Once while filling in at an emergency room. I heard a conversation between an attending physician and the doc who had just arrived to work the evening shift. The attending physician asked him to check the X ray to ensure that the NG tube he had just placed was in the correct position before they fed the patient.

Actually, I knew the lady he was talking about. A few days earlier, I had accepted the transfer of an elderly Lakota lady who had a stroke; she was confused, and it was hoped that the presence of Lakota speaking staff would help her during the recovery stage, until she was well enough for her family to take her home.

But she was still having trouble swallowing, and so the attending physician decided to put in a temporary NasoGastric tube, from her nose into her stomach, to give her food, until the swallowing reflex improved, something that often just takes a week or two.

Now, this lady was not terminal, and was expected to recover. But the ER physician looked at him, grinned slyly and said: Why put in a tube? Why not just give her morphine, ha ha.

The attending physician said: Excuse me? He didn’t believe what he had just heard. And the doctor repeated his remark.

Essentially, this physician was suggesting that we kill the lady using what is sometimes called “Terminal sedation”.

The attending sardonically said: Well, the tribe frowns on such things here, and went on to tell the nurses to keep an eye on the guy, and that he’d drive back later that evening to check the X ray.

Now, this ER physician was moonlighting at our hospital. He was taking a residency at an esteemed hospital in Baltimore. His credentials were excellent, but  obviously, he lacked something. Racial prejudice? Possibly. Ethics? Probably. This was before we had experts in our medical journals who promote defend euthanasia as a rational choice (and wink at euthanasia given without anyone’s request).

Perhaps what he was really lacking was common sense, since the family and the local American Indian Movement activists wouldn’t have sat still very long if it was known we were killing their people.

Last week, some blogs linked to an article in the UK Telegraph, where some Palliative Care physicians (these are docs who treat pain and the terminally ill) wrote a letter complaining that the NHS guidelines for terminal sedation were being carelessly used, or sometimes even deliberately misused as a form of euthanasia.

Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away. But this approach can also mask the signs that their condition is improving, the experts warn…

Yet there are times when huge amounts of narcotics are needed to relieve pain.

Often we can arrange a dose that allows pain relief without putting the person completely to sleep, but sometimes the dose needed to relieve suffering will be close to the dose that sedates them so much that their breathing rate goes low.

The skill of a good physician is to balance the two, so that the person is out of pain and dies of his illness, not the medicine. Why is this important? Because most of us have had patients who we told the family that they were dying, only to have them get over the infection, and promptly wake up after a day or two and live for one or two or six or 12 months more.

So how can doctors “know” when to stop everything?

One clue is “multi system failure”. The elderly person with pneumonia who has a stroke or heart attack, and then his kidneys or liver fails too.

Another is to simply keep a person comfortable, and let them eat and drink as they desire, (without tubes) but give them enough pain medicine to keep them pain free.

I am Catholic, so know that “extraordinary” care is optional, and in some cases this means no ICU for heart attacks or pneumonia if Granddad is 80 and says he wants to stay in his home (and family members are comfortable with that).

Indeed, a less invasive “palliative” approach to caring for the elderly is often more humane and is better medical care than risking dementia and confusion that can occur in a noisy strange intensive care unit.

Many people in medicine joke that they have a “do not resuscitate” tatooed on their chest, yet I suspect they mean “do not resuscitate if I’m dying” not “do not resusitate if I am healthy except for an irregular heartbeat”. Respirators are usually considered extraordinary care, and many people have “no respirator” as part of their living wills.

But what about an acute problem? We had a patient aspirate food and die because the ER physician saw “no respirator” and decided not to do an emergency bronchoscopy to take out the piece of food, because it would require a respirator as part of the post operative care.

Similarly, when a person has severe brain damage and can’t swallow, feeding tubes don’t really prolong life (they tend to die of aspiration pneumonia since they can’t swallow saliva).

But again, sometimes the problem is temporary, or the feeding tube might allow care at home rather than a nursing home for those with neuromuscular problems.

And then there are cases like Terry Schiavo, where the feeding tube was literally removed to kill her, without trying a feeding rehabilitation program to see if she could take food.

Among the elites, of course, we see those proud who say they never want to be like that, and want to chose death instead.

But the dirty little secret is that often those who “chose” death do so because the society around them send them the message that such people are useless and a burden. Such a message underlies the writings of some bioethic professors, who see no problem with not funding care for the most vulnerable in society.

Nor is this “rationing” limited to intensive care or surgery. Take Daniel Callahan, head of the influential think tank at the Hastings Center.

In Daniel Callahan’s book “Setting Limits”, he not only would limit intensive care and surgery for some handicapped and elderly people, he would not even treat a severely senile elder or severely brain damaged child with antibiotics or IV’s for an acute illness.

Going back to our elderly Lakota lady: she eventually got better. But remember, she was at a Federal hospital with dedicated staff and a family who cared for her.

But what if she were a poor black woman, in a busy Baltimore Hospital Emergency room, where a physician who despised her for her helplessness would see her as a candidate to “just give morphine, ha ha”?

Suffering is terrible, and temptation to relieve the suffering of one’s loved ones is huge. Yet history shows that such ideas as “the right to kill die” tend to get out of control, especially in a society where money is god and cost control more important than lives.

Which is why minority patients are less likely to have “living wills” and “end of life” directives than the affluent Caucasian patient.


Nancy Reyes is a retired physician living in the rural Philippines. She writes essays at HeyDoc Xanga Blog.

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