There is much to say - both good and not-so - about last Sunday's (December 27) NY Times front page article on palliative sedation ("Hard Choice for a Comfortable Death: Drug-Induced Sleep"). The issue is provocatively presented with an inconsistent, but clear insinuation that something may be amiss. I wonder what you all think; however, I am most concerned about the photos (Photos: Ozier Muhammad/The New York Times) which may easily be taken in, without the benefit of reading the explicating text. Front page: "Frank Foster, sleeping under sedation to relieve pain and other effects of liver cancer..." He's all alone, no one at his bedside. One may wonder, is he being drugged to death and left to die? The article continues further on in section one, on 2 full pages. Three large photos on the first of those pages are of Gloria Scott, an African American "terminal cancer patient" being attended by a white doctor. In one of the photos Ms Scott is being handed a pen by that physician to sign a "do not resuscitate" order. The caption below that one, in the NYT online photo gallery, reads "At first Ms. Scott fiercely resisted signing a 'do not resuscitate' order, but in late November, she changed her mind and signed one with Dr. Shaiova." The 3rd of these pictures is of Ms Scott asleep or in coma; the caption reads: "Early this month she was near death; her doctors said later they believed the drugs had not hastened her end." Do we believe that? These photos beg some uncomfortable questions: Has this woman made an informed set of choices, and without undue influence? The reader/observer is left wondering: Has she pushed, however subtly, into the 'no code,' the 'terminal sedation'? We should problematize "palliative sedation" (as Alex Smith, Patrice Villars, and I attempted to do in a recent Lancet article). In fairness to the author of this NY Times article, she does point out that physicians and other hospice workers, as well as ethics committees, are working to develop clear guidelines and policies regarding this practice. But, in the article, there is also hand-wringing over it, and incomplete arguments both for and against the various forms (not fleshed out) of 'palliative sedation' ... and then those photos. It leaves the reader unsure what to think - befuddled, perhaps ... or suspicious. Re people who use the acceptability of palliative sedation as an argument for the acceptance of euthanasia, Joseph Fins is quoted as saying: People who adopt this argument say, "We know what you're really doing, it's crypto-euthanasia. Polemics really have no place at the bedside." Disputatious argumentation at the bedside, no. But clear and cogent arguments regarding how we are treating people who are suffering at the end of life, yes.
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The question regarding terminal sedation is complicated, I agree, and highly individual. Missing from the article is the fact that in these situations the doctor often has 2 patients, the one in hospice and the family member(s). Treatment is often aimed at the family, simply because they are the ones often doing the talking, asking and negotiating. The "Ivan Ilyich" moment may be denied because of competing concerns, or often, compassion. The opposite can also be true, where family/doc may force a suffering person into an undesired "conscious death." Asking "would do you think she would have wanted" often helps, but not always.
The question regarding whether Gloria Scott was "pushed" into 'no code' is really not the question to ask, from my perspective. Given the known data about the futility of coding a patient with terminal cancer(Bedell, Rozenbaum, many others), and the added harm it often causes (broken ribs, pain, tubes in every orifice and places that aren't meant to be orifices at all, just to name a few), shouldn't the question be why is "full code" often our default position in these patients? This is one of the most crazy making aspects of American medicine from my perspective, and a place where we 'lie by omission', 'lie by TV show', or 'lie by euphemism' to our patients the most. I think a more realistic (than what we usually do) way to present the code options to a patient with terminal cancer is: "would you like us, in what would naturally be your final moments, to press on your chest and break your ribs, shove a tube down your throat and poke you with needles in lots of places in a chaotic attempt that has a very small chance of giving you more time to be technically alive but unlikely to ever return to meaningful communication with others?"
A code blue event in a patient with terminal cancer is much, much more likely to lead to the above description than to an Ivan Ilyich moment. Indeed one might argue that to code blue moment actually interrupts Ivan Ilyich moments, or other important aspects of the dying process.
Thanks Guy for the post! I'd like to say a bit about "framing bias." The pictures, particularly of the patient alone (see picture in post), are leading. In this picture, implying that palliative sedation is isolating or is for isolated individuals.
Similarly, one's description of a code blue can bias patients and family members, as in Ori's comment. We've touched on this in previous posts, but perhaps we should make it a post of it's own. Simply put - how do you frame discussions of code status to patients? What language do you use? How do you change what you say based on the clinical situation. And where does persuasion - which is ethically permissible - cross over into coercion?
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