Physician: Dying can reveal life's joy

Related story: NYS Commission to study pain care

Some of Dr. George Davis's patients want to die. All of them will. But part of his job is to make sure they don't hurry their deaths due to depression or pain.

Every day, the medical director for The Community Hospice at St. Peter's Hospital in Albany sees people enter hospice care in the final stages of cancer, heart disease, pulmonary diseases or dementia.

They often tell the staff they want to die. But with proper pain management, understanding and support, says Dr. Davis, most patients realize that rather than dying prematurely, they can live the rest of their lives without the pain and fear that leads some to consider physician-assisted suicide.

Dealing with pain

Physician-assisted suicide has become a hot topic in the media. Experts have debated the ethics of doctors' helping their patients to die and discussed whether long-term pain or only terminal illnesses would be qualifying factors in administering euthanasia.

However, Dr. Davis told The Evangelist, the main reasons patients consider euthanasia are pain, fear and lack of hope.

"People come to us with pain that has been dealt with in different ways, which vary greatly according to their care," the physician explained. "People have a tremendous number of fears. They cite pretty quickly the fear of pain, fear of being short of breath and choking or suffocating, especially heart or lung patients; fear of physical pain of different types; fear of being nauseous."

Additionally, he said, patients fear being overmedicated, "that `the medications are going to hurt me or make me so dopey I can't function.' Often, they have a history of being overmedicated."

Hospice help

After they have heard patients' fears about physical pain, the hospice team -- which includes the medical director, doctors, case managers (nurses), chaplains, social workers and volunteers -- reassures the patient that "almost any physical discomfort can be managed with medication," from nausea and feelings of suffocation to other pain.

To avoid overmedicating, patients are started at low doses of pain medication. Dr. Davis said that for the first few days on a new medication, patients may feel sedated, "but after a couple of days, they will become tolerant to that."

The key to good pain management, he said, is encouraging patients to tell the hospice team about their pain before it becomes severe. "We have an image that we don't want to be talking about pain: `I'll only tell them when it gets really bad.' The initial step is to get them to let us know."

Pain scale

Patients are asked to rate their pain on a scale of zero to ten or zero to five, and to alert the staff even for pain rating a one or two. "It's easier to treat then," explained Dr. Davis.

The drug most often used for pain management is morphine. "It is a good drug in the sense of [avoiding the complication of] not being able to breathe," Dr. Davis said. "It takes that [fear] away."

Since most patients are in hospice care for only a month or so before their deaths, the fear of becoming addicted is not an issue, he said. Such side effects as nausea and constipation are easily managed.

In regard to patients' concerns about feeling sedated by the drug, the physician quotes a study in Lancet magazine in which cancer patients on high doses of morphine were asked to drive a car. Since morphine is absorbed by pain receptors, the patients could tolerate high doses and had no difficulty driving.

Other medications used in pain management include codeine, percocet and Motrin. Dr. Davis added that rather than giving the drugs only when the patients are already in pain, a 'round-the-clock medication schedule better manages discomfort.

Emotional pain

Once patients' physical pain is dealt with, "there obviously can be other types of pain in terms of spiritual or emotional pain," the physician stated. Often, that's when patients speak of assisted suicide.

"Sometimes, it has not been an issue, but it becomes more of an issue while they're on the program," he noted. "The idea of suicide comes up, either with one team member or another. They say, `I want to die.' But they may really want to talk about what dying means to them. They really are asking what their options are."

All terminally ill patients experience losses, he said, from changes in their level of dependency on others to losing hope. Hospice teams provide support to combat those fears as well.

"They have fear of having no control over their life," Dr. Davis said. "They feel the disease has taken over. We give them back some control."

At ease

Patients often ask, in relief, "I can really just lie here and think about what my next step is?"

"We say, `Yeah, you can,'" Dr. Davis said. "We do promote the ability of the family and patient to decide what they want. The goal is no longer to cure or change what is going to happen, but to make the quality of each day as good as possible. We turn over as much control as possible to the patient and family."

Terminally ill patients often deal with estrangements from family members as well. When this causes emotional pain to patients, Hospice teams try to reunite families, "at least to say goodbye."

Chaplains help patients to deal with the spiritual pain they may experience, said Dr. Davis, "the existential issues of what their life has meant, their relationship to God. They may revisit previous deaths that have not been adequately grieved; that comes up not infrequently."

Reassurance

Above all, the doctor added, patients who are dying -- and their families -- want reassurance that they are making the right decisions. Sometimes, family members disagree over care; in that case, the job of the Hospice team is to "help them deal with it, help them see that the end is coming."

Pain management and counseling, he said, provide hope. "People have an image of Hospice as being a doom-and-gloom thing. It's really, `Let's talk about the life we have left.' Celebrating that life becomes very important."

As the debate over physician-assisted suicide rages on, Dr. Davis said that hospice care needs to be considered as an important factor.

"We need to look at it as a real possibility that physician-assisted suicide is a lack of hope," he stated. "I think people don't need only the hope of a cure. Hospice redirects that hope. There are other kinds of hope we can create. One of those is not having pain. Another is spending the rest of your life as you want to."

(To contact The Community Hospice, call 1-800-678-0711. Also, the Albany diocesan Public Policy Committee has announced the production of a video to explain the current debate about physician-assisted suicide. The video is to be used in parishes to help Catholics learn more about the issue. The video will be scripted by the Public Policy Committee, which hopes to include comments from Bishop Howard J. Hubbard, counselors and hospice workers. The video will be available for parishes in the fall along with a packet of resource materials and contact persons to provide additional information about physician-assisted suicide.)

Quotes from life-inspiring video...

* "We believe that life is a sacred gift from God, to be cherished and protected. There is a new threat to the gift of life: physician-assisted suicide. The Christian response to serious illness is skilled medical treatment and loving support for patients and their families. It is not assisted suicide, a so-called `mercy killing.'" -- Bishop Thomas Daily, Diocese of Brooklyn

* "We are creatures of God. Life is a gift of God. We are not absolute masters of that life; and so when we take into our own hands the moment of our death, the way we shall die, and actively bring it about, or ask someone else to participate with us and help us, in assisted suicide, we are violating the basic notion of God's sovereignty over human life and over the universe....It is not a free choice. [A dying person has a] temptation to feel that you're a burden to other people [which] creates in them a sense of unworthiness, a sense of guilt....Once you relax an important prohibition life not killing, the first time is easy, the second time is easier -- and you go down the slope. That's actually happening." -- Dr. Edmund Pellegrino, Georgetown University, Kennedy Institute of Bioethics

* "Up until that last moment of life, I think we have something to offer." -- Officer Steven McDonald, who was paralyzed by a bullet.

(Editor's note: These quotations come from a video on physician-assisted suicide released by the Dioceses of Brooklyn and Rockville Centre.)

NYS Commission to study issues of pain care and treatment for dying...

New York State Attorney General Dennis Vacco has announced the formation of a state commission to study issues of pain care and treatment for the dying.

The Commission on Quality Care at the End of Life includes 19 experts on cancer, AIDS, medical ethics and health care for the dying.

Two of the members, Dr. Janet Garigulo of Capital District Hematology/Oncology Associates in Latham and Dr. Ann Saldanha, chief of pathology and clinical laboratories at Mercy Hospital in Buffalo and an associate pathologist at Newfane Inter-community Hospital, were suggested by the New York State Catholic Conference, which represents the bishops in public policy matters.

The commission will evaluate current state laws for quality care of the terminally ill in order to "make physician-assisted suicide a less-attractive alternative to truly compassionate and professional medical care," stated Attorney General Vacco.

Kathleen Gallagher, associate director of the Catholic Conference, applauded the effort. "We certainly feel we're going to be working in collaboration with the commission," she told The Evangelist.

The commission is expected to make proposals for changes in the treatment of the dying in February 1998. (KB)

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