|
IN YOUR PRIME
Dear Dad,
Of course I'm flattered, and honored, that you'd turn to me for help and support. Let's
hope, first off, that you never need this sort of assistance. I'd much rather lend you a
helping hand with your computer!
As you know, I am no stranger to these matters of life and death, as well as the
beguiling states which exist in between --such as persistent vegetative state. Early on in
my career, as a physician-in-training, I was blessed with some wonderful teachers of both
the science and the art of medicine.
The many months I spent in the Intensive Care Unit at University Hospital in
Jacksonville, FL were seasoned by the wisdom of two truly wonderful teachers,
Drs. Katherine Koch and Henry Rodefer. It was 15 years ago, but I remember much of it like
it was yesterday.
One of the things I learned early on, which has helped me ever since, is to know precisely
what the obligation of the physician is. After all, often the cases are heart-wrenching:
young adults struck down in their prime; confused love ones struggling with life and
death decisions.
Ultimately though, the physician's role comes down to this: to assist the family in
ascertaining what the patient would have wanted under the current circumstances. If the
patient could still express their wishes, what would they say? There were times when I
could literally see the weight rise up off of a confused and frightened family member's
shoulders when I explained to them, that this was now our goal. They didn't need to
make this decision, nor did I.
I have always felt strongly that this was the physician's --and the family's--
responsibility. And that to move beyond this represents a false omniscience, a hubris of
the highest order.
And so, in 1990, when the United States Supreme Court ruled that a family could not
withhold the tube "feedings" of their daughter and allow her to pass away peacefully, as
nature had clearly intended and as she herself would have wanted, I could not remain
silent.
I wrote an opinion piece, When The Courts Play God,
(similar to this only better written!) which was published in The Miami
Herald.
That woman was Nancy Cruzan. Her case and the case of Terry Schiavo are extremely
similar. Both involve young women cruelly robbed of their sentience, rendered into a persistent vegetative state.
Both involve loving family members who sought and who seek to do what they believe
their loved one would have wanted under these extraordinary circumstances.
(There is the extra twist in the Schiavo case, of course, of a husband and Terry Schiavo's
parents who disagree. However, absent any malice, it is the position of the husband that
this is what his wife would have wanted. The parents do not take issue with this, but cite
instead the belief that she can still somehow recover, despite a unanimity of medical
opinion to the contrary.)
Enter the meddling politician.
What is right? What is wrong? Irrelevant! The only thing that matters is what Terry
Schiavo would have wanted. But one by one, Florida legislators and finally the governor
took their turn usurping the will of Terry Schiavo.
Frequently, as did our governor, they sought to play what they thought was their trump
card, that to remove Terry Schiavo's feeding tube was to "starve her to death." That
made for good sound bites; and I'm sure they all hoped for a small bump in their pole
numbers.
Had any of these people actually taken care of critically ill patients at any point in their
lives, perhaps they would have been better informed.
For instance, the AMA council on ethics has previously ruled, and most ethicists concur,
that to surgically implant a feeding tube in a patient's gastrointestinal tract for the
purpose of nutrition, is morally and ethically not significantly different from placing a
breathing tube in their trachea (windpipe) and placing the patient on a ventilator
(breathing machine).
But where tube feedings look innocuous (who hasn't seen an IV pole and fluid on
television?), the breathing machine has the look of drama. While few would
argue that the latter involves "heroic measures," tube feedings don't generate the same
sort of emotional response, and are therefore thought of in different terms.
But what really is the difference? The patient on the ventilator is unable to draw air into
his lungs and extract life. The patient (in persistent vegetative state) on tube feedings is
unable to sip water or take pureed food from a teaspoon placed at their lips
--basic sustenance. To approach
the care of these patients differently is ethically inconsistent.
But would any of these politicians, masquerading as medical ethicists, have been making
the same claims if Terry Schiavo were on a ventilator? Probably not.
The other medical issue worthy of note in these cases is this idea of
"starving to death." End of life
studies that focus on quality and comfort, have shown that patients who are allowed to
pass away without an intravenous line (and are therefore allowed to become dehydrated),
appear to experience less discomfort than those who receive this "palliative" treatment.
In other words, the discomfort brought about by the IV outweighs any comfort which
might have been brought about by the hydration. Thus, dehydration does not appear to
adversely affect the quality of the process of dying. (In fact, it could be argued that the
physiology of dehydration actually creates a sort of natural anesthesia.)
While the sound bites may have played well, the simple truth is that if Terry Schiavo's
surgically implanted tube is removed from her stomach, she will not die of "starvation,"
but will instead pass away from dehydration.
It would have been nice if the men who decided to make this most personal of decisions
for this woman had availed themselves of some basic facts, but it still would have been
irrelevant.
For while it is easy to get sucked into an existential debate over questions such as "is a
person with no cortical function truly alive?" or "when does life begin - or end" or even,
"what is life?" These are not appropriate questions for this setting, nor do they help us in
deciding the correct --the moral-- course of action. There is only one relevant question
that brings us closer to that: what would Terry Schiavo have wanted?
The man she chose to spend the rest of her life with, the man with whom she fell asleep at
night, believes he knows.
Unfortunately for Terry, and for all of us, it appears that politicians, attorneys, and courts
of law feel as if they can invade our bodies against our wishes --unless those wishes have
been committed to paper.
One last thing that the Cruzan and Schiavo cases hold in common: neither would have
come about had either completed a Living Will.
So Dad, of course, you know I'll be there for you. But do your son --and your attorney
daughter-- a favor: mail us a copy of your living will. Not that we don't enjoy reading
your In Your Prime column every week! And here I'll certainly defer to "The
Counselor," but I don't think it would stand as a legal document. Hey, as you well know,
these politicians can do some pretty good spin!
Finally, on a serious note, I include one last piece of practical advice. Many states,
including my home state of Florida, have laws that dictate to their Emergency Medical
Services when resuscitation efforts may and may not be withheld. Bottom line: there
may well be a form --in addition to a Living Will-- which you need to have completed
and readily available in order to show Fire Rescue, so that they feel comfortable not
beginning "heroic measures."
Make sure you have multiple copies of your Living Will, and this additional document, in
the possession of both your physician and your attorney, as well as your family
members and loved ones.
You never know when an omniscient politician may decide that you need a tube
surgically implanted in your body.
|
Outrageous Associations
