end-of-life

Canada and the Euthanasia Endgame

nancyvalko assisted suicide, disability, education, end-of-life, euthanasia, law, Living wills, medical ethics, pro-life

Several nations like Belgium and the Netherlands have had legalized assisted suicide and/or euthanasia, even for minors and for people just “tired of life” But now the worst is Canada which legally approved MAiD (medical aid in dying) it in 2016, according to Alex Schadenberg of the Euthanasia Prevention Coalition

Alex Schadenberg quotes Kevin Yuill, a professor who spoke at the Euthanasia Symposium in Brussel in November who said:

“Canada has the dubious honour of being the global capital of euthanasia. Through its medical assistance in dying (MAID) programme, Canada killed more people with lethal injections last year than any other country on Earth – many of them poor, homeless or hopeless. And soon, from March 2023, lethal injections will be offered to anyone who judges their mental-health difficulties to be intolerable.”

Even worse, some people with disabilities are saying that they are being pressured to take a lethal overdose.

In a November 2022 UK article titled “Canadian man alleges hospital is pressuring him to end his life by assisted suicide”, a man with a disease affecting his brain and muscles is suing his Canadian hospital after secretly recording the hospital staff, stating:

“They asked if I want an assisted death. I don’t. I was told that I would be charged $1,800 per day [for hospital care]. I have $2 million worth of bills. Nurses here told me that I should end my life. That shocked me”.

Mr. Foley has applied for “direct funding” from the Canadian government to “employ agency workers of his own choosing and manage his schedule”.

  

The article also cited “a pro-assisted suicide and euthanasia group of doctors in Canada have recently said that doctors have a “professional obligation” to initiate discussion of assisted suicide and euthanasia with patients who might fit the legal criteria. They claim there is nothing in Canadian law which forbids this.”

CANADIAN STATISTICS

The UK article also notes that:

“In 2021, 10,064 people ended their lives by assisted suicide and euthanasia, an increase of over 32% from the previous year, accounting for 3.3% of all deaths in Canada.

According to the latest report on Medical Assistance in Dying from Health Canada, 17.3% of people also cited “isolation or loneliness” as a reason for wanting to die. In 35.7% of cases, patients believed that they were a “burden on family, friends or caregivers”. (Emphasis added)

Canada was set to approve MAiD for people with mental illness but recently, the Canadian government announced its plan to temporarily delay MAiD eligibility  for people whose sole medical condition is mental illness.

CONCLUSION

In 1993, just 3 years after Nancy Cruzan, a woman in a so-called “vegetative state” died a long 12 days after her feeding tube was removed in my home state of Missouri, a letter in the Journal of the American Medical Association by Dr. Ezekiel Emanuel, a prominent ethicist and 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”.

Ominously, he also 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.)

“(O)ur collective determination as to what lives are worth living” is the very real and frightening potential endgame of legalized euthanasia and it should be stopped now!

Are Near-Death Experiences Real?

nancyvalko brain death, CPR, end-of-life, family, medical ethics, organ donation

In a November 4, 2022 Medscape article titled “‘Lucid Dying’: EEG Backs Near-Death Experience During CPR”, researchers found brain wave recordings taken during in hospital cardiac arrest resuscitation (cardiopulmonary resuscitation) lends support to near-death experiences reported by some people who survived cardiac arrest.

In the Medscape article and according to lead investigator Sam Parnia, MD, PhD:

“These recalled experiences and brain wave changes may be the first signs of the so-called ‘near-death’ experience, and we have captured them for the first time in a large study,” lead investigator Sam Parnia, MD, PhD, with NYU Langone Health, says in a news release.

Identifying measurable electrical signs of lucid and heightened brain activity during CPR, coupled with stories of recalled near-death experiences, suggests that the human sense of self and consciousness, much like other biological body functions, may not stop completely around the time of death, Parnia adds.” (Emphasis added)”

According to the article, the researchers used “audiovisual testing of awareness with continuous real-time EEG and cerebral oxygenation monitoring” during the resuscitation.

While only 53 of the 567 patients survived (9.3%), 28 survivors completed interviews with 11 reporting “unique, lucid experiences during resuscitation.”

According to Dr. Parnia:

“Our understanding of death has gone through a seismic shift in the last few years,” and

“The biological discoveries around death and the postmortem period are completely different to the social conventions that we have about death. That is, we perceive of death as being the end, but actually what we’re finding is that brain cells don’t die immediately. They die very slowly over many hours of time,” Parnia noted. (Emphasis added)

Dr. Parnia presented the findings November 6 at a resuscitation science symposium at the American Heart Association (AHA) Scientific Sessions 2022 in Chicago.

The Medscape article also noted that not everyone agrees:

“Ajmal Zemmar, MD, PhD, with University of Louisville, Louisville, Kentucky, noted that several studies, including this one, “challenge the traditional way that we think of death — that when the heart stops beating that’s when we die.”

The observation that during cardiac arrest and CPR, the brain waves are still normal for up to an hour is “fairly remarkable,” Zemmar told theheart.org | Medscape Cardiology.

“However, whether there is conscious perception or not is very hard to answer,” Zemmar cautioned. 

“This type of research tries to bridge the objective EEG recordings with the subjective description you get from the patient, but it’s hard to know when conscious perception stops,” he said.”

WHAT DOES THIS ALL MEAN?

Over the decades, there have been many studies of near-death experiences and an October 31,2022 Medscape article by a nurse practitioner who describes how both negative and positive near-death experiences can impact an individual.

There is even a 2020 Frontiers in Neurology article “The Neurology of Death and the Dying Brain: A Pictorial Essay” that explores some of the potential effects of issues like near-death experiences on the clinical determinations of death and organ donation.

But whether or not you believe in near-death experiences, there is one crucial lesson here: We must always treat any ill person-awake or presumed unconscious-with the respect due any person when we talk to and care for them.

I have often told the story of “Mike”, a young man catastrophically injured in a car crash whose doctor said the if he survived, he would be a “vegetable”. We nurses talked to Mike and eventually he started to respond to us but not the doctor.

Mike was shipped off to a nursing home but almost two year later, he returned to thank us and told us he was getting married. When we laughed and told him how he started to respond to us but not the doctor, Mike became very serious and said he would not respond to the doctor because he heard the doctor call him a “vegetable”!

CONCLUSION

But my favorite story is about working on a medical floor caring for an elderly gentleman who was dying and showed no awareness of his 4 adult sons sitting at his bedside.

I encouraged his sons to talk to him, but they said they didn’t know what to say and didn’t think he could hear anyway.

I took the man’s hand and noticed that it was strong and callused like a man who worked with his hands.

I asked the sons was their dad did and they all started relating stories about his love of farming and then told funny stories about how their dad reacted to their antics growing up.

Pretty soon, all the sons were laughing and telling their dad how much they appreciated him as I quietly left at the end of my shift.

When I returned the next day for my next shift, I was not surprised to learn that the dad had peacefully died during the night with his sons at his side. But I was surprised to find that one of the sons stayed until I came back and wanted to talk to me.

“Lady, you were right! He did hear us!” he told me.

It turned out that the sons had continued talking to their dad after I left and when they said they were ready to leave, their dad opened his eyes, looked at them, smiled and then closed his eyes and peacefully died.

What a wonderful memory for his sons-and me!

PLEASE READ BEFORE YOU AGREE TO BE AN ORGAN DONOR

nancyvalko assisted suicide, brain death, brain injury, end-of-life, euthanasia, medical ethics, organ donation

Whether we are renewing our driver’s licenses, watching the TV news or just picking up a newspaper, it’s impossible to miss the campaign to persuade us to sign an organ donation card such as this one. We see story after story about how grieving relatives have been comforted by donating a loved one’s organs after a tragic death, and how grateful the people are whose lives have been changed by the “gift of life”.

But are ethical lines being crossed in the zeal to obtain organs to transplant?

While most people presume that organs can be removed and transplanted only after “all efforts to save your life have been exhausted” and brain death has been determined, that presumption is no longer necessarily true.

Now, organ donation can occur with a person who is in a coma and considered close to death but who does not meet the criteria for brain death. In those cases, a organ donor card or relatives who have agreed to withdraw a ventilator (a machine that supports or maintains breathing) and have the person’s organs removed for transplant if or when when the heartbeat stops. This was called DCD or donation after cardiac death until some doctors found that the stopped heart could be successfully restarted it in the patient receiving the transplant!

Now, that ethically questionable procedure is called donation after circulatory death (also DCD) since circulation stops when the heart stops.

If circulation does not stop within 60 minutes, the organs are deemed to be too damaged for transplant and the patient dies without donating organs.

IT GETS WORSE

Last month a September 29, 2022 article in Medpage titled “No Brain Death? No Problem. New Organ Transplant Protocol Stirs Debate-Is it ethical to pull the plug in patients who aren’t brain dead, then restart their hearts?” reported on a new procedure to get more organs:

“With little attention or debate, transplant surgeons across the country are experimenting with a kind of partial resurrection: They’re allowing terminal patients to die, then restarting their hearts while clamping off blood flow to their brains. The procedure allows the surgeons to inspect and remove organs from warm bodies with heartbeats.” (Emphasis added)

The article also said that this new procedure is being criticized by doctors like Dr. Wes Ely and the American College of Physicians that warned the procedure raises “profound ethical questions regarding determination of death, respect for patients, and the ethical obligation to do what is best.”

MY JOURNEY TO DISCOVER THE FACTS ABOUT BRAIN DEATH

Back in the early 1970s when I was a young intensive care unit nurse, no one questioned the innovation of brain death organ transplantation. We trusted the experts and the prevailing medical ethic of the utmost respect for every human life.

However, as the doctors diagnosed brain death in our unit and I cared for these patients until their organs were harvested, I started to ask questions. For example, doctors assured us that these patients would die anyway within two weeks even if the ventilator to support breathing was continued, but no studies were cited. I also asked if we were making a brain-injured patient worse by removing the ventilator for up to 10 minutes for the apnea test to see if he or she would breathe since we knew that brain cells start to die when breathing stops for more than a few minutes.

I was told that greater minds than mine had it all figured out so I shouldn’t worry.

It was awhile before I realized that these doctors did not have the answers themselves and that my questions were valid.

I also discovered that some mothers declared “brain dead” were able to gestate their babies for weeks or months to a successful delivery before their ventilators were removed and that there were cases of “brain dead” people like Jahi McMath living and maturing for years after a diagnosis of brain death or even recovering like Zack Dunlap. 

If the legal definition of brain death is truly “irreversible cessation of all functions of the entire brain, including the brain stem”, these cases would seem to be impossible.

PRESUMED CONSENT AND LAW

Another problem is “presumed consent” which is the assumption that everyone is willing to donate his/her organs unless there is evidence that they would not want to donate. Illinois narrowly avoided a “presumed consent” statute a few years ago where people who didn’t want to donate had to file an opt out document with the Secretary of State.

Some countries already have “presumed consent” laws, most recently in England that states:

“it will be considered that you agree to become an organ donor when you die, if:

  • you are over 18;
  • you have not opted out;
  • you are not in an excluded group”

Even more horrifying, there have also been proposals to even link organ donation and assisted suicide as “a potential solution to the organ scarcity problem”. Countries like Belgium and the Netherlands already allow this.

CONCLUSION

Organ donation can truly be “the gift of life”, and innovations such as adult stem cells and the donation of a kidney or part of a liver by a living person generally pose no ethical problems and hold much promise to increasingly meet the needs of people with failing organs. I have a grandson whose life was saved by a stem cell transplant and another relative who has had 2 kidney transplants.

Personally, I have offered to be a living donor for friends and my family knows that I am willing to donate tissues like bone, corneas, skin, etc. that can be donated after natural death.

Everyone can make his or her own decision about organ donation but it is crucial that we all have the necessary information to make an informed decision..

Good Healthcare Tips To Help the Elderly

nancyvalko culture, dementia, end-of-life, mental health

My first volunteer work was feeding elderly patients in a local nursing home when I was 13. Although I was nervous at first, I came to love being with these elderly patients and especially hearing their stories.

After I graduated from nursing school in 1969, I took care of many elderly patients in ICU, oncology, kidney dialysis and home health/hospice as well as my own relatives and friends. I learned a lot from all these people about the special needs of older patients and have written about them in my blogs.

 In 2018, I wrote a blog titled “Don’t Write Off the Elderly”  about “Melissa” (not her real name), my friend who is also the mother of one of my best friends and who died recently at the age of 99 years, 9 months and 5 days.

Melissa had wonderful care from her family, caregivers and spiritual support but she also had some difficult situations with the healthcare system. Thankfully, these situations were resolved and Melissa died peacefully and comfortably in her own home, as she had hoped.

So I was delighted to see this wonderful article at ‘Medical Methuselahs’: Treating the Growing Population of Centenarians (medscape.com) from the website Medscape for healthcare professionals that can help not only doctors and nurses but also older people and their friends and families.

Although this article is mainly about people who reach 100, it has observations and tips that can help other older people over 65. And as an older person myself, I really appreciate the positive outlook in this article.

Although the article is longer than most other Medscape articles, it is well worth reading for anyone who is older or who has elderly friends and/or relatives.

Here are some excerpts and all emphasis is mine:

1.“Priya Goel, MD is a New York doctor who works for a national home healthcare company that primarily serves people older than 65. Dr. Goel has observed that although some of the ultra-aged live

in nursing homes, many continue to live independently. They require both routine and acute medical care.

Dr. Goel urges her colleagues not to stereotype patients on the basis of age, saying that:

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves… Age is just one factor in the grand scheme of things.” Dr. Goel visits her patients aged 65 and up in their homes to provide herself with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

2. Geriatrician Thomas Perls, MD says “”People can age so very differently from one another” and agrees that “that healthcare providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. People can age so very differently from one another,” he said and that:

“Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good healthcare, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Perls said.

“Paying diligent attention to these behaviors over the long run can have a huge payoff” and

“Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Perls, “the older you get, the healthier you’ve been.“

3. “We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.”

4. Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present ― just making sure that they feel like they’re still in control of their body and their day,” she said.”

6. And, in a very important observation: 
“Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia ― they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Flomenbaum said the children often asked whether their parents should enter a nursing home.

 “And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.”
 Dr. Flomenbaum also said: 
“The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you ― whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.” 

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning ― until they hear what they’ve been missing.
 I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Perls said.” 

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.”

7. The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Baker, a joy of the job is hearing centenarians share their life stories.”

CONCLUSION

In helping to care for many elderly people over many decades, I can attest to the wisdom and hope of these experts.

Aging itself is not a terminal disease and it can be a wonderful time to spend more time with loved ones and reflect on how much we have learned and can still enjoy in every stage of life!

Pain, Choice, and Canada’s now “most permissive euthanasia legislation in the world”

nancyvalko assisted suicide, Cancer, Compassion & Choices, culture, dementia, disability, economics, end-of-life, euthanasia, hospice, law, medical ethics, mental health

In his excellent July 10, 2022 blog, Alex Schadenberg, chair of the International Euthanasia Prevention Coalition, reveals that now “Canada’s medical assistance in dying (Maid) law is the most permissive euthanasia legislation in the world”.

He says “Canada’s MAiD law currently allows suicide facilitation for persons with disabilities and is on track to expand in March 2023 to those living with mental illness. “ (Emphasis added)

How did assisted suicide/euthanasia laws get so far and so fast down the proverbial “slippery slope”?

In my December, 2016 blog “Pain and ‘Choice’”,  I wrote about how I saw the warning signs when I was a new nurse in 1969.

Here is my blog:

PAIN AND “CHOICE”

December 15, 2016 nancyvalko 

It was 1969 and I was fresh out of nursing school when I was assigned to a patient I will call “Jenny” who was thirty-two years old and imminently dying of cancer. She was curled up in her bed, sobbing in pain and even moaned “just kill me.” The small dose of Demerol I injected into her almost non-existent buttocks every four hours “as needed” was not helping. I reassured Jenny that I was immediately calling the doctor and we would get her more comfortable.

However, I was shocked when the doctor said no to increasing or changing her medication. He said that he didn’t want her to get addicted! I told him exactly what Jenny said and also that she was obviously very close to death so addiction would not be a problem. The doctor repeated his no and hung up on me.

I went to my head nurse and told her what happened, but she told me I had to follow the doctor’s order. Eventually, I went up the chain of command to the assistant director of nursing and finally the Chief of the Medical Staff. The verdict came down and I was threatened with immediate termination if I gave the next dose of Demerol even a few minutes early.

I refused to abandon Jenny so for the next two days before she died, I spent my time after my shift sitting with her for hours until she fell asleep. I gave her whatever food or drink she wanted. I stroked her back, held her hand and told stories and jokes. I asked her about her life. I did everything I could think of to distract her from her pain and make her feel better. It seemed to help, although not enough for me. I cried for Jenny all the way home.

And I was angry. I resolved that I would never watch a patient needlessly suffer like that again.

So, I educated myself by reading everything I could about pain medicine and side effects. I also pestered doctors who were great at pain control to teach me about the management, precautions, and rationale of effective pain management. I used that knowledge to advocate and help manage my patients’ pain as well as educating others.

I was delighted to see pain management become a major priority in healthcare and even called “the fifth vital sign” to be evaluated on every patient. I saw new developments like nerve blocks, new drugs, and regimens to control pain and other techniques evolve as well as other measures to control symptoms like nausea, breathlessness, and anxiety. Now we also have nutritional, psychological, and other support for people with terminal illnesses and their families.

Best of all was that I never again saw another patient suffer like Jenny despite my working in areas such as ICU, oncology (cancer) and hospice.

TWENTY-FOUR YEARS LATER

When my oldest daughter was 14, she attended a public high school where the science teacher unexpectedly started praising the infamous Dr. Jack Kevorkian and his public campaign for legalized assisted suicide and euthanasia.  Kevorkian’s first reported victim was Janet Adkins, a 54 year old woman with Alzheimer’s in no reported physical pain who was hooked up to a  “death machine” in the back of a rusty van. Mrs. Adkins was just the first of as many as 130 Kevorkian victims, many if not most of whom were later found to have no terminal illness. Kevorkian escaped prosecution-even after he harvested a victim’s organs and offered them for transplant-until the TV show 60 Minutes aired Kevorkian’s videotape showing him giving a lethal injection to a man with ALS (Lou Gehrig’s disease). Shockingly, Kevorkian served only 8 years in prison before he was paroled and eventually became a media celebrity peddling assisted suicide and euthanasia.

My daughter, who never before showed any interest in my speaking and writing on the topic of assisted suicide, now stood up and peppered her teacher with facts about Kevorkian. The teacher asked her where she learned her information and she answered, “From my mom who is a cancer nurse”.

Sarcastically, he responded “So your mother wants to watch people suffer?” My daughter responded “No, my mother just refuses to kill her patients!” End of discussion.

CONCLUSION

But not the end of the story. Tragically, we now have legalized assisted suicide in several states and serious efforts  to expand it to include people without physical pain but with conditions like Alzheimer’s, mental illness or other psychological distress as well as even children.

As Wesley Smith recently and astutely observed:

 “Moreover, the statistics from Oregon and elsewhere show that very few people commit assisted suicide due to physical suffering. Rather, the issues are predominately existential, such as fears of being a burden or losing dignity

The public is being duped by groups like Compassion and Choices that campaign for legalized assisted suicide on the alleged basis of strict criteria for mentally competent, terminally ill adults in unbearable physical pain to freely choose physician-assisted suicide with (unenforceable) “safeguards”.

The emerging situation throughout the world is more like Kevorkian’s dream of unfettered and universal access to medical termination of the lives of “expendable” people. How much easier is that when people with expensive mental health problems, serious illnesses or disabilities can be encouraged to “choose” to be killed?

Rest in Peace, “Melissa”

nancyvalko bereavement, Covid 19, culture, disability, end-of-life, faith, family, inspiration

I have written blogs about my elderly friend “Melissa” (not her real name) and some of her health care experiences to explain some of the pitfalls elderly people may encounter when they get seriously ill.

I have known “Melissa” for decades and, with her permission, she agreed to my writing about her in my blogs. She was thrilled to hear about my 2018 blog “Covid 19 and Nursing Homes”   and my 2020 blog “Don’t Write Off the Elderly”.

She even told me she like the name “Melissa” better than her real name!

I first met Melissa when she was in her 80s through her daughter who is also one of my favorite people.

Both were involved in planning the beautiful wedding reception at my home when my second husband and I were married in 2008. Melissa even remembered my favorite flower and made beautiful centerpieces with them for every table.

After Melissa could no longer drive, I took her to Mass at her parish and then to Chic-Fil-A on Fridays for breakfast with her daily Mass friends until she couldn’t physically make it.

I then visited her on Fridays and was inspired when she accepted hospice care and the care of her family with grace and gratitude.

Eventually, she spent her last days in a bed near a large window where she could watch the birds at her birdfeeder and have some of her beloved flowers at her bedside.

During that time, Melissa and I laughed a lot, prayed together, chatted about current events and family, and watched funny videos and old episodes of TV shows she enjoyed like “Barney Miller” and “Bewitched”.

She also told me many of the fascinating stories behind the pictures of her and her family covering the walls of her room.

Melissa died peacefully on May 6, 2022, at her home at the age of 99 years, 9 months and 5 days, lovingly cared for by her family and great home health and hospice providers.

A devout Catholic, Melissa was unafraid of death and knew she would meet her late husband and her son who died at age 4. Another son unexpectedly died at 56, shortly before Melissa.

Melissa generously donated her body to Logan College to help future doctors with their education.

After her funeral Mass, her family had a Celebration of Life event with pictures and stories about her life. There was a lot of laughter and some tears as we all talked about Melissa and what she meant to us.

CONCLUSION

Melissa and her family are an inspiration to me and an example of how to have a good death, something that seems impossible to many people.

I visited her the day she died peacefully and comfortably, but not awake.

She died just as she hoped.

We will miss you Melissa but we will never forget you!

Rest in peace.

A DISTURBING BUT IMPORTANT LOOK INTO THE TRAINING OF DOCTORS FOR MEDICALLY ASSISTED SUICIDE

nancyvalko assisted suicide, Canada, Compassion & Choices, conscience rights, disability, end-of-life, law, medical ethics, mental health

Most people seem to assume that medically assisted suicide is a simple matter of getting a doctor to prescribe a lethal overdose, taking a pill or two and then go to sleep and die. Many seem unaware that a second consulting doctor (or other healthcare provider in some states) must agree.

This view, abetted by polls, well-funded groups like Compassion and Choices as well as a mostly sympathetic mainstream media, is disastrously wrong.

A stunning February 2022 article in Medscape for healthcare providers titled  “Medical Aid in Dying: Your Clinical Guide and Practice Points” exposes some very real problems with medically assisted suicide that are largely hidden from the general public.

But while citing a Gallup poll showing that 74% of the American public support legalizing “medical aid in dying” (their preferred term for medically assisted suicide) as well as 58% of doctors, the article admits that:

“Study data, however, have revealed a discrepancy between attitudes about legalization and willingness to practice. Only 15% to 22% of physicians in favor of legal access to medical aid in dying would be willing or likely to provide such assistance” (Emphasis added)

And citing Oregon, the first state to legalize assisted suicide, the article claims that:

“Pain management and hospice use have improved in Oregon since passage of the Death with Dignity Act” but also that “Opponents of medical aid in dying express concern that in Oregon, more than 70% of patients who elect medical aid in dying are elderly and have cancer–both being commonly associated with depression–but fewer than 5% are referred for psychiatric evaluation”. (Emphasis added)

Tellingly, the article recognizes the toll assisted suicide can take on the medical professionals involved:

“A Mental Note for the Healthcare Provider: Discussion of end-of-life options represents a profound event for both the patient and the healthcare provider. Do not neglect your own self-care while guiding your patient through the emotionality that can be brought on by end-of-life decision-making.” (Emphasis added)

THE MEDICALLY ASSISTED SUICIDE PROTOCOL IS COMPLICATED

It is recommended that the patient does not eat or drink for 6 hours before ingesting the lethal dose called D-DMAPh.

Anti-nausea medication and a gastric motility medication is to be taken 1 hour before ingesting the life-ending medication.

A large dose of Digoxin to slow the heart is taken 30 minutes later and then a compound of anxiolytic, opioid and tricyclic medications are to be swallowed in less than 90 seconds.

Recommendations include:

– adding a favorite liquor may counter the bitterness of the mixture

– a small amount of sorbet can be ingested to avoid potential post-ingestion esophageal burning or distress

-Prepare for the possibility that the medication may not work if not quickly and fully ingested; it is crucial that the patient who self-administers not fall asleep before consuming the full dose-Patients should not take the medicine when alone or in a public place

-kept carefully out of the reach of children and vulnerable adults

-and must be disposed of properly. (Emphasis added)

For special circumstances:

“It is legal in all jurisdictions for physicians, other HCPs, or family members to assist in medical aid in dying but not to administer medical aid-in-dying medications.[1-9] The law requires that the patient self-administer the medication through ingestible means, which may include:

•         Drinking the medication mixture

•         Ingesting through a nasogastric tube

•         Ingesting the medication through a feeding tube, or

•         Insertion through a rectal catheter

Patients are permitted to receive help in preparing or mixing the medication for self-administration, but the patient must take a voluntary, affirmative act (i.e., swallowing or pushing a syringe) and administer the medication him- or herself. Medical aid-in-dying laws do not allow physicians, family members, or anyone else, including the dying person, to administer medical aid-in-dying medication by intravenous (IV) injection, parenteral injection, or infusion.” (Emphasis added)

The article states that decision-making capacity is the basis of informed consent and that:

“Guidance begins with assessment of the patient’s decision-making capacity and understanding of palliative measures as alternatives to or concurrent with medical aid in dying. No matter the practice specialty, HCPs (health care providers) are trained on the art of assessing a patient’s medical decision-making capacity and their ability to understand the situation, appreciate the consequences, reason rationally, and express a choice.” (Emphasis added)

If there is a concern, the patient:

 “must be referred for additional evaluation by a licensed psychiatrist, clinical psychologist, or clinical social worker. The request for aid-in-dying medication does not proceed unless the mental health professional affirms that the patient is free of mental illness, acute psychological distress, or demoralization.” (Emphasis added)

COMPLICATIONS

The article admits that complications such as regurgitation and seizures can occur but says they are infrequent.

Prolonged dying can also occur so the “families should make contingency plans for how to manage such circumstances” and “remain calm and engage with hospice or other support services as needed. Families should understand that to help avoid unnecessary deployment of police and emergency medical personnel, they should not call 911.” (Emphasis added)

The article also warns that:

“Those present at the death may witness the following changes, which frequently occur during the natural dying process: snoring; gurgling noises; changes in rate of breathing; and fluctuations in body temperature that may leave their skin cool, warm, moist, or pale. Physical movements or other external signs of distress are sometimes exhibited, but the internal peace of the person is not disturbed.” (Emphasis added)

Sadly, the article reports that 4% of patients in Oregon “chose not to inform their families of their decision” even though support groups “strongly recommend that at least 1 other person be present” but not the doctor.

LEGAL REQUIREMENTS DIFFER WIDELY BETWEEN STATES

The article illustrates how dramatic the differences are in state laws such as the eligible medical providers in New Mexico to include APRNs (advance practice registered nurses) and physician assistants and no consulting provider is required if the patient is in hospice.

and

“In Hawaii, a mental health evaluation is mandatory for all patients requesting medications under the law. In New Mexico, a mental health evaluation is also required if the patient has a recent history of a mental health condition or intellectual disability.” (Emphasis added)

Required waiting periods to make the second request varies from as little as none in Oregon and New Mexico if the patient is unlikely to survive the waiting period to at least 20 days in Hawaii.

The article also recommends that health care providers familiarize themselves with the assisted suicide group Compassion and Choice’s Doc2Doc helpline that “offers free, confidential telephone consultation with clinicians who are experienced in providing end-of-life medical care”.

Right now, 9 U.S, states (California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont,  Washington)  and the District of Columbia have medically assisted suicide laws and 12 states (Massachusetts, Delaware, Minnesota, New York, Pennsylvania, North Carolina, Indiana, Kentucky, Rhode Island, Virginian, Arizona and Utah) have bills in their legislatures.

And there are more states seeking to expand their existing assisted suicide laws such as Vermont S 74  that threatens conscience rights by defining assisted suicide as a “healthcare service” and allows assisted suicide by telemedicine and Washington state HB 1141 that expands the prescriber to PAs (physician assistants), advanced registered nurse practitioners and allows the lethal dose to be sent by mail or courier.

CONCLUSION

Our neighbor Canada is a cautionary tale about the inability to limit medically assisted suicide.

In a June, 2021 article in the Psychiatric Times titled “First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders” , Dr. Mark Komrad chronicles the expansion of the 2016 MAID (medical aid in dying) law allowing medical euthanasia (the doctor directly administers a substance that causes death, such as an injection of a drug) and physician-assisted suicide for the terminally ill to expand to those “with nonterminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable”.

Now, those Canadians “whose only medical condition is a mental illness, and who otherwise meet all eligibility criteria, will not be eligible for MAID until March 17, 2023″. (Emphasis added).

As a nurse with over 50 years of personal and professional experience in hospice, critical care, oncology, etc., I am willing to do anything for sick people– except kill them or help them kill themselves. These people deserve better!

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

What is a “Death Doula” and Why is Compassion & Choices so Interested?

nancyvalko assisted suicide, Compassion & Choices, end-of-life, law, medical ethics

Most people have heard of doulas, specially trained people who help pregnant women during pregnancy, labor, birth, and immediate postpartum by providing “emotional, physical, and informational support”.

My daughter used a doula for both of her children and was so happy with the results that she is considering taking the training to become a doula in the future.

But now, there are “death doulas” that have nothing to do with birthing.

As Wesley Smith wrote about in a 2014 article titled “Good Grief: Now It’s “Death Doulas”, there was an op-ed in the LA Times about the Hippocratic oath and the terminally ill by a journalist and medical professor who wrote:

“If we allow medicine to prolong life, should we also allow it to shorten life for the terminally ill?

We could, however, skirt the controversy entirely: What if we created another class of medical professionals known as death doulas, who could fill a gap between treatment doctors and hospice workers?” (All emphasis added)

But “death doula” idea continued and in 2017,  the “National End-of-Life Doula Alliance (NRDA) was formed and even more importantly in 2018:

“a special council within The National Hospice and Palliative Care Organization (NHPCO), the leading hospice and palliative care membership organization in the US, was held. The purpose of the special Council is to provide information and resources to its members, affiliated organizations, and the public regarding the role of end-of-life doulas.” (Emphasis added)

Unfortunately, while the NHPCO “opposes MAID (medical aid in dying) as “a societal option to alleviate suffering”, the American Academy of Hospice and Palliative Medicine (AAHPM) has had a position of “studied neutrality” on the issue of medically assisted suicide since 2007.

According to a New York Times June 2021 article “Death Doulas’ Provide Aid at the End of Life” , there are nearly 800 members in the National End-of-Life Doula Alliance with membership nearly doubling in the past year and increasing interest in training programs such as the International End-of-Life Doula Association, Doulagivers, and the Doula Program to Accompany and Comfort.

Death doulas do not have to be medically trained and death doula training and certification programs can cost as little as the $189.00 holiday special online course at the International Association of Professions Career College for 6 weeks part-time.

According to the New York Times, death doulas “don’t get involved in medical issues” but rather, “they support clients emotionally, physically, spiritually and practically.” Prices for these services “range from $25 an hour on up, although many do it voluntarily.”

WHY IS COMPASSION & CHOICES INTERESTED IN DEATH DOULAS?

Last month, Compassion & Choices (the largest organization attempting to pass assisted suicide laws in every U.S. state) filed an amicus brief in the federal court case Full Circle of Living & Dying v. Sanchez in support of a lawsuit to protect “to protect the First Amendment free speech rights of death doulas in California.”

The plaintiff Full Circle of Living & Dying is described by Compassion & Choices “as a non-profit organization that provides death doula services and home funerals”.

The defendant in the Full Circle of Lining & Dying lawsuit is the California Cemetery and Funeral Bureau which issued a 2019 order to the death doula plaintiffs to:

“immediately discontinue advertising and operating as a funeral establishment until a license is issued by the Bureau” and “threatened fines of up to $5,000 if Full Circle continued to operate without a license.”

Compassion & Choices’ chief legal advocacy officer Kevin Diaz argues in the amicus brief that:

Full Circle “has a disclaimer on its website that they are not funeral directors, do not offer funeral home services, and do not operate out of a funeral home”; that “Full Circle does not need a physical location for its services and the cost of obtaining such a location far exceeds the non-profit’s small budget.”

and added that

“a ruling in favor of the California Cemetery and Funeral Bureau “will force most, if not all, death doulas out of practice.” (Emphasis added)

As Kim Callinan, the President and CEO of Compassion & Choices explains in her 2021 article “Medical Aid in Dying: The Role of Death Doulas” for the National End-of-Life Doula Alliance newsletter:

“Death doulas can play a key role in shifting end-of-life care from a paternalistic to patient-directed system by bringing non-judgmental support to patients and serving as their advocate. This is particularly needed for patients who would like the option of medical aid in dying. All too often, interested and eligible patients are unable to navigate the complicated, multi-step process to access medical aid in dying (aka medically assisted suicide); too many unfortunately die suffering. (All emphasis added)

CONCLUSION

Over more than 52 years, I have cared for many dying people, both personally with friends, my mother and daughter and professionally in cancer units, critical care and home hospice. The people I have cared for range from babies to the very elderly.

My interest in people with terminal or life-threatening illnesses started when I first became an RN in the late 1960s and saw people with terminal cancer routinely secluded in in a private room at the end of a hall.

I asked the more experienced nurses how I should approach these patients and if I should be cheerful or solemn.

These nurses said they didn’t know the answer either so I had an idea. I decided to go visit these patients after I finished my shift and just ask to sit down and speak with them. Many of these wonderful people told me how isolated and lonely they felt when friends and family members treated them differently and we would talk about what they wanted both before and after their expected deaths.

I shared what I learned with the other nurses and family members who were relieved to know how they could help.

Whether or not these people were in hospitals, institutions or at home, the goal was always to help them live as well as possible until death. It was imperative that these people felt loved, respected and cared for even when they seemed to be unconscious. I also saw that the person’s relatives and friends also needed understanding and support. It helped that I personally knew how hard it can be to lose a loved one.

I feel privileged to have cared for my loved ones, friends, patients and their families and I never witnessed an excruciatingly painful death or was tempted to help end a life because I knew how to help.

It will be interesting to see what happens in the Full Circle of Living & Dying v. Sanchez case but I know that no matter whether a person is physically healthy or terminally ill, assisting a suicide is never good healthcare!

Why “Living Wills” Are Not Working Well

nancyvalko advance directives, Compassion & Choices, end-of-life, Living wills, medical ethics

In a stunning October 8, 2021 article titled “What’s Wrong With Advance Care Planning?“ in the prestigious Journal of the American Medical Association, three prominent supporters of “living wills” and other advance care documents admit that after 30 years of the promotion of such advance care plan (ACP) documents:

“The assumption that ACP will result in goal-concordant end-of-life care led to widespread public initiatives promoting its use, physician reimbursement for ACP discussions, and use as a quality measure by the Centers for Medicare & Medicaid Services, commercial payers, and others. However, the scientific data do not support this assumption. ” (Emphasis added)

Drs. R. Sean Morrison, Diane E Meier, and Robert M. Arnold are prominent doctors and ethicists at prestigious institutions who have long promoted the advance care documents that are asked about when people enter hospitals, nursing homes, long care facilities, etc.

I have been writing about such documents and their uses and hazards for decades.

ACPs were promoted as essential to document a person’s healthcare wishes like Do Not Resuscitate orders and forgoing interventions like feeding tubes and ventilators in the event that the person is unable to speak for himself or herself. Many such documents also designate a trusted friend or relative to assist in the potential future decision-making process.

All adults have been encouraged to make such documents regardless of their health status because it was assumed that such ACPs would lead to higher quality care at the end of life.

But, as the authors now admit: “The inability of ACP to achieve its desired outcomes represents the gap between hypothetical scenarios and the decision-making process in clinical practice settings.” (Emphasis added)

After 52 years of experience working in ICUs, oncology (cancer), dialysis, hospice and home health as well as caring for relatives and friends, I wholeheartedly agree with the authors that:

“Treatment choices near the end of life are not simple, consistent, logical, linear, or predictable but are complex, uncertain, emotionally laden, and fluid. Patients’ preferences are rarely static and are influenced by age, physical and cognitive function, culture, family preferences, clinician advice, financial resources, and perceived caregiver burden (eg, need to provide personal care, time off from work, emotional strain, out-of-pocket or noncovered medical costs), which change over time.” (Emphasis added)

WHAT DOES WORK?

The authors point to the patient having a trusted person in advance to act as a surrogate decisionmaker and improving the communication with healthcare providers in real time. They also point to:

“training clinicians and preparing patients and families to engage in high-quality discussions when actual (not hypothetical) medical decisions must be made is needed to achieve the outcomes that ACP has not.” (Emphasis added)

However, pitfalls still remain.

Patients and their decisionmakers do need accurate information about their conditions and potential treatments.

However, as I found as a nurse, patients and their surrogate decisionmakers often have negative preconceptions (often reinforced in the media) about treatments such as cardiopulmonary resuscitation, ventilators, feeding tubes, etc.

Unfortunately in hospital situations, the advance care plans with the common DNR (do not resuscitate) directive are sometimes misinterpreted as not wanting to live  or “do not treat” when the person had assumed it would apply only in extreme circumstances. And some healthcare institutions have medical futility policies that allow doctors to overrule the person’s decisionmaker.

In addition, we have well-funded organizations like Compassion and Choices that not only work to get assisted suicide laws passed in every state but also promote their own advance directive to allow the lethal “healthcare option” of VSED (voluntary stopping of food and water) to ensure death.

Particularly in the frail elderly, it can be difficult to determine whether or not a person is truly dying. And while we are never required to accept treatment that is medically futile or excessively burdensome to us, sometimes this can be hard to determine. Far too many times, feeding tubes and other interventions are automatically assumed to be futile and/or burdensome. But there is another alternative that is often ignored: trying an intervention with the option of stopping it if it truly is futile or burdensome.

There are no guarantees in life or death but even finding out that something doesn’t work can be a step forward and can relieve any guilt in the surviving relatives.

CONCLUSION

I was surprised but very pleased to read that the three prominent doctors writing the article “What’s Wrong With Advance Care Planning?” after years of promoting “living wills” and other end of life documents.

But, in the end, the real answer is a return to the traditional medical ethics of “First, do no harm”, a presumption for life and excellent, unbiased information.

That is why my husband and I made our own healthcare directives to require full information about all options, risks and benefits before making medical decisions.

And, most importantly, that we believe that “quality of life” is something to be improved, not judged.

The “Population Bomb” Fizzles, but Now There is a Birth Dearth with Grave Consequences in Many Countries

nancyvalko abortion, aging, assisted suicide, Compassion & Choices, culture, disability, economics, end-of-life, family, family planning, law

 Dr. Paul R. Ehrlich was an entomologist (a scientist who specializes in the study of insects)  at Stanford University when he published his bestseller “The Population Bomb” in 1968.  Although initially ignored, it incited a worldwide fear of overpopulation and ultimately became one of the most influential books of the 20th century.

In his book, Ehrlich predicted that unless population decreased, “hundreds of millions of people are going to starve to death” in the 1970s.

That did not happen but 50 years later in a 2018 interview with Smithsonian magazine writer Charles C. Mann, Paul Ehrlich claimed that the book’s main contribution was to make population control “acceptable” as “a topic to debate.”

However, as Mr. Mann wrote:

” But the book did far more than that. It gave a huge jolt to the nascent environmental movement and fueled an anti-population-growth crusade that led to human rights abuses around the world.” (Emphasis added)

But even 50 years later and with the population declining in many countries, Paul Ehrlich continued to insist that:

“Population will fall, either when people choose to dramatically reduce birthrates or when there is a massive die-off because ecosystems can no longer support us. (Emphasis added)

THE HARSH REALITY TODAY

In 1980, China began a strict one child per married couple policy that even included forced abortions for women who did not comply.

In 2015, China raised the limit to two children, citing a “rapidly aging society and a shrinking working-age population”.

China has now increased the number of children to 3 children but as a June 3, 2021 Wall Street Journal article states “China Delivers Three-Child Policy, but It’s Too Late for Many“.

Even with years of declining birthrates, there are fewer young people willing to buck the trend of postponing or forgoing marriage and children.

The result is an aging population with a shortage of children. In one Chinese province almost 40% of the province’s population of 880,000 are 60 or older and there is a surging demand for nursing homes. The local government is looking for private investors to help some 7,000 elderly residents who cannot take care of themselves.

Even beyond China, a May 22, 2021  New York Times article titled “Long Slide Looms for World Population, With Sweeping Ramifications“ recognized that:

“All over the world, countries are confronting population stagnation and a fertility bust, a dizzying reversal unmatched in recorded history that will make first-birthday parties a rarer sight than funerals, and empty homes a common eyesore.” (Emphasis added)

HUNGARY FIGHTS BACK

A replacement rate of about 2.1 is necessary to sustain a population but the population in Hungary had been declining since 1981. It reached an all-time low of 1.23 in 2011.

Katalin Novák, the Minister for Family Affairs in Hungary, has facilitated a family-friendly approach that has seen birth rates start to rise. The birth rate is now up to 1.56, still low but improving.

As Minister Novak states:

“The government’s measures of the past ten years have evidently moved demographics in the right direction. The number of childbirths, abortions, the infant mortality rate, marriages, and divorces have all moved in a favorable direction. This also proves that we have made the right decision when we made family-centered governance a priority and are now on the right path. Families are enjoying government support, and we are helping our youth by giving them the opportunity to start a family whenever they want.” (Emphasis added)

THE SITUATION IN THE UNITED STATES

As of 2019 (the latest year for which data is available), the U.S has the lowest fertility rate on record and the lowest number of births in 35 years.

As the New York Times noted in its article about population decline:

“The change may take decades, but once it starts, decline (just like growth) spirals exponentially. With fewer births, fewer girls grow up to have children, and if they have smaller families than their parents did — which is happening in dozens of countries — the drop starts to look like a rock thrown off a cliff. (Emphasis added)

CONCLUSION

The “population bomb” theory has had unintended and disastrous consequences, even in the U.S. and despite immigration.

In 2018, a US Census Bureau article predicted “The Greying of America: More Older Adults than Kids by 2035” for the first time in US history-joining other countries with large aging populations.

As the US Census Bureau states:

“With this swelling number of older adults, the country could see greater demands for healthcare, in-home caregiving and assisted living facilities. It could also affect Social Security. We project three-and-a-half working-age adults for every older person eligible for Social Security in 2020. By 2060, that number is expected to fall to two-and-a-half working-age adults for every older person.” (Emphasis added)

A country with more older people than children can unbalance a society socially, culturally and economically.

Even worse, legalizing abortion and assisted suicide/euthanasia will only make the situation more dire the US.

Since the US Supreme Court legalized abortion in 1973 with the Roe v. Wade decision,  more than 62,000,000 abortions have been performed and now the new Biden administration wants to roll back restrictions on abortion  and make abortions taxpayer-funded. 

And as efforts by groups like Compassion and Choices to legalize assisted suicide throughout the US has now spread to 9 states and the District of Columbia despite pro-life and disability rights opposition, we should not be surprised if there is another US Supreme court case in the future like the 1997 Vacco v Quill Supreme Court case  that attempted to establish physician-assisted suicide as a fundamental right for the terminally ill like the Roe v. Wade abortion decision legalizing abortion for (initially) just women in the first three months of pregnancy. 

Instead of threats to human beings at the beginning and end of life, we should be welcoming new lives and families as well as caring for the elderly, disabled and poor to improve and stabilize ourselves and our country.