debate, in which life-ending tactics are being pursued aggressively by their advocates?  Will the principle be upheld that each life is sacred, and that we should not be in the business of taking life?
As I ponder these concerns, I am sensitive that my patient and his family need special attention in regard to his care now.  Hospice may eventually be of great benefit to him.  Right now a transition period seems appropriate, in which we work harder than ever to care for the patient, not just the disease.  What he and his family need most is that the caregivers who know them best ensure that he will be cared for and comforted, not abandoned.