Thinking about euthanasia lately

Great Debates
1

The current situation of a couple we know has had me thinking about euthanasia lately. The husband’s mother has been living with them for 5-10 years. She is now 97 and “near death.” She has been receiving in-home hospice care for the past several months. She has not been independent in her care for the previous couple of years.

Life in their home has been pretty miserable since probably a week or so before x-mas. The old lady is apparently in considerable pain, despite huge amounts of morphine. She is awake much of the night, screaming in pain and asking God to take her, saying she wants to die and doesn’t understand why God is forcing her to continue like this. For the past several days she was refusing to eat. So we figured she would starve to death within a week or so. But yesterday she decided she wanted to eat… I don’t know how lucid she is now - at best it seems to come and go.

So, I’m wondering what people think about euthanasia in such a situation. Yes, I know it can be a “slippery slope,” but if at all possible please restrict your answers to the situation as I describe it (and I’m describing it as accurately as I can.)

When the old lady said she wished to die and was placed on hospice months ago, should she have had the option of medically assisted suicide? How about now, when it is questionable whether or not she has control of her faculties - should her family be able to request that she be medically “put down”?

Personally, I would HATE to ever be in a position where I was impacting my childrens’ lives the way she has her son’s family. And I’ve told my kids that if I ever get to that point, I wish they would put a pillow over my head (which my ever-helpful so tells me may not be sufficient. Nice to know he has been thinking of such things!) In the situation I describe above, would you be willing or able to kill an aged relative? If so, how would you go about it? I thought either an overdose of meds, or perhaps suffocation - maybe in combination.

Oh yeah, and I might as well go first.
Yes, I think this old lady shuld have been provided euthanasia as an alternative to hospice.
Yes, at this point I think the medical community should assist the family by fatally adjusting this woman’s meds.
And yes, even if I had not gotten my parent’s permission before, at this point, I think I would kill them. At least I would seriously consider it. But I cannot seriously say how I would feel about it afterwards.

2

Does she have an advance directive on file? If so, does it indicate that she does not want any extraordinary measures taken to prolong her life–no machines, breathing or feeding tubes, etc? I bring this up since it is an important and relevant point regarding such issues.
That said, in almost any state, you can’t “put someone down” or have a doc do it because to do so is illegal. If you were to kill your relatives, even to relieve their suffering, you’d be jailed if someone found out that you did it. That’s my understanding.

And that said, I think we need to change our laws.

I don’t think I could suffocate my mom but I would provide her with the necessary meds to end life quietly and painlessly if I only knew what they were and if I could be sure I wouldn’t spend the rest of my life in prison. (No, we are not in this situation–not even close.)

3

It’s not a question of “Can do we do it?”, more than being a question of “Is it ethical to do so?”

Most physicians including me, under certain circumstances, declare "“DNR” - Do Not Resuscitate state, based on certain conditions. But declaring euthanasia when we have a living being which can continue to do so, is usually not an option.

Any human being can be miserable, wanting to die, but it still depends if he/she is eligible for the ticket, considering that someone who knows him/her might want him/her to live. Also, the risk/benefit of an euthanasia should also be taken into account (sometimes religious beliefs can to extreme lengths).

I just want to conclude: “The final decision is usually not in our hands. If it is, do not take any harsh decisions”. Of course, there might be a lot of places where euthanasia makes sense, but usually, the final decision is best taken by the physician in consultation with the patient - it should not be something decided by anyone else.

4

The couple is more my wife’s friends than mine, and I do not know too terribly many specifics. I am quite certain, however, that there is a DNR. She is not on a ventilator, intubation, or anything else.

Bottomline, her heart, lungs, and such just won’t quit. For the past 3 weeks she has been nothing more than a bedridden body, with little movement of her limbs, and her family and nurse completely responsible for feeding and cleaning her. For a month or more prior to that, whenever she would get out of bed, her tissue-thin skin would tear.

5

The desire or the request to die must be evaluated in light of the lucidity of the patient, and there’s a lot to doubt when the person making the request does so under the influence of terrible pain.

That said, if it were my mother (who’s advanced directive requires policemen to shoot her if she’s too slow crossing the street), I would seriously consider trying to engineer an overdose of morphine on my own somehow.

6

DNR is very different from euthanasia. So if the supporters of the patient agree to DNR, that would free us from making a decision (but the euthanasia discussion would go on!). From what I can glean from your ‘bottomline’, I assume that the usual causes of mortality are unlikely to happen. However…

Since this thread IS about euthanasia, I refrain from commenting about anything else.

7

The main issues are:

  1. Lucidity - You need to know that the person is making a conscious choice
  2. Prospects - Whether or not there’s any particular hope of something better
  3. Liability - When a person dies on their own, everyone can safely say that it wasn’t murder. If a person is euthanized, how do you know for certain that they weren’t forced or coerced into it?

Personally, when it comes to questions of life or death, I don’t think anyone has any right by any measure to decide this for someone else. If we can tell a person that he has no right to die, there’s essentially no limit to what rights we can deprive a person of, for nothing could ever be more personal than that.

I’d say that if a person is lucid enough to push a button (or signal to push a button) then it’s up to them. If they were coerced into it, that was their choice, and more importantly is almost certainly going to be a statistical anomaly. But where possible, it must be the person himself who presses the trigger.

If the person isn’t lucid enough to make a choice like that, then it falls to the family and the doctor to make the choice. But the doctor must agree, in this case, that there’s no better prospects.

8

What’s the medical community (I assume you mean us doctors, here) got to do with it?

You want to kill her, kill her. She’s much too feeble to resist. What, exactly, is the difference (morally…legally…) between me killing her with an OD of morphine and you killing her with a pistol?

Mods: I assume you realize these are rhetorical points. I am not recommending a course of action but simply trying to expose the farce of assuming that having a physician kill a patient is somehow fundamentally different from anyone else killing them.

9

Well, doctors have training as to how to do it the most painlessly and ready access to the means. But perhaps more importantly, they could serve as an “uninterested third party” with expertise beyond the particular case.

10

This argument seems pretty shit. Do you think it’s ethical to extend someone’s extreme suffering because others might want them to live?

This is a catch-22: “anyone experiencing enough suffering to wish for death is also in enough suffering to preclude lucid thought. Therefore requests for euthanasia cannot be taken as requests from sane minds.” Besides, I would argue that when one is in intense pain with no end in sight, asking for death would be the more logical and lucid thing to do. No one should have to experience suffering that intense because others with a responsibility to respect your wishes started second guessing you.

You’re being facetious. She wishes to die, and anyone who really cared for her would spare her the indignity.

11

Euthanasia is known to crop up as an issue here in Australia from time to time, but after watching how my grandfather passed away, I was left totally and utterly baffled as to what the pro-euthanasia crowd have their pants in such a twist over.

My grandfather, who had become bed-ridden due to lupus, instructed the hospital staff to stop providing him with intravenous nutrients (which was permitted), he then chose to stop eating. He then asked to be doped up with so much morphine that he was rendered unconscious, again which was permitted. He slept for nearly a week, then died.

Now, if such a way to go is within the confines of the law (not sure if such an occurrence would be permitted or not in the US), then why is euthanasia such a big issue? Sure, you can’t ask for someone to stick a big bad skull-and-cross-bones needle in your arm and have it all over and done with in seconds, but there is “nearly as good” option available, so… what gives?

12

If she’s in “considerable pain” despite being on morphine, she’s not on enough morphine.

It’s unethical to just kill someone outright with morphine (or sodium pentathol, or potassium, or whatever) if that’s your primary goal. But it’s absolutely ethical to keep on increasing the morphine dose for a suffering terminal patient until she’s no longer suffering, even if that same dose is enough to depress her respiratory drive.

The idea here is the “double effect” principal: if an action has a good outcome and a bad outcome, and you can’t get the good outcome any other way, and the good outcome sufficiently outweighs the bad, then it can be an ethical act. This is well established in the canon of medical ethics, and particularly so in this situation.

As long as she (if she is capable of making decisions for herself) or her surrogates (if she isn’t) understand the risk of increasing her morphine to possibly fatal levels, if that’s what it takes to alleviate her suffering, then it’s OK to do it. This happens every day in every hospital in America.

13

Euthanasia aside, your friends don’t have to go through all the pain they’re going through now, do they? They could just put her in an inpatient hospice, surely?

Oh, and to address the OP, no, I personally wouldn’t euthenase anyone, but I would provide them the means to end it themselves (on the lines of Kervorkian’s machine) even if only by a button-push. I think it should be on option on those self-administered morphine drips.

14

Those who wouldn’t allow another person to escape the pain somehow just have no idea how bad the pain can get.

One of my friends died yesterday. I’m certain that the pain medication contributed to her death. She was in horrendous pain after a stroke before Christmas and was screaming a lot of the time when she was conscious. This was her second stroke and it seems to have taken her mind this time. I was glad that her daughter chose to keep her out of as much pain as possible. Both of them have been lovely, loving women.

15

(by Chief Pedant
You want to kill her, kill her. She’s much too feeble to resist. What, exactly, is the difference (morally…legally…) between me killing her with an OD of morphine and you killing her with a pistol?

You miss the point. I was not addressing the question of whether or not she wishes to die, or whether euthanasia is appropriate here, but whether it is somehow preferential to have a physician kill her.

A nice test for those promoting euthanasia in a given circumstance is to have the individual who is most confident it’s the right choice be the the executioner. As a rule of thumb, the best proxy for the patient is the person most close to her.

16

Ok, still you could have made your point clearer by not using phrases like “too feeble to resist”, as if it were against the patient’s will (and again in your post, “executioner”). Still I think your suggestion of using a handgun is also deliberately ridiculous, of course that method has many aesthetic and psychological downsides. It’s messy and distressing to both parties. This is the first time I’ve heard of Kevorkian’s machine, but that seems like a better alternative all around. At any rate, if I were ever in a position to be sure that euthanasia is the best choice left for a loved one and it were legal, I would have no problem administering the narcotics or whatever myself. Just like I would have no problem with the euthanasee doing it herself, or a physician doing it.

17

Then she’s not getting enough morphine. Seriously, if she’s in pain like that she needs more pain medication. WTF is wrong with her doctors?

Is she’s anxious/mentally distressed there is help for that, too - when my mother was dying we actually gave her more medication for her anxiety than for her pain. Again, WTF is wrong with her doctors?

Or is it that the family hasn’t told the doctors about this?

What you’re describing is sort of normal end-of-life behavior according to my sister, who is an MD and an assistant director of a hospice. It’s not that these folks “refuse” to eat, they’re just really not hungry. At all. A common theme is that they stop being thirsty. So they stop eating and drinking and pass away. Of course, you can get around that with a feeding tube - but if someone is terminal, in hospice, and is not experiencing distress from lack of food/fluids why would you do that? Well, people do that because it upsets the family - it bothers them that mom (or whoever) is no longer eating and drinking. So I hope your friends don’t get a feeding tube for the old lady just to relieve their own distress.

I think before we start considering killing people we should make sure we really have done everything possible to alleviate their pain through other means. And I’m not convinced that has occurred in this case.

My mother was bedridden, almost unable to move, and in hospice earlier this year. If she had been moaning/yelling/screaming in pain I would have reached for the bottle of morphine by her bedside and given her a dose. In fact, I actually did that several times. If the morphine didn’t seem to be working I’d go to her doctors and ask what more we could give her. No, it didn’t really occur to me to ask how to kill her.

But,* strictly hypothetically,* if I HAD wanted to end her suffering via euthanasia I would have simply vastly overdosed her on the pain meds. We had enough in the house to do exactly that. After which she would have simply fallen asleep and never woken up.

^ What he said.

^ This. I suspect if we really followed that guideline we’d take care of the vast majority of cases where people now would contemplate euthanasia. The issues usually seems to be suffering/pain control, and I don’t think our society does enough of that in the proper manner.

What makes you think the situation would be any different inpatient? Or even as good?

If the patient’s doctors aren’t providing adequate pain relief now, what makes you think they’ll do it inpatient?

While caring for an invalid at home is difficult - I know, I helped my mother-in-law care for her dying husband, and I was a primary caregiver to my mother this year - the family doesn’t always view it as the worst possible situation. The advantage of home hospice is that EVERYTHING revolves around the patient. In the hospital my mother was disoriented, distressed - actually terrified - of the noise, the bright lights, the strangers, was alone when she wanted company, was woken up on the hospital’s schedule… At home we adjusted the lighting in her room for her comfort, keep things quiet, the people around her were known to her, she slept when she wanted to without being disturbed, someone came whenever she called. She suffered much less in her own home, and isn’t that the goal here?

Both my father in law and my mother died without a single bedsore on either of them, despite being unable to turn over by themselves for several weeks. In hospitals, it’s unusual for such patients not to have skin break downs. While there was some pain and fear both of them had adequate pain control. Yes, at the end the amount of morphine required more or less knocked them out but so what? They’re dying and the point is to make that as pain free as possible. Did their pain meds hasten their deaths? Maybe. Frankly, I don’t know and I don’t care if they did - they died in as little pain as possible and that was the whole point.

18

Yeah - your choice of words makes your position quite clear. I’m not exactly sure why this couple made the decision to have in-home as opposed to inpatient hospice. And they have never said they wish the old lady euthanized. I am not close enough to them to raise the subject, especially not at this time. Not certain what meds she is administered how. I know she is getting morphine, and I know the other day the DIL said they doubled her “sleep medicine” and she - and the family - slept through the night for the first time in a while. So I also obviously am not privy to their relationship with their caregivers.

If the appropriate medications were available, I would not have any opposition to administering the fatal dose myself. No reason to employ an MD “executioner.”

And yeah, my sympathy for these friends of my wife’s is tempered by my belief that their situation results from their choices among available options.

As I said, I know there can be a slippery slope. But in this particular instance I do not understand the argument for allocating any financial or emotional resources to keeping this shell of a former person “alive” for another day. AFAIK there has been no reason to believe that she will recover to any significant extent that she will get out of her bed, care for herself, be freed from strong meds, or enjoy any quality of life.

19

Just echoing Broomstick with some IRL anecdotes:

It’s absolutely normal for those near the end of life to no longer take food or drink since their bodies no longer give them sensations of hunger and thirst. When they become unable to swallow and have left instructions for no feeding tube to be inserted, they’re on the way out. My dad had Alzheimer’s and lost the desire, on occasion, to eat or drink (he thought he had done so already) some time before he passed (due to anaphylactic shock from an antibiotic, actually).

My friend P. is one of those people who is unable to let go. When her mom was near the end of her life–sleeping almost all the time, not lucid, thin as a reed-- P kept trying to shove pureed food down her throat even when the woman was barely conscious or could barely swallow. Why this was allowed to go on at all, I do not know. P. said she was “fighting for” her mom to stay alive. The poor woman needed to be released. I’d seen her up close and personal and she was more dead than alive.

20

This is not a situation where euthanasia is appropriate, it is an example of bad palliative care.

Someone needs to examine the lady- if she is in pain from constipation or bowel obstruction morphine is not the best solution to the problem.

She may not be absorbing the morphine she is being given, her doses may not be being given correctly, she may be on the wrong doses. Someone needs to assess that.

NO-ONE should be distressed, screaming in pain near the end of their life. That is an appropriate time to call a physician to the house, urgently. I know that GPs here would consider a palliative care patient in distress as about as urgent as it gets and a GP would try to be at the house within the hour.

This lady could well be around for days to weeks- she deserves to spend that time pain-free- if that means she needs to be sedated to unconsiousness (terminal sedation) then that is legal, humane and entirely appropriate.

If that just means a syringe driver with sedation, morphine and anti-emetics, that is what she should get (diamorphine, midazolam and haloperidol would be a common combination used here).

Usually when someone enters the last 48 hours of their life they are semi-conscious or unconscious and do not eat or drink. This is the natural process of dying. This lady doesn’t seem to be there yet.

I’m with Chief Pedant on this- there is no moral difference between a doctor giving a lethal injection and a relative smothering someone with a pillow in their sleep- both being quick, relatively painless and fairly effective. I don’t want to kill someone to save their family from getting their hands dirty just because I’m a doctor.

How, exactly, would a physician who has possibly looked after someone for years and been intimately involved in their final illness be “uninterested”?