THE debate on physician-assisted dying is gaining momentum worldwide, and particularly so in SA, as a result of the recent landmark judgment in the High Court in Pretoria permitting an applicant to die, assisted by his doctor.
It is important that there should be absolute clarity on the issues involved, especially the meaning and role of palliative care.
Extraordinary advances in the science and technology of medicine have enabled doctors to cure patients way beyond previous expectations and to artificially prolong life — which, in many situations, not only prolongs suffering but often causes it.
Unfortunately, caught up in the excitement of this, the thrust of teaching has become curative. Science and technology have become the basis of medical practice; the patient-centred approach has been lost.
There is no code of ethics or legal precedent to prevent a doctor or nurse acting in a humanitarian and compassionate manner but doctors often are confused and, therefore, too much suffering is associated with dying.
This confusion of doctors and nurses is due to an imagined conflict between their duty to care for a patient in the patient’s best interests and misconceptions about their legal and moral right to relieve pain and/or other distressing symptoms.
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THIS often results in their reluctance to administer the necessary medication in adequate dosages to dying patients, who therefore, often suffer a tortured death, without adequate relief from terror-filled pain, or even worse, struggling to breathe.
Palliative care is broadly defined as comprehensive medical management intended to alleviate suffering. Every doctor and nurse should be trained in the skills and ethos of palliative care, taught the distinction between it and doctor-assisted dying, and also the indications for each.
There are many instances when curative treatments are futile. When treatments are bound to fail, or when being alive is no longer meaningful, giving patients life-prolonging medication or artificial life support is contra-indicated.
When chemotherapy is continued, even when it is known that it is futile, it can cause side effects that are more traumatic than the disease.
With good palliative care as their only treatment, patients often live a little longer and have time for family and friends with their suffering controlled until they die with dignity — a good death.
In my experience with cancer patients over many years, I have found patients are more afraid of how they are going to die than of death itself. The request for assisted dying is often a request for an end to suffering, as few patients have knowledge of what good palliative care might offer.
The difference between palliative care and doctor-assisted dying is intent. When a patient is terminally ill, the intention of palliative care is to actively relieve any form of suffering until the patient dies a natural death.
When a large amount of pain-relieving medication is required to control the pain, it may hasten the moment of death. But the intention was to relieve the pain and not to end the life, which was occurring naturally. Therefore, this is generally accepted as not being euthanasia.
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TERMINAL sedation is an ingredient of palliative care. It implies giving patients, whose suffering is not controllable by the usual palliative care measures, a sedative in normal doses to keep them asleep until they die a natural death. It is reversible, so sometimes the patient is woken up to see what the situation is, and may or may not be sedated again.
Sedation is invaluable in emergencies, such as when the terminal event is an inability to breathe. An immediate intravenous injection of a strong sedative (morphine is not a sedative) will prevent the dying patient from experiencing a horrendous death.
In the Oxford Textbook of Palliative Medicine, Derek Doyle and Carl Furst state that terminal sedation is not a form of euthanasia.
In doctor-assisted dying, the intention is to end the life of a patient whose situation is intolerable. The patient may or may not be terminal but has a no quality of life and no medical intervention. Palliative care would be of benefit to them.
It is not an alternative to palliative care for the terminally ill, but there are situations where it can be indicated if good palliative care is not adequate. This applies particularly to people who are not terminal, but whose suffering of various kinds is unbearable, and who are without any quality of life.
There should be a trajectory of care in the management of patients, from curative with a palliative care component to palliative care only — and possibly to doctor-assisted dying, if the situation warrants it.
Palliative-care teams need to be available in all hospitals — public and private — to assist doctors who have difficulty controlling the suffering of their patients. They can relieve the load of overworked staff, assist in building their morale and because patients often are discharged earlier, it is cost beneficial to have such teams.
This also applies to medical aid costs. The unnecessary expenditure on futile interventions — scans, blood tests, X-rays, life-support machines and life-sustaining medications — increases not only the suffering of the patient but the cost for medical aid schemes. This, in turn, increases the subscriptions and so limits the availability of care for many.
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IT IS important for everyone to make an advance directive (living will). It is important that patients’ doctors and families know their wishes. It is essential for patients who may become unable to communicate, as a result of a stroke or other catastrophic event.
A living will must be made while the patient is of sound mind, reviewed at intervals and changed if desired. Discussion with the family and house doctor is essential. Change your doctor if he or she will not co-operate with you. You are both entitled to your views.
Although terminal palliative care is morally and legally acceptable, many doctors ignore a living will. Legislation to enforce compliance with living wills is long overdue.
• Browde is a former professor of radiation oncology at Wits University and the Johannesburg Academic Hospital. She founded the Johannesburg Hospital Palliative Care Team in 2000.
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