As a member of the growing company of octogenarians, I spend much of
my
time exploring a decade I never thought I would achieve. As ever the early
symptoms of change lie in the detail. Many of the engagements in my diary
have to do with funerals, memorial services, or visits to the bedsides of
stricken friends. I no longer lay down wine but search punctiliously
through
vintners’ lists for the magic words “drink now”. This attitude to death is
fashioned by an awareness that the final milestone can’t be too far down
the
road. I speculate less about the possible causes of my death than about
the
manner of my dying.
Because we octogenarians are a gossipy lot, I know I’m not alone and
anecdotal experience suggests that many of my medical contemporaries no
longer toe the party line on euthanasia with the enthusiasm they showed
when they were sprightly 60 year olds.
That’s why I found this article[1] depressing. Having progressed
solemnly
though its five pages, I was left with an image of mediaeval philosophers
sitting in a tower earnestly discussing the number of angels who could
dance
on the head of a pin while outside in the open landscape less enlightened
persons lay suffering in ditches.
As is traditional in our journals this case history is written by the
doctors. We
read in detail the arguments they consider and the agonising they endure
before reaching their decision. We hear nothing directly from the woman or
her family. Their actions and their attitudes are described not by them
but as
they are perceived by her doctors.
The medical narrative is, however clear. A woman, having taken the
precaution of writing and signing an advanced directive and a seemingly
detailed suicide note, swallows a potent concoction of sedatives and sinks
into what she assumes will be oblivion. (I can only guess at her
assumption
because we hear nothing about her religious beliefs or indeed of the
beliefs
of those who made the life or death decision for her. These are surely
relevant. Some might consider them “competing interests”.)
Denied oblivion the woman wakes up in hospital with a left
hemiparesis.
Luckily, however, treatment is at hand and methotrexate gives her
“excellent
symptomatic relief from her arthritis ” before she is “diagnosed with
depression and started on fluoxetine.” Thanks to the traditional use of
the
passive voice we don’t know who made that diagnosis or why but, three
months later, she goes home “almost pain free and mobile with assistance”.
We next encounter her six months later when the doctor(s) who saw her
thought she was “cheerful”. She “acknowledged" that her quality of life
had
improved, but “considered” it was still poor. She also "maintained” that
she
would have preferred to have had her wishes respected, to have retained
her
independence and dignity, and not to have survived. “This position,” we
are
told, “was confirmed in a subsequent letter.” Yet we see no quotation from
the letter which might offer some idea of what she really thought as
opposed
to what her doctors thought she thought.
Indeed we hear nothing at all about what happened to her and her
family
during those six months. We do learn, however, that “she was grateful to
the
staff for attempting to act in her best interests”, but then kindly
patients (and
most are kindly) are often grateful to nurses and doctors who make
mistakes
if they think the mistakes were made with good intentions.
The narrative, and article, end with a chilling sentence: “She lived
almost
pain-free for another 18 months with some reservations but no resentment
over her management and unfortunately (!!) subsequently died in
hospital in a manner which she had tried to avoid.”
“Serves you right, madam", whispered the Devil in my ear, "for
placing your
trust in irrelevant fripperies like advance directives that fly in the
face of one
of the traditional precepts of our profession: Doctors know best.”
Ever mindful of the fears of elderly fools like me, the BMJ offers
consolation
on another page where Alex Paton,[2] a former consultant physician who
knew the ropes, describes how he managed to win for his wife the dignified
death that she and her family desired.
To achieve this they had to remove her from hospital. They had
difficulty
persuading the doctors to let her go but succeeded after, of course,
signing a form saying they were acting “against medical advice”. At home
she
received “impeccable” attention from doctors and nurses, apart from one
“small incident” — a cool medical reaction to the family’s unanimous
dismissal of the idea she should have a series of blood tests “just to
make
sure there is nothing treatable”. She spent the last fortnight of her life
surrounded by her husband, her four children and their families “able to
talk
and laugh and share in the gossip until near the end”.
I’ve long admired the writing of Alex Paton. The articles he
published down
the years in this and other journals revealed him as not just a skilled
but a
compassionate physician. I now salute him for saving his wife from the
fate
suffered by the woman in the first case history for whom the resources of
modern medicine were deployed, against her wishes, to render her fit
enough
to die “unfortunately” in the very manner she had tried to avoid.
An old friend of mine, two days before his undignified death in a
dirty under-
staffed ward, described the process as “well-intentioned inhumanity”.
1. Bonner S et al. Are advance directives legally binding or simply
the
starting point for discussion of patients’ best interests? BMJ
2009;339:b4667
2. Paton A, Letting go. BMJ 2009;339:b4982
Rapid Response:
Who claimed medical parentalism was dead?
As a member of the growing company of octogenarians, I spend much of
my
time exploring a decade I never thought I would achieve. As ever the early
symptoms of change lie in the detail. Many of the engagements in my diary
have to do with funerals, memorial services, or visits to the bedsides of
stricken friends. I no longer lay down wine but search punctiliously
through
vintners’ lists for the magic words “drink now”. This attitude to death is
fashioned by an awareness that the final milestone can’t be too far down
the
road. I speculate less about the possible causes of my death than about
the
manner of my dying.
Because we octogenarians are a gossipy lot, I know I’m not alone and
anecdotal experience suggests that many of my medical contemporaries no
longer toe the party line on euthanasia with the enthusiasm they showed
when they were sprightly 60 year olds.
That’s why I found this article[1] depressing. Having progressed
solemnly
though its five pages, I was left with an image of mediaeval philosophers
sitting in a tower earnestly discussing the number of angels who could
dance
on the head of a pin while outside in the open landscape less enlightened
persons lay suffering in ditches.
As is traditional in our journals this case history is written by the
doctors. We
read in detail the arguments they consider and the agonising they endure
before reaching their decision. We hear nothing directly from the woman or
her family. Their actions and their attitudes are described not by them
but as
they are perceived by her doctors.
The medical narrative is, however clear. A woman, having taken the
precaution of writing and signing an advanced directive and a seemingly
detailed suicide note, swallows a potent concoction of sedatives and sinks
into what she assumes will be oblivion. (I can only guess at her
assumption
because we hear nothing about her religious beliefs or indeed of the
beliefs
of those who made the life or death decision for her. These are surely
relevant. Some might consider them “competing interests”.)
Denied oblivion the woman wakes up in hospital with a left
hemiparesis.
Luckily, however, treatment is at hand and methotrexate gives her
“excellent
symptomatic relief from her arthritis ” before she is “diagnosed with
depression and started on fluoxetine.” Thanks to the traditional use of
the
passive voice we don’t know who made that diagnosis or why but, three
months later, she goes home “almost pain free and mobile with assistance”.
We next encounter her six months later when the doctor(s) who saw her
thought she was “cheerful”. She “acknowledged" that her quality of life
had
improved, but “considered” it was still poor. She also "maintained” that
she
would have preferred to have had her wishes respected, to have retained
her
independence and dignity, and not to have survived. “This position,” we
are
told, “was confirmed in a subsequent letter.” Yet we see no quotation from
the letter which might offer some idea of what she really thought as
opposed
to what her doctors thought she thought.
Indeed we hear nothing at all about what happened to her and her
family
during those six months. We do learn, however, that “she was grateful to
the
staff for attempting to act in her best interests”, but then kindly
patients (and
most are kindly) are often grateful to nurses and doctors who make
mistakes
if they think the mistakes were made with good intentions.
The narrative, and article, end with a chilling sentence: “She lived
almost
pain-free for another 18 months with some reservations but no resentment
over her management and unfortunately (!!) subsequently died in
hospital in a manner which she had tried to avoid.”
“Serves you right, madam", whispered the Devil in my ear, "for
placing your
trust in irrelevant fripperies like advance directives that fly in the
face of one
of the traditional precepts of our profession: Doctors know best.”
Ever mindful of the fears of elderly fools like me, the BMJ offers
consolation
on another page where Alex Paton,[2] a former consultant physician who
knew the ropes, describes how he managed to win for his wife the dignified
death that she and her family desired.
To achieve this they had to remove her from hospital. They had
difficulty
persuading the doctors to let her go but succeeded after, of course,
signing a form saying they were acting “against medical advice”. At home
she
received “impeccable” attention from doctors and nurses, apart from one
“small incident” — a cool medical reaction to the family’s unanimous
dismissal of the idea she should have a series of blood tests “just to
make
sure there is nothing treatable”. She spent the last fortnight of her life
surrounded by her husband, her four children and their families “able to
talk
and laugh and share in the gossip until near the end”.
I’ve long admired the writing of Alex Paton. The articles he
published down
the years in this and other journals revealed him as not just a skilled
but a
compassionate physician. I now salute him for saving his wife from the
fate
suffered by the woman in the first case history for whom the resources of
modern medicine were deployed, against her wishes, to render her fit
enough
to die “unfortunately” in the very manner she had tried to avoid.
An old friend of mine, two days before his undignified death in a
dirty under-
staffed ward, described the process as “well-intentioned inhumanity”.
Michael O'Donnell
mod@doctors.org.uk
1. Bonner S et al. Are advance directives legally binding or simply
the
starting point for discussion of patients’ best interests? BMJ
2009;339:b4667
2. Paton A, Letting go. BMJ 2009;339:b4982
Competing interests:
None declared
Competing interests: No competing interests