assisted suicide

“Good” News about Dying in America?

nancyvalko assisted suicide, conscience rights, euthanasia, medical ethics

This month Medscape, a subscription news service for medical professionals, published the article “Good News about Dying in America” by Dr. George Lundberg. Dr. Lundberg is the former editor of the Journal of the American Medical Association (JAMA)  and editor-at-large of Medscape itself as well as a member of the Institute of Medicine of the National Academies.

But the title “Good News about Dying in America” is ironic because this article is really a homage to the pro-death movement. In the article, Dr. Lundberg approvingly chronicles a recent history of the “right to die” movement in the US including the rise of legalized physician-assisted suicide and his part in it.

Although he writes that he is not looking forward to his own death, he maintains that

To accomplish medical and cultural change, one needs to work at the levels of moral beliefs and ethical standards with professional and individual leadership.Subsequent changes in state and federal laws and regulations may be needed. Economic drivers can move it along. But first, you have to get their attention.” (Emphasis added)

Dr. Lundberg congratulates himself for getting this attention started by publishing the anonymous 1988 JAMA article “It’s Over Debbie”  which Lundberg claims is a “factual tale of a caring physician using intravenous morphine to end the horrid pain-wracked life of a young woman with terminal ovarian cancer.”

However, when you read this short article, you read about a doctor in training who, under the cloak of anonymity, writes about being on call at a hospital and awakened in the middle of the night to see a patient he had never met before. He describes “a 20-year-old girl named Debbie was dying of ovarian cancer. She was having unrelenting vomiting apparently as the result of an alcohol drip administered for sedation.” He writes that her condition was“a cruel mockery of her youth and unfulfilled potential” but that Debbie’s only words to him were “Let’s get this over with”. An older, dark-haired woman staying with Debbie was assumed by the young doctor to be her mother.

Then, in the anonymous doctor’s own words, he writes :

The patient was tired and needed rest. I could not give her health, but I could give her rest. I asked the nurse to draw 20 mg of morphine sulfate into a syringe. Enough, I thought, to do the job. I took the syringe into the room and told the two women I was going to give Debbie something that would let her rest and to say good-bye. (Emphasis added)

After giving Debbie the the lethal overdose, the doctor writes:

I waited for the inevitable next effect of depressing the respiratory drive. With clocklike certainty, within four minutes the breathing rate slowed even more, then became irregular, then ceased. The dark-haired woman stood erect and seemed relieved.

Quite a different story from what Dr. Lundberg  proudly portrays as a caring act. Is the deliberate killing of a newly met patient without request, explanation or actual consent by a doctor in training really part of Dr. Lundberg’s  vision of “(t)he cultural change we need now is to allow death to occur when its time has come and to do so with dignity and without undue pain and suffering for the patient to the greatest extent possible?”

Dr. Lundberg writes further on other “breakthrough” moments in medicalized killing after the “It’s Over Debbie” article:

Next was Dr Timothy Quill and his disclosure in the New England Journal of Medicine in 1991 that he prescribed barbiturates at the request of a leukemia patient to allow her to end her life. Then, beginning in 1990, Dr Jack Kevorkian and his suicide machine assisted in the deaths of more than 100 patients; the right message writ large but by a deeply flawed messenger. (emphasis added)

As a medical professional myself, it is horrifying that such influential medical people not only have embraced the concept that it is acceptable and even compassionate to medically kill people, but now promote it.

And there is a jarring apparent lack of empathy and understanding of the challenges serious illness poses to patients and their families at the end of Dr. Lundberg’s article:

hospitals interested in their patient safety statistics might do well to note that much of what is chalked up as deaths related to medical error is actually occurring with the frail elderly, often in critical care units (CCUs). Many of these patients probably should not be in the CCU anyway. Maybe not even in hospitals. …. Help your safety statistics; let the dying die at home. (Emphasis added)

While Dr. Lundberg’s article is appalling to those of us who refuse to kill our patients or help them kill themselves, it is important for all of us to understand that many of our alleged “experts” are leading us into a cultural as well as medical and legal war over human extermination.

Some Canadian Veterinarians Offer to Teach Doctors about Euthanasia

nancyvalko assisted suicide, euthanasia, medical ethics

In February 2015, the Canadian Supreme Court unanimously voted to legalize physician-assisted suicide.  In September 2015, it was revealed that Canada’s Quebec province was preparing euthanasia kits with lethal injections for distribution to doctors for assisted suicide.

In December, Canada’s National Post published an article titled “‘We can definitely help’: What vets can teach doctors about assisted dying“ that reports:

Before every euthanasia, Dr. Amy Wilson prays things will go smoothly — that her patient will sedate well, that she’ll hit the vein with the catheter on the first try, that there will be no sudden, involuntary spasms or grunts for breath that can be agonizing for owners.
Wilson, like all veterinarians, is trained to put suffering animals to death as humanely as possible. She does it more often than she wishes she had to, but she does it well. Now, as Canada continues to debate the way forward on assisted dying, she and other vets say there is much they can teach doctors about a different kind of animal — humans

One argument long promulgated by assisted suicide/euthanasia proponents is that we should put people out of their misery just as we do for our pets.

However, pets become at risk for many reasons:

According to the American Humane Association, the most common reasons why people relinquish or give away their dogs is because their place of residence does not allow pets (29%), not enough time, divorce/death and behavior issues (10% each). The most common reasons for cats are that they were not allowed in the residence (21%) and allergies (11%).

Many are then taken to animal shelters. About twice as many animals enter shelters as strays compared to the number that are relinquished by their owners but nevertheless about 1/3 each year, approximately 2.7 million animals, are euthanized.

According to the website Petful, pets in animal shelters in the United States are euthanized every year for three major reasons: illness, aggression and overpopulation.

Regarding illness, the website states:

Because most shelters operate on tight budgets, the cost of treating every animal’s illness is impossibly high.Many shelters have veterinarians to prescribe medications and perform exams for sick animals, but the decision to euthanize must still be made sometimes after considering several factors:
•The severity of the illness
•The chance of recovery
•How infectious the disease is
•The cost of treatment
•The length of treatment
•The adoptability of the pet

Do we really want to adopt a veterinary standard that makes it acceptable to euthanize people as well as pets when illnesses are too expensive or  personalities are too difficult or simply when there are too many of them around?

Effects of Euthanasia on Veterinarians

Although the National Post article is generally supportive of veterinarians teaching doctors to perform euthanasia, it does document the emotional distress that can affect even veterinarians who perform euthanasia:

Studies suggest people whose jobs require them to kill animals are at risk of a phenomenon known as PITS – perpetration-induced traumatic stress. Euthanasia was one of the reasons Rothenburger (a veterinarian) chose to leave practice; she now specializes in pathology. When she used to perform euthanasia, “I put this filter on: This was ending suffering. That was the role I had to play. But it often wasn’t easy, and it’s hard to keep your professional persona on when you’re trying not to shake while you’re injecting the medication, or not cry with the owners until you’ve done your job.”

Studies have documented a higher suicide risk among vets than the general population. A 2010 survey by the Canadian Veterinary Medical Association found 19 per cent of those who responded had seriously thought about suicide, half reported experiencing burnout and 27 per cent were taking anti-depressants. Rothenburger belongs to a closed Facebook page called Not One More Vet. “It’s a safe place for vets to talk about things they need to get off their chest,” she says, “like compassion fatigue, and maybe that tough euthanasia.” (Emphasis added)

Many years ago, my adult children and I had to have our beloved cat Callie euthanized because of an inoperable cancer. We decided to stay with Callie throughout the procedure because we wanted to surround her with love until the end. However, the procedure had some unexpected difficulties and we all found the process stressful and incredibly sad.

When we left, I told my children that if anyone ever tried to euthanize me for any reason, they had better stop them.

People are not animals and they must not be treated like animals.

New Study: Suicide Contagion and Legalized Physician-Assisted Suicide

nancyvalko assisted suicide, bereavement, suicide

 

Even before my 30 year old daughter Marie died by suicide in 2009 using an assisted suicide technique, I was writing and giving talks on physician-assisted suicide (PAS) for years. Even then, I worried about effect of the mainstream media portraying PAS as a civil right and even “courageous”, especially since the existence of suicide contagion aka “copycat suicides” was well known. I was not surprised when after Marie’s death, at least two people close to her became suicidal. Thankfully, they were saved by treatment.

Now we have even more information about this from a Southern Medical Journal a medical journal article that was published at the same time Governor Brown signed the California’s PAS law. In the study “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” , researchers meticulously examined suicide rates in Washington and Oregon after those states passed PAS laws.

The results are shocking. In those states, the researchers found a 6.3% increase in total suicide with a larger increase (14.5%) among individuals 65 or older. Moreover, there was no decrease in nonassisted suicides (people taking their own lives), despite the claims of PAS advocates that legalizing PAS would reduce the overall number of nonassisted suicides. Instead, the researchers found that “Rather, the introduction of PAS seemingly induces more self-inflicted deaths than it inhibits.”

On November 20, 2015, the Washington Post newspaper published an excellent op-ed article titled “The Dangerously Contagious Effect of Assisted-Suicide Laws “ by Dr. Aaron Kheriaty, an associate professor of psychiatry and head of the medical ethics program at the University of California at Irvine. Citing the medical journal study, Dr. Kheriaty concludes that:

“Debates about physician-assisted suicide raise broad questions about our societal attitudes toward suicide. Recent research findings on suicide rates press the question: What sort of society do we want to become? Suicide is already a public health crisis. Do we want to legalize a practice that will worsen this crisis?”

Is Suicide Really a Public Health Crisis?

The national Centers for Disease Control website reports the following statistics in a section titled “Suicide and Suicide Attempts Take an Enormous Toll on Society”. Here are some excerpts:

• Suicide is the 10th leading cause of death among Americans
• More than 40,000 people died by suicide in 2012
• More than 1 million people reported making a suicide attempt in the past year.
• More than 2 million adults reported thinking about suicide in the past year.
• Most people who engage in suicidal behavior never seek mental health services.

Costs to Society
The following estimates are based on 2010 CDC data and refer to people age 10 and over.
• Suicide costs society over $44.6 billion a year in combined medical and work loss costs.
• The average suicide costs $1,164,499. (Emphasis in original)

The toll on survivors, family member or friends of a person who died by suicide is also enormous, as I can personally attest:

• Surviving the loss of loved one to suicide is a risk factor for suicide.
• Surviving family members and close friends are deeply impacted by each suicide and experience a range of complex grief reactions including, guilt, anger, abandonment, denial, helplessness, and shock

.
Fighting Suicide Contagion

It is tragic that suicide prevention organizations ignore the PAS issue and the mainstream media is almost uniformly sympathetic to the PAS movement despite World Health Organization and national media guidelines for suicide reporting. This has allowed PAS groups like Compassion and Choices not only to press harder for universal PAS laws but also to even change the names of such laws to euphemisms such as “End of Life Options” or “Death with Dignity” to disguise the fact that physician- assisted suicide is obviously suicide.

However, Dr. Kheriaty in his Washington Post article also talks about a related phenomenon called the Papageno effect that:

“suggests that coverage of people with suicidal ideation who do not attempt suicide but instead find strategies that help them to cope with adversity is associated with decreased suicide rates.”

I have always maintained that our stories as suicide survivors, people with disabilities or terminal illnesses, etc. offer hope and inspiration while those about PAS promote despair and hopelessness. We need to tell our stories publicly.

All of us and especially people in states that are currently targeted by groups like Compassion and Choices for legalization of PAS, need to know and share the real facts about PAS as well as suicide prevention and treatment, including the national suicide hotline number (1 (800) 273-8255) and website (www.suicidepreventionlifeline.org).  Suicide prevention and treatment can work whether people are considering PAS or killing themselves.

Addendum: Ironically, just as I was finishing this blog, I was interrupted by a call from a man living in another state with an incurable, disabling condition. He was referred to me last month when he saw a segment on a celebrity’s suicide involving the same condition and decided that he wanted to go to California to use the newly passed PAS law. I talked to this man for quite some time.

I was elated when this gentleman now told me that the resources I recommended, the people he talked to and even just the fact that someone cared did change his mind and he no longer wants to end his life. He said he now wants to start actually living again.

This man’s story shows why we must not discriminate between suicide and physician-assisted suicide when it comes to suicide prevention and treatment.

Germany Legalizes Assisted Suicide-As Long As It Is “Free”

nancyvalko assisted suicide, euthanasia, medical ethics, nursing

While the UK Parliament overwhelmingly defeated a physician-assisted suicide bill in September 2015, less than two months later the German parliament has passed a law legalizing some assisted suicides. As Reuters News reported:

“The bill, which was upheld with 360 out of 602 votes, criminalizes organizations that assist patients in terminating their own lives for profit. It is meant to prevent the commercialization of the procedure as a “suicide business.”

However, single instances of suicide assistance – by a doctor or relative – do not contradict the new law. A husband who helps his terminally ill wife to die would not be prosecuted.

“Commercial” assisted suicide would be punished by up to three years imprisonment, even if doctors allegedly perform the procedure to relieve suffering.

Why Germany?

The law is a surprise to many, especially since Germany has long been sensitive to the issue of euthanasia following its’ history in World War II when the Nazis used the practice to kill over 200,000 people with mental and physical disabilities as well as millions of Holocaust victims.

Actually, the 1945 Hadamar Trial involving euthanasia by healthcare professionals at the Hadamar psychiatric clinic was the first mass atrocity trial in the US zone of Germany following World War II. As a nurse, I was particularly horrified when I first read about the famous study of the willing participation of nurses titled “Killing while caring: the nurses of Hadamar”

What can we expect?

Former Justice Minister Brigitte Zypries said the new German assisted suicide law “will open an era of great legal uncertainty” and will certainly be appealed to the Federal Constitutional Court.

But If efforts to stop the German law fail, the law will doubtless be expanded in the future as other countries in Europe have done.

Although ignored or dismissed in the US, the expansion and problems of euthanasia/assisted suicide in European countries like the Netherlands, Belgium, Luxembourg and Switzerland show the danger of first accepting a supposedly “limited” assisted suicide law.

For example, the Netherlands now uses lethal injections to dispatch infants with disabilities and adults of any age even without physical illness or consent. Belgium has done planned organ donation after euthanasia by lethal injection with the Ethics Committee of Eurotransplant even formulating recommendations for organ donation after euthanasia.  And Switzerland has a booming business with assisted suicide organizations like Exit and Dignitas even though a study showed that 16% of assisted suicide deaths in Switzerland are of people who have no underlying illness.

Conclusion

As the late Richard John Neuhaus wisely said ” I believe in the slippery slope the same way I believe in the Hudson River. It’s there.”

But until we are ready to recognize the potent logic about the disastrous and unintended consequences when we legalize “just a little bit” of legalized medical killing, we may find that the slippery slope has no bottom.

Physician-assisted Suicide: Nurses in the Line of Fire

nancyvalko assisted suicide, conscience rights, medical ethics, nursing

Years ago, the newly legalized Oregon physician-assisted suicide law caused much discussion at my St. Louis hospital. Some of my fellow nurses said that they supported such a law but when I asked them if they would participate, they were shocked. “No, of course, the doctor would have to do it!”, one exclaimed. Some nurses, like perhaps most people,  thought assisted suicide would only occur at a patient’s home with his or her family sitting with the patient watching the drinking of the lethal overdose.

I explained that in hospitals or hospices, would we expect the assisting doctors to be present when the patient ingested the lethal overdose, not to mention staying with the patient and family during the time it could take for the patient to die? My colleague agreed that nurses, not doctors, would probably bear the brunt of the “dirty work” of assisted suicide.

Back in 2000 and three years after Oregon legalized physician-assisted suicide, I saw an article from Nursing Spectrum magazine titled “Assisted Suicide: What Role for Nurses?” that stated:

Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients,” says Pam Matthews, RN, BSN, administrator for Evergreen Hospice, Albany, OR, “but in reality, nurses are usually the ones in the line of fire…. Much of nurses’ roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.” (emphasis added)

How many nurses are really willing to “advocate” for physician-assisted suicide? The article states:

“Before PAS became law, it was publicly debated, and we performed surveys of our hospice teams’ feelings on the issue,” Matthews says. “We found that most nurses felt strongly that patients should have the choice of PAS, although most said they would not participate in the event.” (emphasis added)

Recently, I spoke to a nurse in Washington State who is against physician-assisted suicide law about nurses’ experience with physician-assisted suicide in her state. She referred me to a 2014 study in the Journal of Pain and Symptom Management titled “Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death”. (click on link and click PDF to read the full text)

While 21% of the Washington hospices in this study, mostly religiously-affiliated, refused any involvement in assisted suicide, this study sadly confirms the how legalization has affected both hospices’ and nurses’ role in assisted suicide.

Here are some excerpts:

First of all, the study notes that:

(T)he primary patient rights organization that facilitates arrangements for physician-assisted death, Compassion & Choices, refers terminally ill patients to hospice programs as a first resort for end-of-life caregiving. (emphasis added)
And admits that:
The authorizing legal statutes in both states (Oregon and Washington) make no reference to the experience of severe pain or intolerable suffering as an indication for a patient to make a request for physician-assisted death but rely entirely on the entitlement due a patient in respect of their personal dignity. (emphasis added)
However, the study rationalizes the upwards of 90% of physician-assisted suicide victims being enrolled in hospice:

The designation of a ‘‘physician’’ as the primary professional resource for patients allows hospice programs to maintain fidelity to the norm that ‘‘hospice neither prolongs nor hastens dying’’ (our emphasis). In short, although most patients who use the Death with Dignity rights are enrolled in hospice, hospice programs want to stress that this is a ‘‘physician-directed’’ process, not ‘‘hospice-assisted’’ death.” (emphasis added)

The study provides further dubious rationalization:

Although the phrase (“hastening death”) is descriptively accurate about what typically happens when a patient ingests the medication, describing the process in this manner appears to compromise a central hospice precept that dying or death is not to be hastened. It thus raises a broader question about an evolving hospice identity and integrity in which, in contrast to historical tradition and practice, hospice programs are willing to incorporate practices that hasten death. Insofar as several hospices in both Oregon and Washington have policies with respect to palliative sedation, in which pain relief is the primary goal even if death is hastened as a secondary consequence, it may be that some hospice programs could legitimately claim that the issue has already been resolved, and physician-assisted death is the moral equivalent for hospice of palliative sedation.” (emphasis added)

As far as allowing the hospice nurse to exercise his or her conscience rights:

In every circumstance in which personal, moral, or ethical values are cited as a basis for a caregiver to request they withdraw from being the responsible caregiver for a patient that makes a request, another staff member must be available to assure continuity of care and avoid violating the hospice value of non-abandonment.” Two traditional tenets of hospice philosophy-non-abandonment and refraining from ‘‘hastening death’’-remain prevalent values but create their own complications. (emphasis added)

One obvious complication is that it may not always be possible to find another nurse willing to be involved in the assisted suicide and if not enough willing nurses can be found, this “right” to withdraw may result in workplace discrimination against such nurses or even rejection of some potential hospice nurses before employment.

The article also cites a surprising reason, denied or unmentioned in news stories, for some hospice policies restricting nurses from actually attending the assisted suicide:

This may be particularly compelling in circumstances where the patient experiences complications with the medication (e.g., when the patient aspirates the medication), and some further medical treatment is needed by the patient for death to occur. In this context, the restriction on hospice staff presence serves as a further check against physician-assisted death becoming hospice-assisted death.
(emphasis added)

In the conclusion, the study refers to a 2011 Hastings Center Report by ethicist Bruce Jennings, MA:

Jennings contends that legalized physician-assisted death presents a defining moral choice for hospice identity because ‘‘legalization(of physician-assisted death) would liberate dying people from what hospice had been teaching could be a meaningful and valuable time of life. On the other hand, a major part of that quality of living while dying that hospice champions is autonomy, respect, and dignity. How could hospice stand against that?”  (emphasis added.)

For the sake of ourselves, our patients and our profession, how can we nurses NOT make a stand against physician-assisted suicide?

Euthanasia Kits, Conscience rights and Coercion

nancyvalko assisted suicide, Canada, conscience rights, medical ethics

The country that gave us Celine Dion, Mike Myers and Joni Mitchell is now giving doctors euthanasia kits?

As I wrote in a September blog “Disaster in Canada”, this past February, the Canadian Supreme Court unanimously ruled to end the long-standing ban on physician-assisted suicide and gave federal and provincial governments 12 months to craft legislation to respond to the ruling. Despite concerns raised by opponents of assisted suicide, the Canadian supreme court agreed with the trial court that physician-assisted suicide laws like that in Oregon has curtailed such abuses and missteps. “The risks associated with physician-assisted suicide,” the high court stated, “can be limited through a carefully designed and monitored system of safeguards.”

But even before such legislation is made, Canada’s second largest province Quebec is jumping to allow to active euthanasia via lethal injections.

In a shocking article in the British Medical Journal titled “’Euthanasia kits’ are prepared for Quebec doctors as palliative care centres rebel on right to die” , new guidelines from the College of Medicine in Quebec on physician-assisted suicide include “euthanasia kits”. These kits contain three sequential injections: a benzodiazepine sedative to relieve anxiety, a barbiturate to induce coma, and a curare-type neuromuscular block to stop the heart and respiration with backup doses, and detailed instructions. These kits will be available to all licensed physicians in Quebec. (Emphasis added)

Ironically, this lethal injection protocol mimics the lethal injection protocols used in the US for executions that are now being challenged by groups like the ACLU as “cruel” and “inhumane.”

The rationale for doctor-administered lethal injections over the self-administered oral lethal overdoses just signed into law in California is explained in the BMJ article:

The college decided that doctors should administer the drugs intravenously rather than simply prescribe an oral drug. Yves Robert, secretary of the college, said that this had involved seeking advice from abroad, including speaking to the first doctor to legally prescribe life ending drugs in Oregon, USA, nearly 20 years ago. “He told us there were some bad side effects,” Robert said, including regurgitation and, in a few cases, reawakening days later.” (Emphasis added)

Apparently, the annual Oregon state health reports on assisted suicide that rely merely on the assisting doctors’ self-reporting of problems are not much of a “safeguard”. Nonetheless, all the public (and the Canadian supreme court) continues to hear is that physician-assisted suicide laws are working well without any problems.

PUSHBACK

But the existence of euthanasia kits is not the whole story.

As the BMJ article reports, all 29 of Quebec’s palliative care centers announced a collective decision not to offer physician-assisted suicide, now renamed “medical aid in dying.” At least for now.

One director stated that “There is no doctor here who’s willing to push that syringe.”

This refusal has apparently enraged physician-assisted suicide supporters like Gaétan Barrette, Quebec’s health minister, who stated:

“Once again, this is a comment that prioritizes the views of the physician, when the law is made for the patient,” said Barrette. “I have a very formal announcement to make to these doctors: physicians, nowhere in Quebec, are owners of the institution. Not of the institution, nor of the floor, nor of a single bed. In no way can a doctor say: ‘In room 326, this will never happen.’ That is completely inappropriate.”

So now there are now efforts to challenge the conscience rights of objecting doctors.

Euthanasia/assisted suicide supporters know that without enough medical professionals willing to perform medicalized killing, the movement itself is dead.

Unfortunately, such supporters have had better luck in the US with convincing groups like the California Medical Association, the American Public Health Association, The American College of Legal Medicine, American Medical Student Association and American Medical Women’s Association and The American Academy of Hospice and Palliative Medicine to support legalized physician-assisted suicide or take a “neutral” position using polls, not principles.

It is a myth that physician-assisted suicide will only ever involve oral lethal overdoses requested by terminally ill patients in unbearable pain. As we have seen with the relentless progression of medically assisted killing in Holland, Luxembourg, and Belgium, it is just a matter of time before lethal injections are considered more humane than unreliable oral overdoses and the pool of potential victims expands beyond the terminally ill and just those who request it.

Tragically, it is a very short step from saying “I would not want to live like that” to saying “No one should live like that.”

Like those doctors of conscience in Quebec, those of us in the US who are also medical professionals need to be our own Resistance Movement against medicalized killing and the efforts to coerce us into participating.

Why California’s Governor Brown is Wrong About Physician-assisted Suicide For “Excruciating Pain”

nancyvalko assisted suicide, medical ethics, palliative care

When California Governor Jerry Brown signed the physician-assisted suicide law, he wrote

“In the end, I was left to reflect on what I would want in the face of my own death,” the governor wrote. “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

Gov. Brown apparently believes the two myths promulgated by pro-assisted suicide organizations and most mainstream media about physician-assisted suicide: 1. Unbearable pain is routine in terminal illnesses and often cannot be relieved. 2. Unbearable pain is the reason people choose physician-assisted suicide.

As a former hospice, oncology, trauma, and critical care nurse, I made sure my patients had the best pain control possible after one unforgettable incident that happened shortly after I graduated from nursing school.

In 1969, I cared for a 32-year old woman I will call “Joan” who was dying from cancer. Joan looked emaciated with her skin  stretching over her bones and she was in terrible pain. Joan’s pain was so intense at times that she even talked about wanting us to kill her. At the time she was on a relatively small dose of Demerol given by an intramuscular shot every 4 hours as needed for pain.

I gave her the shot, wincing as I injected it into her shrunken buttock but the shot did nothing for her pain. I went to my head nurse who said to repeat the injection in four hours but  “Joan” continued to have intense pain.

I reported this to my head nurse and Joan’s doctor, suggesting that the dose be increased and/or given more often. The doctor told me no because he said he did not want her to “become addicted” to pain meds. I couldn’t believe my ears. I told him that she was imminently dying, even asking us about killing her to relieve the pain. Joan didn’t have to worry about addiction. I knew that from nursing school. The doctor still refused.

I went over his head to the chief of staff and the assistant director of nursing to plead for Joan. Instead, I was told that if I gave Joan her shot even 15 minutes earlier than the 4 hours, I would be fired.

I was frustrated to the point of tears but I knew there was one thing I could do.

I spent the last two days of Joan’s life with her as much as possible while working my shifts. After my shifts, I would sit with her for hours telling her stories, stroking her back, and doing whatever I could to distract her from the pain until she finally fell asleep. I would not abandon her.

After Joan died, I decided to learn everything I could about pain relief so that I could rebut a future ignorant doctor and help my patients. And I did. I studied every article on pain relief that I could find and talked to experts in the field as well as experienced colleagues. I’m still doing this 46 years later.

I never again had a patient die with severe pain.

For example and 20 years later, I started working on an oncology (cancer) floor in honor of my mother who I cared for until she died  from cancer and Alzheimer’s disease. As I promised my father, I made sure she was comfortable and Mom was even alert and in good spirits at the end.

I loved my new job in oncology but one day I came in hearing a woman down the hall screaming. That was unusual on our floor. It turned out that this woman I’ll call “Kim” was also a 32-year old woman with terminal cancer.

Kim’s pain had been under good control at home with long-acting morphine pills supplemented with fast acting morphine pills to relieve breakthrough pain. However, her family mistakenly thought that since her pain was relieved, she did not need to take her long-acting pills. Kim agreed but the result over a short time was terrible pain unrelieved by slowly increasing a morphine drip.

Working with the doctor, I came up with an overnight game plan to aggressively and quickly treat her extreme pain. The doctor agreed after I promised to monitor Kim closely so that her breathing would not be compromised.

By the next morning, Kim’s pain was finally under control and shortly afterward, she was able to be discharged home on her usual medication regimen.

Governor Brown, using pain as a reason to enlist doctors and nurses to help patients kill themselves is perverse not only because pain can be controlled, especially with the medical advances we have today but also because Oregon’s own report shows that physician-assisted suicide victims in Oregon cited “Losing autonomy”, “Less able to engage in activities making life enjoyable”, “Loss of dignity”,“ Losing control of bodily functions” and “Burden on family, friends/caregivers” before “Inadequate pain control or concern about it” as the top end of life concerns.

Personally, I will continue to fight for good pain and symptom control for all patients as passionately as I oppose physician-assisted suicide.

CALIFORNIA GOVERNOR SIGNS ASSISTED SUICIDE BILL AND MY 1996 ARTICLE “NO BLANK BULLETS”

nancyvalko assisted suicide, conscience rights, euthanasia, medical ethics

USA Today article: Calif. governor signs assisted suicide bill

Comment: Note the quote about why Governor Brown signed this bill after it was defeated 4 times in committee with weeks of deliberation: “In the end, I was left to reflect on what I would want in the face of my own death,” the governor wrote. “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

Unfortunately, it seems too many people base their judgements about physician-assisted suicide based on possible future self-interest rather than what the bill allows-medicalized killing by suicide-instead of the terrible consequences on people at risk, medical ethics and society.

Almost 20 years ago and before Oregon implemented its physician-assisted suicide law, I wrote the following commentary for the January-March 1996 edition of the Patients Rights Council newsletter. I believe it is just as valid today.

No Blank Bullets

Ready… aim… fire!

All the B-movie scenes I watched as a child flashed through my mind when I heard that a convicted murderer had been recently executed by firing squad. My visceral reaction was to cringe, instantly imagining the terror of being blindfolded and waiting for the bullets to hit. What I couldn’t imagine, though, were the feelings of being one of the men called to pick up and aim a piece of cold, hard steel at another human being. Would the man cope by pretending it was just another round of target practice? Would he try to remember the details of the murders and the tears of the victims’ families to muster the outrage that such crimes call for? What did he feel after the execution — sadness or satisfaction?

I was not surprised to later learn that one of the firing squad guns contained only blank bullets. In such circumstances, it is sensible to protect each executioner from the certain knowledge that he personally ended another’s life. In the more common lethal injection executions, the process is said to include at least two people and two buttons to start the process. Again, the procedure for legally terminating another life tries to protect those whom society asks to perform the awful task.

It is ironic, therefore, that society is considering the addition of yet another kind of execution to the legal list — assisted suicide — but this time without the blank bullets.

Few people would seriously consider legalizing relative– or family-assisted suicide. The inherent dangers of this type of private killing are much too obvious. Thus, the goal must be physician-assisted suicide or, more accurately, health care professional-assisted suicide, since nurses also must necessarily be involved when the assisted suicide occurs in a health facility or home health situation. We doctors and nurses are the ones society is now considering asking to perform the act of terminating lives, but unlike the firing squad or the lethal injection team, we will know and have to live with the certain knowledge that we caused death.

It is doubly ironic that when a convicted murderer tries to discourage efforts by lawyers to stop his or her execution, this is considered as a sign of stress or mental disorder, while a sick person’s willingness to die is considered an understandable and even courageous decision! How do we reconcile the two views that killing is the ultimate punishment for a convicted murderer and, at the same time, the ultimate blessing for an innocent dying or disabled person?

Both the American Medical Association and the American Nurses Association have recently issued strong statements against assisted suicide and euthanasia. While acknowledging the very real deficiencies too often found in care at the end of life, these organizations call for more education and access to help instead of the simple but dangerous option of killing terminally-ill or severely-disabled people or helping such people kill themselves. It is eminently logical that our concern for life should not be limited to just the curable.

And, although some polls show that a significant number of doctors and nurses, like the general public, say they could support assisted suicide in a hypothetical case, when faced with the realities and ramifications of legalizing the practice, most express deep concerns and fears regarding its implementation.

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 have drawn to separate killing from caring now be erased by legislators or judges?

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.

This should not be surprising. Think about it. All of us have had at least fleeting thoughts of suicide in a time of crisis. Imagine how we would feel if we confided this to a close friend or relative who replied, “You’re right. I can’t see any other way out either.” Would we consider this reply as compassionate or, instead, desperately discouraging? The terminally-ill or disabled person is no different from the rest of us in this respect.

I often wonder if right-to-die supporters really expect us doctors and nurses to be able to assist the suicide of one patient and 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 really want to risk more Jack Kevorkians setting their own standards of who should live and who should die?

The excuse that the only real issue is the patient’s choice would be cold comfort to us doctors and nurses when we have to go home and face the fact that we helped kill another human being or had to remain silently powerless while some of us legally participated. There will be no blank bullets then for us — or for society.

MERCATORNET: GOVERNOR BROWN, DO NOT SIGN THE DEATH WARRANT OF UNHAPPY PEOPLE

nancyvalko assisted suicide, bereavement, medical ethics

FRIDAY, 25 SEPTEMBER 2015
Governor Brown, do not sign the death warrant of unhappy people
BY NANCY VALKO

My daughter was the victim of assisted suicide, but she is not the only one.

Right now, a law hurriedly pushed through the California legislature after multiple defeats sits on the desk of Governor Jerry Brown and awaits his signature. As both a mother and a nurse I beg Governor Brown to veto it.

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. Derek Humphry is the founder of The Hemlock Society, now included with other assisted suicide groups and known as Compassion and Choices. 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 physician-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.

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. Often media coverage or publicity around one death encourages other vulnerable people to commit suicide in the same way.

Think of Brittany Maynard, the young woman with a brain tumour who moved to Oregon to kill herself last November with a doctor prescribed overdose. Weeks before she killed herself, Ms. Maynard partnered with the well-funded Compassion and Choices organization to raise even more money to promote the legalization of physician-assisted suicide throughout the US.
There was an immediate and unprecedented media frenzy surrounding Ms. Maynard’s tragic story that routinely portrayed her pending suicide as “heroic” and even counting down the days to her suicide. Personally, I thought this looked like a crowd on the street shouting for a suicidal person on a window ledge to jump, but the narrative worked with much of the public.

One problem with the media frenzy is that it violated well-established public health standards for how we talk about suicide. The National Institute for Mental Health has warnings about reporting on suicide that include “Risk of additional suicides increases when the story explicitly describes the suicide method, uses dramatic/graphic headlines or images, and repeated/extensive coverage sensationalizes or glamorizes a death.” (emphasis added) Instead, the NIHM recommends including “up-to-date local/national resources where reader/viewers can find treatment, information and advice that promote help-seeking”.

However, Compassion and Choices even denies that physician-assisted suicide is suicide, insisting instead that the media use euphemisms like “aid-in-dying” and “death with dignity” in cases like Ms. Maynard’s. However, this defies common sense and even the definition of suicide as “the intentional taking of one’s own life.” Apparently, there are reasons for this:
A 2013 Pew Research Center poll showed that public opinion on physician-assisted suicide law is closely divided, with 47 percent of US adults approving and 49 percent disapproving. A Gallup poll article showed eliminating the term “suicide” in public polls on assisted suicide laws can increase support by as much as 20 percent. Changing the terminology of assisted suicide also allows immunity for assisting medical professionals and gets around standard life insurance policies that deny payouts for suicides occurring in the first two years of a policy.

I have been a registered nurse for 46 years, working in intensive care, oncology, hospice and home health among other specialties. Personally and professionally, I have cared for many people who attempt or consider killing themselves.
Some of these people were old, chronically ill or had disabilities. Some were young and physically healthy. A few were terminally ill. I cared for all of them to the best of my ability without discrimination as to their condition, age, socioeconomic status, race or gender. I will do anything to help my patients — except kill them or help them kill themselves.

It is outrageous that physician assisted suicide laws support privatized lethal overdoses for some suicidal people without even the oversight and protections we insist upon for a convicted murderer on death row. Suicide prevention and treatment works, and the standards must not be changed just because some people insist their desire for physician-assisted suicide is rational and even a civil right.

My Marie was one of the almost 37,000 reported suicides in 2009. In contrast, only about 800 assisted-suicide deaths have been reported in the past 16 years in Oregon. According to the Centers for Disease Control (CDC) suicide was the 10th leading cause of death for Americans in 2012, with “More than 1 million people reported making a suicide attempt in the past year” and “More than 2 million adults reported thinking about suicide in the past year.”. The CDC estimates that suicide “costs society approximately $34.6 billion a year in combined medical and work loss costs”, not to mention the emotional toll on families.

Obviously our real health-care crisis here is a staggering and increasing rate of suicides, not the lack of enough assisted suicides.

Yet, the assisted-suicide movement relentlessly continues to demand the participation of medical professionals like me and the approval of society for at least some suicides — for now. Those demands must be denied.

My daughter Marie was a victim of these demands to control life by embracing death. How many more people must we lose before we truly understand that evil never limits itself because evil always seeks to expand unless it is stopped. In the case of physician-assisted suicide, “No” can be a life-saving word.

Nancy Valko is a registered nurse living in St Louis, Missouri, and spokesperson for the National Association of Prolife Nurses. Recently retired from bedside nursing, she is now an advance legal nurse consultant. She writes and speaks on ethics issues around the US, and blogs at A Nurse’s Perspective on Life, Healthcare and Ethics.

This article is published by Nancy Valko and MercatorNet.com under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation. Commercial media must contact us for permission and fees.

Addendum: Mercatornet is a fascinating website about “navigating modern complexities” and encompasses a range of issues. I am pleased to have had a number of articles published there over the years including  “Organ donation: crossing the line- Linking the “right to die” with organ donation has opened a terrible Pandora’s Box”, “ Have death panels already arrived?” and “The campaign against conscience rights”

DEATH REFERRALS AND CONSCIENCE RIGHTS

nancyvalko assisted suicide, conscience rights, medical ethics

In his September 23, 2015 article “Ontario doctors squeezed on conscientious objection to assisted suicide” ,  Michael Cook states that

“The legalisation of physician-assisted suicide in Canada after February’s decision by the Supreme Court is starting to affect doctors. The College of Physicians and Surgeons of Ontario has quietly issued a directive that conscientious objectors must help them find someone willing to do so.”

Mr. Cook also writes that such a directive requires unwilling doctors to make

“an effective referral to another health-care provider” defined as ‘a referral made in good faith, to a non-objecting, available, and accessible physician, other health-care professional, or agency’.”

and

“It was approved by College Council in March despite overwhelming opposition to the demand for ‘effective referral’.”

Personally and as a nurse, I could not refer for either abortion or physician-assisted suicide. Not only do I oppose these actions but I also don’t know any ethical or scandal-free organizations or practitioners that perform death procedures.

And does “mandated referral” also mean that I am forbidden to give any accurate but negative information about these procedures? Probably.

Here is what happened to nurses in Oregon after the physician-assisted suicide law took effect and even though the Oregon Nurses Association (ONA) is part of the American Nurses Association which opposes against assisted suicide.

The ONA’s 1997 guidelines on the “Role of the Registered Nurse in Assisted Suicide” states that

“ONA supports the patient’s right to self-determination and believes that nurses will and must play a primary role in end-of-life decisions.”

And here are some excerpts from that paper concerning those “Nurses Who Choose Not To Be Involved”:

According to the ONA, such nurses may:

“Conscientiously object to being involved in delivering care. You are obliged to provide for the patient’s safety, to avoid abandonment and withdraw only when assured that alternative sources of care are available to the patient.” (Emphasis added)

I faced such a situation myself years ago when I was told that there was no other nurse available when I refused to comply with a death decision. I was almost fired.

Furthermore, according to the position paper, such objecting Oregon nurses may not:

“Subject your patients or their families to unwarranted, judgmental comments or actions because of the patient’s choice to explore or select the option of assisted suicide.” (Emphasis added)
Or
“Subject your peers or other health care team members to unwarranted, judgmental comments or actions because of their decision to continue to provide care to a patient who has chosen assisted suicide.
Abandon or refuse to provide comfort and safety measures to the patient.” (Emphasis added)

My point is that mandated referral must be opposed. It is just another kind of required participation and denial of conscience rights that is intended to silence the objections of doctors and nurses and even threaten their careers.

But above all, conscience rights protect patients and their right to safe health care.