“Rational” Suicide and the “Elderly”

An article in the May, 2018 issue of the Journal of the American Geriatrics Society titled “Rational Suicide in Elderly Adults: A Clinician’s Perspective”  by Meera Balasubramaniam, MD, MPH  recently appeared in both medical and nursing news sources.

Dr. Balasubramaniam begins with a case study of  “Mr. A” who at age 72 is considered a “baby boomer”, along with a whole section on the “baby boomer” generation-those born between 1946 and 1964 (ages 54-72).

Mr. A was a retired widower who had recently undergone successful cancer surgery and used a walker. He had no terminal illness but  he told a nurse that he always entertained the idea of ending his life “while I’m still doing well” and that if his health showed signs of failing or became too arduous, he would consider suicide. He stated “I’ve lived a good life. I’ll see how it goes, but it’s better to die well in my early 70s than have a life in which I have to be anxious before every doctor’s visit or have repeated surgery or end up in a nursing home.” (Emphasis added) A psychiatric consult showed no mental health problem.

Dr. Balasubramaniam says she wrote this article to “explore whether ethical arguments in favor of physician–assisted suicide apply to elderly adults who are tired of living but are not terminally ill”. (Emphasis added)

While claiming to not take a view on “whether suicide in non–terminally ill elderly adults can be rational”,  Dr. Balasubramaniam states that “It is important to consider the possibility that the combination of negative perceptions toward aging and dependency, greater social isolation, increasing access to drugs, greater need for autonomy, and an overall generational familiarity with suicide may be accounting for a higher proportion of older adults like Mr. A expressing the wish to end their lives on their own terms”. (Emphasis added)

DEATH AND THE BABY BOOMERS

It may seem incredible to even consider “tired of life” and older age as a “rational” reason for medically assisted suicide. However, Holland and Switzerland already allow it and the article itself cites the UK group “My Death My Decision” (formerly SOARS, The Society for Old Age Rational Suicide) that supports the idea that mentally competent older adults should have the right to assisted suicide rather than face an uncertain life that may be “fraught with frailty and dependence”.

As a Baby Boomer myself, we baby boomers were among the first teenagers exposed to a growing societal acceptance of new concepts like divorce , “free love” with the help of the birth control pill and legalized abortion, the “population bomb” predicting global cataclysm if people didn’t stop reproducing, the use of illegal drugs like marijuana and LSD for recreation, the rejection of religious principles and the slogan “don’t trust anyone over 30”.

So perhaps it should not be puzzling that people over 55 comprised the majority of people dying by physician-assisted suicide in the latest Oregon report since we saw so many of the traditional civil and moral moorings in society pulling loose when we were at an especially vulnerable age.

CONCLUSION

As one sage said, “Old age ain’t for sissies!” But, of course, this is not a “rational” excuse for legalizing assisted suicide for anyone-of any age.

Still, our older citizens are an especially high risk group for elder abuse, household accidents, money scams, social isolation, age-related medical bias and poor or even dangerous nursing home care.

Having friends, family and a meaningful purpose in life becomes harder when older people see their loved ones die or move far away and physical or mental limitations develop in themselves. Many older people fear losing their independence as well as being a “burden” on others.

Medically assisted suicide is not the answer but what else can we do to help?

We can start with our own family members, friends and neighbors. Like all of us, older people need to feel loved and appreciated. Look for ways to assist an older person that he or she might not have considered or be too embarrassed to ask about.

When I was a young wife and mother, our church parish started a Good Samaritan program to identify and help people with special needs of any age. It was a great success and our parish became more inclusive and accessible to everyone, especially the elderly. That was a benefit to all of us.

Other programs such as visiting one person for one hour each week in a local nursing home have helped some parishes to combat the sad reality I have seen that few people in nursing get  visitors, especially people with dementia.

Many of us naturally feel uncomfortable about going to nursing homes, but such places are usually thrilled to have volunteers and most have training programs.

Personally, my first volunteer activity was as a young teenager in a nursing home and it changed my perception of “old people” and life itself. I was amazed by the wisdom and stories the residents told as well as how much they appreciated anything I did. It was a great experience for a shy, gawky teen like myself.

Many years later, I took my young children to visit their grandmother in a nursing home after telling them what to expect in terms of sights, smells and sounds. Afterwards, my youngest daughter asked why everyone wanted to touch her leg while I held her. When I explained that the residents rarely saw a 2 year old and were so glad to see her, she grinned and said “OK!”.  She understood even at that young age.

In a society that seems to constantly celebrate youth and health, we need to make sure that our elderly also feel valued and supported.

And we might just save a life!

 

 

 

 

“Fatal Flaws”: A Must-See Film

With the American Medical Association considering changing its’ long-standing opposition to physician-assisted suicide despite the recommendations of its’ ethics committee and the California assisted suicide law declared unconstitutional now reinstated pending appeal, assisted suicide/euthanasia groups like Compassion and Choices (the well-funded former Hemlock Society) are ramping up efforts nationwide to legalize assisted suicide.

Along with major media outlets overwhelmingly supporting their efforts and a recent Gallup poll showing  that the “Majority of Americans (73%) Remain Supportive of Euthanasia”, how do we fight against this and educate the public?

One excellent answer can be found in the recently released 80 minute film “Fatal Flaws”.

“Fatal Flaws” features filmmaker Kevin Dunn who spent three years traveling throughout Europe and North American asking the question “should we be giving doctors the right in law to end the life of others by euthanasia or assisted suicide?”

In the film, Mr. Dunn respectfully interviews people and experts on both sides of the issues and the candid testimonies are powerful and moving. I have viewed the film myself and I believe that showings of this film to senior citizen groups, pro-life groups, churches and clergy, medical professionals, etc. would go a long way in educating the public, many of whom are supportive  or unsure of where they stand.

The film was produced in association with The Euthanasia Prevention Coalition. For information on purchasing the  “Fatal Flaws” film and/or the accompanying pamphlets, please go the Euthanasia Prevention Coalition “Fatal Flaws” site.

There will be a preview viewing of the film at the National Right to Life Convention June 29, 2018.

On a personal note: I am speaking at the NRL convention myself on the Alfie Evans’ case June 30, 2018 and I would love to meet those of you attending the convention.

 

 

Good News/Bad News about Alzheimer’s

First the good news:

Alzheimer’s disease is a currently irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.

However, a new study “Estimation of lifetime risks of Alzheimer’s disease dementia using biomarkers for preclinical disease” shows that “most people with preclinical Alzheimer’s disease will not develop Alzheimer’s dementia during their lifetimes”, according to a mathematical analysis based on several large, long-term studies.

According to the Alzheimer’s Association , the term “preclinical” refers to “a newly defined stage of the disease reflecting current evidence that changes in the brain may occur years before symptoms affecting memory, thinking or behavior can be detected by affected individuals or their physicians”.

Although biomarkers are still being investigated and validated, this new study can be reassuring to many people worrying that, for example, forgetting where they left their car keys means the beginning of Alzheimer’s.

While the cause of Alzheimer’s is still a mystery, research on the disease is massive and ongoing. Currently, there are drug and non-drug treatments that may help with both thinking and behavior symptoms. There is hope.

THE BAD NEWS

With the many negative stories in major media about Alzheimer’s, it is no wonder that people are so afraid of it.

As Deakin University Professor Megan-Jane Johnstone says in her book “Alzheimer’s disease, media representations and the Politics of Euthanasia-Constructing Risk and Selling Death in An Ageing Society”  :

“Alzheimer’s has been portrayed as the ‘disease of the century’ that is poised to have a near catastrophic impact on the world’s healthcare system as the population ages…

This representation of the disease—along with other often used terms such as ‘living dead’, a ‘funeral that never ends’ and a ‘fate worse than death’—places Alzheimer’s as a soft target in the euthanasia debate because it plays to people’s fears of developing the disease and what it symbolizes. It positions Alzheimer’s as something that requires a remedy; that remedy increasingly being pre-emptive and beneficent euthanasia.” (Emphasis added)

While countries like Belgium and Holland have long allowed lethal injections for people with Alzheimer’s , this is forbidden in the US-for now. However, assisted suicide groups are now trying new “living wills” stating that if or when the person is diagnosed “with Alzheimer’s or another incurable dementing disease”, he or she refuses not only a feeding tube but also even assistance with oral eating and drinking to end their lives.

Compassion and Choices, the well-funded former Hemlock society, has long promoted VSED (voluntary stopping of eating and drinking) as a legal alternative to assisted suicide in states without assisted suicide laws. But at the present time, people who cannot make medical decisions because of  conditions like Alzheimer’s cannot sign an advance directive.

So influential major media outlets like the New York Times often publish articles such as the May 30, 2018 article titled “Alzheimer’s? Your Paperwork May Not Be in Order” that quote Dr. Judith Schwarz:

“People should at least understand what the normal process of advanced dementia is about,” Dr. Schwarz said. “Feeding tubes are not the issue…. Opening your mouth when a spoon approaches is a primitive reflex that persists long after you’ve lost the ability to swallow and know what to do with what’s put in your mouth.” (Emphasis added)

Dr. Schwarz’s advice?

“Complete her organization’s Advance Directive for Receiving Oral Food and Fluids in the Event of Dementia.”

But what Dr. Schwarz and others do not want to talk about is the often tragic reality of deliberate death by starvation and dehydration.

Although media articles portray VSED as a gentle, peaceful death, a 2018 Palliative Practice Pointers article in the Journal of the American Geriatric Society  titled Voluntary Stopping Eating and Drinking” states:

“VSED is an intense process fraught with new sources of somatic and emotional suffering for individuals and their caregivers…The most common symptoms encountered after starting VSED are extreme thirst, hunger, dysuria (painful urination due to concentrated urine NV),  progressive disability, delirium, and somnolence.” (Emphasis added)

Most chillingly, the authors state:

 “Because an individual with delirium may forget his or her intention and ask for drinks of water, caregivers will struggle with the need to remind the incapacitated individual of his or her own wishes. This possibility should be anticipated and discussed with the individual in advance. While reminding the individual of his or her prior intentions may feel like coercion, acquiescing to requests for water will prolong the dying process for someone who has clearly articulated the desire to hasten death.” (Emphasis added)

The authors also state that if the patient’s suffering becomes severe, “proportionate palliative sedation and admission to inpatient hospice should be considered”. This is not the so-called peaceful death at home within two weeks that people envision with VSED.

Lastly, on the legal requirement of  a cause on the death certificate, the authors state:

“the clinician may consider including dehydration secondary to the principle illness that caused the individual’s intractable suffering. Although VSED is a self–willed death (as stopping life support might also be), use of the word “suicide” on death certificates in this context is discouraged because in incorrectly suggests that the decision for VSED stemmed from mental illness rather than intolerable suffering.” (Emphasis added)

So, like assisted suicide, the real cause of death is basically falsified with the rationale that the deliberate stopping of eating and drinking to hasten death is just another legal withdrawal of treatment decision like a feeding tube.

CONCLUSION

Years ago, my mother told me that she never wanted to be a burden on her family.

I never told my children that-especially when they were teenagers and already thought I was a burden to their lifestyles! Instead, I told them that the “circle of life” includes caring for each other at all ages and stages. Such caring also eliminates future guilt and leaves a sense of pride that we did the best we could for each other during our lives.

When my mother developed Alzheimer’s in the late 1980s (and later terminal thyroid cancer), a friend asked if I was going to feed her. At the time, my mother was fully mobile and able to get ice cream out of the freezer and eat it. I was shocked and offended.

“Do you want me to tackle her?!” I asked my friend.

“Oh, no!”, he answered, “I was talking about a feeding tube later on.”

I told him that my mother would die of her disease, not from deliberate starvation and dehydration.

Near the end of her life, we did spoon feed my mother and she enjoyed it very much before dying peacefully in her sleep.

For decades now, I have enjoyed caring for many people with Alzheimer’s or other dementias both personally and professionally.  I can attest that such people can be sweet and funny and as well as difficult at times.

Just like the rest of us!

Surprising Twist to a Good News Story You May Have Seen

TV and social media are reporting a wonderful story about Dr. Eric Voigt and Nicole McGuinness. Dr. Voigt, an ENT physician, was watching the “Beachfront Bargain Hunt” TV show (one of my own semi-guilty pleasures) when he noticed that a woman on the show named Nicole McGuiness seemed to have a suspicious lump in her neck. Alarmed, Dr. Voigt turned to Facebook find her and urge her to get the lump checked. Nicole had her lump checked and it was thyroid cancer. She will be starting treatment soon and is very grateful to Dr. Voigt for his sharp eye.

However, this story has a surprising twist.

Nicole was diagnosed in December 2015 with a glioblastoma cancer in her brain at age 29 and was successfully treated and doing well after almost 3 years.

Ironically, Brittany Maynard was also 29 and had a glioblastoma brain cancer when she decided to move from California to Oregon, a state that legalized assisted suicide in 1997. She and her family moved to Oregon so that Brittany could commit physician-assisted suicide before her symptoms became more severe. The date she chose was November 1, 2014. Brittany also agreed to help Compassion and Choices (the former Hemlock Society) use her story to raise funds with the goal of legalizing physician-assisted suicide throughout the US.

After weeks of widespread and sympathetic media coverage, Brittany did take a doctor-prescribed lethal overdose on her planned date.

Ironically and 5 months later, CBS’s TV show “60 Minutes” reported on an innovative treatment for glioblastoma brain cancer . And, as I wrote in my blog “Could Brittany Maynard Have Been Saved?, this innovative treatment was granted breakthrough status by the FDA in 2016.

No one will never know if Brittany could have been one of the people this treatment could help.

CALIFORNIA AND PHYSICIAN-ASSISTED SUICIDE

The first target state for Compassion and Choices’ campaign for legalizing assisted suicide after Brittany’s assisted suicide was her home state of California. Both Brittany’s mother and husband went to California to support a physician-assisted suicide bill. Although the bill apparently died in committee, Governor Jerry Brown called a special legislative session to deal with healthcare spending where the assisted suicide bill was resurrected and passed. Governor Brown then signed it into law in October, 2015. Over 100 people died by assisted suicide in the first six months after the law took effect.

However just last month, a California judge overturned the law stating that the California Legislature violated the law by passing it outside of the scope of health care spending which was given as the reason for a special session and thus was unconstitutional.

This decision was quickly appealed by the California attorney general to the Fourth Circuit Court of Appeals who upheld the judge’s decision.

Now Compassion and Choices has filed an appeal on behalf of a palliative care doctor and two terminally ill patients in California to get California’s law back into law.

Stay tuned for further developments.

CONCLUSION

As a former oncology and hospice nurse, I pray that Nicole has a speedy recovery from her thyroid cancer and I am still saddened by Brittany’s assisted suicide but assisted suicide is not a remedy for cancer.

I remember when just a few decades ago, AIDS was the poster disease for legalizing assisted suicide. Then it became terminal cancer after AIDS became treatable. Now the scary poster disease is Alzheimer’s.

And that’s how the slippery slope works.

Instead, we need realistic hope and real support for people and their families dealing with difficult situations rather than just offering the “solution” of death.

 

 

Don’t Write Off The Elderly

Late last year, my 95 year old friend I will call “Melissa” fell and fractured her hip which is especially serious at her age. In one study of people over 65 who fractured a hip, up to 50% died in 6 months with the highest mortality rates found in people over 90 years old.

In Melissa’s case, she also had long-term chronic congestive heart failure when she fell in her bathroom at home. She underwent successful surgery and was sent to a rehab facility where she developed a blood clot that went to her lungs. After successful treatment of that complication, she later developed a life-threatening pneumonia after returning to the rehab facility. She had difficulty breathing even with 100% oxygen by mask and 911 was called. I was with her when the ambulance arrived and I followed it to the hospital.

In the Emergency Room, the doctor asked her son and I about how aggressive to be if her heart or breathing worsened. I said “Ask her!” and the doctor was stunned when she vehemently said “Yes!”, even after he explained the potential problems with cardiopulmonary resuscitation and ventilators. My friend has a durable power of attorney naming her daughter as her health decision maker but the doctor wrongly assumed my friend was not able to speak for herself and that Melissa’s son and I were her decision makers. Thanks to our smartphones, Melissa’s daughter and I were in constant phone contact during that time.

After a few weeks in the hospital, Melissa astonished the doctors by recovering with antibiotics and a temporary BiPap (a face mask machine to support her breathing) until the antibiotics took hold. Then, after another short stint in a facility, my friend was finally able to go home with outpatient rehab and help from family and friends.

Going home was Melissa’s first goal.

This week, she accomplished the second of her goals: returning to Friday Mass and breakfast at Chick-Fil-A for her weekly outing with friends again. Her last goal is to celebrate at her 96th birthday party in August and none of us would bet against her achieving that also.

Elder Bias

In a society that seems to almost venerate youth and material success, those of us who are older can be made to feel useless and even a burden.

That can be fatal.

For example and just this month, 104 year old Australian scientist David Goodall who had no terminal illness traveled to Switzerland for physician-assisted suicide and to actively promote it.

According to USA Today, he said that:

My abilities and eyesight are declining, and I no longer want to live this way...I hope something positive will come out of my story and that other countries will adopt a more liberal view of assisted suicide.”

Sadly, he also added that he “had no pressure from his family to change his mind.” (Emphasis added)

David Goodall was a renowned biologist who produced more than 100 research papers and earned three doctorates when:

“In 2016, at 102, the university ordered him to leave his office, calling him a safety risk to himself. Goodall challenged the decision, which was reversed after an outpouring of public support.

Earlier this year, however, Goodall fell while at home alone in his one-bedroom apartment and remained on the floor for two days until he was found by his cleaner, according to The New Daily.

Afterward, Goodall said he was considered incapable of looking after himself. Moreover, most of his friends were dead.”

Philip Nitschke, director of Exit International, a right-to-die organization in Australia called Goodall’s “story of elective, rational suicide by the elderly is an important one.” (Emphasis added)

CONCLUSION

What a sad, depressing story Mr. Goodall’s story is compared to Melissa’s!

This should be a wake-up call to the rest of us not only about the frightening expansion and promotion of physician-assisted suicide but also about how all of us need to recognize the value, wisdom and even inspiration of older people.

We must also recognize that we all need help at some point in our lives. We are totally dependent on others when we are born and many of us need at least some help near the end of our lives. But when we truly care for each other, both the helper and the person being helped are enriched to live their best lives.

 

 

Conscientious Objection and the Duty to Refer

When the Trump administration announced a new department of Conscience and Religious Freedom, the pushback from abortion and assisted suicide proponents like Planned Parenthood and Compassion and Choices was immediate and accompanied by apocalyptic predictions of harm to patients.

Now the term “conscientious objection” is increasingly being used rather than “conscience rights” when it comes to health care professionals. I believe this is not accidental. The term “conscience rights” is a powerful and accepted term about individual rights while “conscientious objection” is associated with the traditional definition of  “A person who refuses to serve in the military due to religious or strong philosophical views against war or killing” and who “may be required to perform some nonviolent work like driving an ambulance.” (Emphasis added)

Nevertheless, in a March 30, 2018 Medscape (password protected) article titled “Should Clinicians With Conscientious Objections Be Protected?”, well-known ethicist Arthur L. Caplan, PhD criticizes the new Conscience and Religious Freedom Division as an expensive “overreaction” that can be mediated by allowing health care professionals to refuse to provide a legal act (like abortion or assisted suicide in certain areas NV) but requiring them “to tell patients where they can go and how they can go about getting it.”

This echoes last year’s New England Journal of Medicine article “Physicians, Not Conscripts — Conscientious Objection in Health Care” by Dr. Ezekiel Emanuel (one of the architects of Obamacare) and Ronit Y. Stahl, PhD. who insist that medical professionals “cannot completely absent themselves from providing these services” and are still required to convey “accurate information” and provide “timely referrals to ensure patients receive care.”

The authors even state that:

“Health care professionals who are unwilling to accept these limits have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession. “ (Emphasis added)

Their rationale for this extreme position is that “the patient comes first, which means the patient’s conscience and autonomy receive priority over those of the physician.”  (Emphasis added)

However, this could now conflict with the recently amended federal Affordable Care Act (aka Obamacare) that states:

 “No qualified health plan offered through an Exchange may discriminate against any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions.”

and

“The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), may not subject an individual or institutional health care entity to discrimination on the basis that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.” (All emphasis added)

THE DUTY TO “CONVEY ACCURATE INFORMATION” AND “REFER”

Ironically, do groups like Planned Parenthood and Compassion & Choices really want to require a medical professional opposed to abortion and/or assisted suicide to convey accurate information?

First of all, medical referrals require a measure of trust. For example, no doctor or nurse would knowingly refer a patient to another doctor or organization that he/ she considers incompetent or unethical or for a procedure the medical professional considers harmful to the patient. When a patient asks for procedures like abortion or assisted suicide, the medical professional should be free to refer the patient to support services like crisis pregnancy centers, etc. or to an ethical palliative care specialist, mental health expert, etc. The medical professional should also be free to convey accurate information regarding abortion such as  how abortions are performed, potential physical and emotional complications, fetal development, etc.  With assisted suicide, the medical professional should be free to discuss such issues as the potential complications of a lethal overdose, the potential effects on family and friends, the criminal/ civil immunity of the assisted suicide doctor if the assisted suicide goes awry, etc.

Medical professionals should also have the right to be honest and tell patients if they personally don’t know any doctor or organization that they would recommend to provide a referral for abortion or assisted suicide.

Patients, especially those in distress, need a well-informed medical professional who really listens to their concerns and responds with facts and helpful options rather than one who just hands out a “politically correct” referral.

CONCLUSION

The so-called duty to perform/participate in a life-ending procedure or refer for one is not really about conscience rights but rather another way to extinguish resistance to abortion and assisted suicide, normalize such procedures into standard medical practice and discourage/bully ethical health care professionals into leaving or never entering the medical professions.

Those of us who believe in medical ethics as, first and foremost, doing no harm to patients must actively fight this for the sake of our professions and for the safety of the public that puts their lives in our hands.

If we don’t speak up for our medical professions and our patients, who will?

 

The Opioid Crisis and Suicide

Statistics show that more than 115 Americans a day die after overdosing on opioids. Opioids  are a class of drugs that include both illegal drugs like heroin and legal prescription pain relievers such as codeine and morphine.

We are told that we have an opioid crisis that needs immediate solutions such as suing drug manufacturers, spending more on drug treatment centers, making drugs like Narcan more available to reverse the overdose if given in time, prescribing few-in any-opioids after surgery, adding more drug education in schools, etc.

Some of these ideas are worthy but are we missing a big existential part of the problem?

In a recent Kaiser Health News article asking  “How Many Opioid Overdoses are Suicides?”, reporter Martha Bebinger relates a heartbreaking interview with a young drug addict:

“She wanted to be dead, she said, glancing down, a wisp of straight brown hair slipping from behind an ear across her thin face.

At that point, said Ohlman, she’d been addicted to opioids — controlled by the drugs — for more than three years.

“And doing all these things you don’t want to do that are horrible — you know, selling my body, stealing from my mom, sleeping in my car,” Ohlman said. “How could I not be suicidal?…You realize getting clean would be a lot of work,” Ohlman said, her voice rising. “And you realize dying would be a lot less painful. You also feel like you’ll be doing everyone else a favor if you die.”” (Emphasis added)

Having had a daughter with drug addiction and relapses for 16 years who finally succumbed to suicide in 2009 using a horrific assisted suicide technique, I recognize the same pain this young woman expresses. I also know the frustration and fears of families and friends desperate to help.

The Kaiser article goes on to quote Dr. Maria Oquendo, immediate past president of the American Psychiatric Association, who said that “[Based on the literature that’s available], it looks like it’s anywhere between 25 and 45 percent of deaths by overdose that may be actual suicides,” *(Emphasis added).

The article also quotes a pair of distinguished economists who say that “opioid overdoses, suicides and diseases related to alcoholism are all often ‘deaths of despair’” caused by “underlying deep malaise”. (Emphasis added)

We have both a suicide and a drug crisis that often overlap due to an overwhelming sense of hopelessness and helplessness.

EXAMINING THE SCOPE OF THE PROBLEM

As psychiatrist Dr. Oquendo notes in a related article, US suicide rates were declining until they “abruptly stopped in1999” and now have increased 25%, especially among adolescent girls.

Now, there are about 123 reported suicides per day in the US  but the real figure may be as high as 3 to 5 times that number because many suicides go unreported as suicide  because of reasons like the stigma of suicide and the difficulty in determining intent.

Additionally, nearly half of US adults have a close friend or family member with a current or past drug addiction.

We have more drug treatment centers and suicide prevention programs than ever (with unfortunately varying levels of quality and allowed family involvement) but the problems continue to persist and even worsen.

CONCLUSION

What has happened in the US since suicide rates started rising two decades ago and drug abuse has surged?

First, we must recognize that American culture, law and politics changed radically in the last two decades and this has drastically affected all of us, especially our young people. For example, the legalization and glamorization of assisted suicide and mind altering drugs like recreational marijuana have not helped anyone want to embrace personal responsibility and caring for others as worthy goals.

We also now have a culture where religious values are often derided as judgmental and even harmful to social progress. Obscene language and violent, hypersexualized entertainment is applauded as liberating rather than offensive. Having children is portrayed as more of a potential economic, professional and personal burden rather than a joyful manifestation of love, commitment and family.

We owe our society and especially our young people a more hopeful, less selfish view of life rather than just the pursuit of  money, fame and pleasure.

Without a strong foundation of love, strong ethics and ideals, the resilience required to weather both the ups and downs of life without drugs or succumbing to suicide can be lost.

As much as we need good, affordable suicide and drug treatment programs, we adults also need to be examples of a truly “good life” and step up to fight the dangerous influences  that are killing our young people.

And we must never give up!

Assassins, Not Doctors

Last year, both Hawaii and New Zealand physician-assisted suicide bills were defeated but, much like zombies, both bills were changed and resurrected for 2018.

As I wrote in a  previous blog about Hawaii’s bill, there are concerted efforts not only to pass but also expand assisted suicide laws. This bill is currently awaiting either passage or defeat in the Hawaii legislature’s Senate.

Recently, I submitted testimony on the “End of Life Choice Bill” to legalize physician-assisted suicide in New Zealand. Currently, the bill is being considered in the Select Committee.

The New Zealand bill is different from Hawaii’s in significant ways. Here are some of the differences, with emphasis added:

-It adds “grievous and irremediable medical condition in an advanced state of irreversible decline in capability”  to the usual condition of terminal illness.

-It give patients the option of 4 ways to kill themselves or be killed, including lethal injections:

(i) ingestion, triggered by the person:
(ii) intravenous delivery, triggered by the person:
(iii) ingestion through a tube:
(iv) injection

-“The attending medical practitioner must be available to the person until the person dies; or arrange for another medical practitioner to be available to the person until the person dies” by being “in the same room”  or “in close proximity to the person”.

-Conscience rights: If doctors refuse to provide the lethal overdose, they must refer to a SCENZ group established by the Director General to “make and maintain a list of medical practitioners who are willing to act for the purposes of this Act as—replacement medical practitioners: independent medical practitioners”,  list of pharmacists, and “to prepare standards of care; and to advise on the required medical and legal procedures; and to provide practical assistance, if assistance is requested.”

-The assisted suicide death (whose official cause is listed “as if assisted dying had not been provided”) must be reported within 14 days and sent to registrar who must send the report to a Review committee consisting of a medical ethicist and a medical practitioner who practices in area of end of life care and another medical practitioner. The Review committee has these functions: “to consider reports sent to it”, “to report about its satisfaction or otherwise with the cases reported” and “to recommend actions that the registrar may take to follow up with which the review committee was not satisfied.”

-Regular reports will be issued every five years after the first to be done 3 years after the law is implemented. These reports go to the minister and Parliament.

WHY DOES NEW ZEALAND “NEED” PHYSICIAN-ASSISTED SUICIDE?

While citing “strong public support” and “compassion” as motivating this physician-assisted suicide law in the explanatory note at the beginning of the New Zealand bill, the authors also cite cases in New Zealand where “the courts are treating the family members who have assisted their loved ones to die at their request with increasing leniency and compassion.” (Emphasis added)

This, they say “demonstrates further issues with the current state of our law, under which it is becoming permissible, in effect, for family members to assist loved ones to take their own lives. This is clearly less ideal, less clear, and considerably more risky than a regulated process in which medical practitioners can, in limited circumstances, assist those who are suffering.” (Emphasis added)

CONCLUSION

This last statement shows how lethally corrupting assisted suicide is: New Zealand must legalize physician-assisted suicide to spare family members while requiring participating doctors to even administer lethal injections at the sick person’s request and stay until he or she dies?

This turn participating doctors into assassins, not medical professionals.

Very few people enter the health care professions ready to kill some patients or help them kill themselves and dispassionately watch them die. But if physician-assisted suicide becomes law in New Zealand, health care professionals and even society itself will be forced to adjust to the new reality.

As I wrote in my testimony on New Zealand’s bill:

“Do assisted suicide supporters really expect doctors and nurses to be able to assist the suicide of one patient, then go on to care for a similar patient who wants to live, without this having an effect on their ethics or empathy? Do they realize that this can reduce the second patient’s will-to-live request to a mere personal whim – perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that they personally helped other human beings kill themselves? (Emphasis added)

Conclusion

Medically assisted suicide is a dangerous proposition that has proven to be impossible to strictly limit, corrupts the essential element of trust in the health care system and makes suicide more attractive to vulnerable people as a way to solve life’s problems.”

 

“Living Wills” to Prevent Spoon-feeding

As so-called “safeguards” for physician-assisted suicide are now starting to be eliminated (See my recent blog “Legal Safeguards, Burdensome Obstacles and Conscience Rights”) , the predicted advance directive (aka “living will”)- already biased against tube feedings-is now on track to include even spoon-feedings.

In an article in Today’s Geriatric Medicine “Judicious Feeding Options at the End of Life” , writer Mike Bassett writes that “In some states, patients can sign directives that allow refusal of feeding when the end of life approaches” and relates the 2013 case of an 82- year-old Alzheimer’s patient whose family filed a lawsuit against a British Columbia nursing home to force the home to stop spoon-feeding her. The lawsuit failed in court but now End of Life Washington , a pro-assisted suicide group, has devised a document called “”My Instructions for Oral Feeding and Drinking”. The document is similar to an advance directive but addresses the signer’s wishes about when to stop oral food and drink in “late-stage” dementia.

Although such a document can be signed, witnessed and notarized, it is not a binding legal document. But this sets the stage for a legal challenge like the British Columbia case but with assisted suicide groups hoping for a different judgment.

The article also interviewed the vice president of constituent services for the Alzheimer’s Association who said that when to stop even oral feeding “should be an important consideration for anyone issuing end-of-life instructions.”

Stephen Drake of the disability advocacy group “Not Dead Yet” made strong points about the dangers of this scheme both in the article and his blog ’End of Life Washington’ Promotes Directive to Prevent Feeding Assistance to Those with Dementia”.

I am not surprised by this new development and here is an excerpt from my September 5, 2016 blog “Ethics and Alzheimer’s-Part Two”:

In 1988 during the Nancy Cruzan case involving a young, non-terminally ill woman in a so-called “persistent vegetative state” whose parents wanted her feeding tube withdrawn so she would die, I was asked if I was going to feed my mother who had Alzheimer’s disease. At the time, my mother had no problems with eating but I knew the real question was about a possible feeding tube later on.

Ironically, I had just written an op-ed on the Cruzan case titled “Feeding is not Extraordinary Care” and I pointed out that if the withdrawal of food and water from people with severe brain injuries was accepted, the pool of potential victims would expand.

I was thinking about people like my mother and, sadly, I was right.

In 1993, just 3 years after Nancy Cruzan died a long 12 days after her feeding tube was removed, a letter in the Journal of the American Medical Association by Dr. Ezekiel Emanuel, one of the future architects of Obamacare, acknowledged that the actual proof purported to show that the Cruzan case met Missouri law requiring “clear and convincing evidence” that Ms. Cruzan would not want to live in a so-called “vegetative” state rested only on “fairly vague and insubstantial comments to other people”.

However, he noted that:

“…increasingly it will be our collective determination as to what lives are worth living that will decide how incompetent patients are treated. We need to begin to articulate and justify these collective determinations.” (Emphasis added.) Source: The American Journal of Medicine January 1993 Volume 94 p. 115

ALZHEIMER’S AND FEEDING TUBES

When I was asked about whether I would feed my mother with Alzheimer’s, I gave the same answer I gave when my baby daughter Karen with Down Syndrome and a heart defect was critically ill in 1983: Their anticipated deaths must be from their conditions, not from deliberate starvation and dehydration.

In the end, neither one needed a feeding tube. My daughter’s kidneys and other organs shut down and, since food or water would cause worse fluid overload, Karen was not given extra fluid and her heart gave out a short time later. In my mother’s case, she eventually needed to be spoon-fed until she quietly died in her sleep.

As a former hospice and ICU nurse, these scenarios are very familiar to me. Multiple organ failure sometimes occurs with critical illness and dying patients often gradually lose their appetites as they approach death. In those cases, we would give what little these people want or need until death. But for people not dying or near death, we made sure that they had at least basic  medical care and the life essentials of food, clothing and shelter. This is-or used to be-simple common sense.

ALZHEIMER’S AS A FATE WORSE THAN DEATH

The easiest way to get people to accept death by starvation/dehydration is to get them to choose it for themselves even before they have a problem.

Thus, media stories of people and their families suffering tremendously because of Alzheimer’s are very persuasive. People fear becoming an economic and emotional burden on their families. Not surprisingly, many people then willingly check off feeding tubes and other medical treatments in their advance directives.

Position papers like that from the American Geriatrics Society and the Alzheimer’s Association can also paint a dark picture:

The Association asserts that research evidence support no medical benefit from feeding tubes in advance dementia and that feeding tubes may actually cause harm in the advanced state of Alzheimer’s. Additionally, it is ethically permissible to withhold nutrition and hydration artificially administer by  vein or gastric tube when the individual with Alzheimer’s or dementia is in the end stages of the disease and is no longer able to receive food and water by mouth

The presumption is that such a death is peaceful and painless when a person is assumed to be unaware in a “vegetative” or late Alzheimer’s state. However, Bobby Schindler has written an account of the reality  of a prolonged starvation/dehydration death on his sister Terri Schiavo that was hidden from the public.

“JOE’S” CASE

Several years ago, I cared for a man with early stage Alzheimer’s who had a serious pneumonia needing a ventilator for a couple of days. Afterwards, Joe (not his real name) was alert and cooperative but the ventilator tube unexpectedly affected his ability to swallow and speak easily. His family asked about a feeding tube and special swallow therapists to try to retrain his throat muscles so that he could eat and drink safely. That is how an even older friend of mine in the same situation but without Alzheimer’s was successfully treated recently.

However in Joe’s case, a neurologist was first called to evaluate Joe’s mental status. I was there as the doctor asked him questions like “How many fingers am I holding up?” The man answered the questions correctly but the neurologist immediately wrote for nothing by mouth including crucial blood pressure medications. He also then recommended no feeding tube to the family. No swallow therapy was ordered. Joe was never asked about this.

When I questioned the neurologist and pointed out that the man had given correct answers by nods and holding up the correct number of fingers when asked, the neurologist responded by saying that the man did not hold up his fingers “fast enough”!

This is the tragic reality when we judge some lives as not worth living.

 

They are Lying to Us!

In my last blog “Legal Safeguards, Burdensome Obstacles and Conscience Rights”, I wrote about influential lawyer Thaddeus Pope’s article “Medical Aid in Dying: When Legal Safeguards Become Burdensome Obstacles” that listed  four ways to address such  “burdensome safeguards” in medically assisted suicide laws: “Expanding From Adults to Mature Minors”, “Expanding From Contemporaneous Capacity to Advance Directives” to pre-choose assisted suicide before becoming incompetent, “Expanding From Terminal Illness to ‘Reasonably Predictable’” and “Expanding From Self-Ingestion to Physician Administration”. (Emphasis added)

Other “burdensome obstacles” Mr. Pope has also cited include the waiting time between requests for assisted suicide and the administration of the lethal overdose for some patients and the physician requirement because of problems finding willing doctors.

While groups like Compassion and Choices and a mostly sympathetic mainstream media continue to tout allegedly strong “safeguards” in assisted suicide laws that allegedly prevent abuse, these “burdensome obstacles”- which already have been mostly eliminated in countries like Canada and Holland- are now beginning to fall here in the US and other new countries. Few of us are aware of this.

HAWAII

A case in point is Hawaii, whose legislature rejected assisted suicide just last year.

This year, a new bill, HB 2739, called the “Our Care, Our Choices Act” was recently fast-tracked in the legislature with testimony scheduled for February 27, 2018. It would allow advanced practiced registered nurses as well as doctors to be the “attending provider” for assisted suicide.

Despite the ubiquitous at least six problems with US assisted suicide laws that I have written about before, the Hawaii legislators claimed “robust safeguards” such as, “if appropriate”, the doctor (or nurse) can refer the terminally ill patient for  “counseling” to be performed by “a state-licensed psychiatrist or psychologist” but just for “determining that the patient is capable of making medical decisions and not suffering from a psychiatric or psychological disorder or depression causing impaired judgment”. This is not the same as the usual psychiatric/psychological evaluation required for other suicidal people. (Emphasis added)

(I submitted my testimony on this bill which is at the end of this blog.)

After “an emotional 5-hour hearing” February 27th, a joint House panel voted in favor of an amended version of HB 2739 that will now head to a vote of the full House in the near future.

The amended bill includes the welcome removal of advanced practice registered nurses as “attending providers” but added social workers to the psychiatrists or psychologists designated as the counselors to determining the patient’s “capability” and allows “counseling” by telehealth instead of in person. Finally, the new bill would also lengthen the time between oral requests for assisted suicide from 15 to 20 days.

Hopefully this terrible new assisted suicide bill will be defeated like last year’s.

But, as usual, Compassion and Choices continues to describe HB 2739 as just:

“Medical aid in dying is an end-of-life medical practice in which a terminally ill, mentally capable individual who has a prognosis of six months or less to live requests, obtains and—if his or her suffering becomes unbearable—self-ingests medication to die peacefully in their sleep.”

We all need to know that we are being lied to about assisted suicide and fight against such laws!


My Testimony on Hawaii’s HB 2739

February 26, 2018

Please Do Not Approve HB 2739, From a Mother and a Nurse

 As the mother of a physically healthy suicide victim who used an assisted suicide technique and as a registered nurse who has cared for suicidal people both personally and professionally for over 40 years, I implore you not to approve the dangerous HB 2739, the “Our Care, Our Choice Act”.

Despite the euphemism of “aid in dying” instead of medically (since advanced practice registered nurses can be “the attending physician”) assisted suicide and the demand for it as a fundamental right, this bill puts both desperate people and our health care system in danger. I want to address both issues.

My Daughter Marie Killed Herself Using an Assisted Suicide Technique

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

SUICIDE CONTAGION

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon.

After Oregon’s physician-assisted suicide law took effect in 1997, the rate of suicide increased. In 2015, the state’s health department said “The rate of suicide among Oregonians has been increasing since 2000” and as of 2012 was “42% higher than the national average”; suicide had become “the second leading cause of death among Oregonians aged 15 to 34 years.” These figures are in addition to deaths under the Oregon assisted suicide law, which legally are not counted as suicides.

My Marie was one of the almost 37,000 reported US suicides in 2009. According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of death among Americans with more than 44,000 people dying by suicide in 2015, more than 1.4 million people reported making a suicide attempt in the past year and almost 10 million adults reported thinking about suicide in the past year. Suicide costs society over $56.9 billion a year in combined medical and work loss costs.

Our urgent health care crisis is the staggering and increasing number of suicides, not the lack of enough medically assisted suicides.

The Effect of Medically Assisted Suicide on Our Health Care System

 MY STORY

Several years after Oregon’s law was passed, I was threatened with termination from my job as an intensive care unit nurse after I refused to participate in a deliberate overdose of morphine that neither the patient nor his family requested after an older patient experienced a crisis after a routine surgery.

The patient had improved but did not wake up within 24 hours after sedatives used with a ventilator were stopped. It was assumed that severe brain damage had occurred and doctors recommended removing the ventilator and letting the patient die.

However when the ventilator was removed, the patient unexpectedly continued to breathe even without oxygen support. A morphine drip was started and rapidly increased but the patient continued to breathe.

When I refused to participate in this, I found no support in my hospitals “chain of command” and I could not pass off this patient to another nurse so I basically stopped the morphine drip myself, technically following the order to “titrate morphine for comfort, no limit.”

The patient eventually died after I left but ironically, a later autopsy requested by the family showed no lethal condition or brain injury as suspected.

The physician who authorized the morphine demanded that I be fired.

I’ve known other doctors, nurses and therapist who have similarly put their jobs on the line to protect their patients. Unfortunately, we are fast becoming pariahs in the face of medically assisted suicide legalization.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of protection for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards. For thousands of years doctors (and nurses) have embraced the Hippocratic standard that “I will give no deadly medicine to any one, nor suggest any such counsel.” Should the bright line doctors and nurses themselves drew to separate killing from caring now be erased by legislation?

As a nurse, I am willing to do anything for my patients — except kill them. In my work with the terminally ill, I have been struck by how rarely these people say something like, “I want to end my life.” And the few who do express such thoughts are visibly relieved when their concerns and fears are addressed and dealt with instead of finding support for the suicide option. I have yet to see such a patient go on to commit suicide.

In 2015, the Canadian Supreme Court approved MAID (medical aid in dying aka medically assisted suicide) and lethal injection suicides began in Quebec, one of Canada’s largest provinces. Now, “only 5 of more than 2,000 Canadian patients who used medical aid in dying self- ingested the lethal medication.”

But a December, 2017 Canadian medical journal article “First Results from a Unique Study” done in Laval, Canada showed that although prior to the law, 48% of doctors said they would participate, 30% with conditions and only 28% said they would never participate, afterwards, 77% of the physicians getting MAID requests refused to actively participate, all of them using the conscientious objection clause, even though the study claimed the majority (72%) were in favor of MAID with only 13% of the doctors neutral or ambivalent. The most common reason given for refusal was “too much of an emotional burden to bear”.

Do assisted suicide supporters really expect us doctors and nurses to be able to assist the suicide of one patient, then go on to care for a similar patient who wants to live, without this having an effect on our ethics or our empathy? Do they realize that this can reduce the second patient’s will-to-live request to a mere personal whim – perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that we helped other human beings kill themselves?

Conclusion

Medically assisted suicide is a dangerous proposition and HB 2739 goes beyond even Oregon’s law by approving advanced practice registered nurses as providers. Other countries have gone farther to include chronic psychiatric conditions, birth defects and even just old age.

We must not discriminate on the basis of health and choice when it comes to desperate people seeking suicide. We must treat all of our citizens with equal concern.