Euthanasia Requests Offer Therapeutic Window
Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.
Sometimes patients won't directly express a desire for death but will hint at it or make deliberately provocative statements. One of Dr. Byock's patients told him that “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.
Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” Dr. Byock said.
“It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia,” he said.
In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that a detailed pain management plan needs to be put in place, with lots of contingencies, in case pain gets out of control. This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.
“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.
In addition, it's a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable; I would assert that it's ethically required, if nothing else is working,” he said.
Another issue for many patients with advanced illness is the worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.
Some evidence suggests that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said. Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.
Dr. Ira R. Byock tells patients that their behavior and attitude can influence the way families respond to the burden of care. Mark Washburn/Dartmouth-Hitchcock Medical Center
How One Patient Found Some Solace
One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief. He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.
Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.
According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain. “I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.
While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety. A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die. Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain. He added that he knew his wife would be devastated if he committed suicide. When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.
