By
Dr.
Mahjabeen Islam
Toledo, Ohio
Selectively
Erring on the Side of Life
Palliative Care,
a relatively new specialty in Medicine,
deals with the care of the terminally
ill or those that have chronic diseases
in which cure is not possible. Whilst
traditionally all efforts are geared
toward life prolongation and cure, here
symptom management and comfort are the
focus.
It originated from the Hospice movement
founded by Dame Cicely Saunders in 1967
in England. A hospice is a place where
terminally ill patients are treated
and the emphasis is on pain and symptom
management. Palliative Care programs
are within acute care hospitals and
whilst a Hospice patient has to typically
be prognosticated to live only six months,
palliative care patients may live several
years but the focus is more on improving
their quality of life rather than putting
them through tests and medicines to
cure them of their malady. Simply stated
quality rather than quantity.
Thanks to Hollywood, America’s
culture is rigidly based on immortality.
So pervasive it is that physicians are
frequently uncomfortable discussing
treatment options in the face of serious
diagnoses. The New York Times correctly
reports how there was a time that families
wanted fruitless treatment stopped but
hospitals insisted it go on. And now
advances in medicine and the media blitz
around a patient or two that might have
awoken from a coma after years, has
some families erring on the side of
life and keeping the patient connected
to life support, awaiting the same miracle
to happen to them.
The advent of Advanced Directives in
the United States goes toward greatly
helping the patient that has thought
things through ahead of time. In these
situations discontinuing life support
and curative treatment become, essentially,
a brainless proposition. It is in situations
where there is no Advance Directive
that we as physicians dealing with the
terminally ill, are faced with families
that are not only overwhelmed with grief,
but also unresolved issues and conflicts
that make it very difficult to arrive
at a cogent plan of action. Families
vacillate and hang on to tenuous conversations
with physicians. To witness this is
nothing short of heartbreaking.
Hospitals across the United States now
have Palliative Care Units, where physicians
and staff specialize in the care of
the seriously ill. The choice to have
these units has nothing altruistic about
it; it is driven by the bottom line.
Studies have shown that the cost incurred
on a patient in the last few days of
hospitalization when they are in the
Palliative Care Unit is one quarter
of what it is when they are in a non-Palliative
Care Unit. And with the government’s
strict eye on utilization, hospitals
find it in their best financial interest
to have Palliative Care Units and specialists.
Terri Schiavo vegetative state in a
hospice in Florida is truly trying for
the family to witness. In my experience
deciding the course of action in a terminally
ill patient depends greatly on the religious
and cultural orientation of the patient
and the family. With non-life threatening
treatment issues Muslim-American patients
are easy to deal with for they believe
in the dua and dawa (prayer and medicine)
concept. The opposing end of the spectrum
here are some Evangelical Christians
who outright refuse treatment and say,
“I will pray over it”. When
it comes to serious diagnoses or discontinuation
of life support, Muslims let go more
easily probably because of the belief
that this life is transitory and the
next the eternal one. And there is no
confusion about playing God for the
Qur’an states clearly that it
is God alone that decides the moment
and the mode of death.
A great deal also depends on the manner
in which the discussion is controlled
by the physician; if unrealistic hope
is held out, the family waits for a
miracle and if realism is brought to
play the family allows death with dignity.
Due to the heavy emphasis on this life
in current-day reform Judaism, and little
on detail about the Hereafter, patients
that do not have an Advance Directive,
may exist connected to a ventilator
for months or years. Evangelical Christians
in this regard can go either way: belief
in the eternal life can have them let
go, or a passionate belief in miracles
can keep that ventilator connected.
If a Living Will and Durable Power of
Attorney for Health Care is not made
out in life, at the time of serious
decision making if the patient is not
competent, the legal system in the United
States gives that power to the spouse.
There have been numerous times that
I have witnessed the conflict between
a couple, the politics if you will,
supervene in the decision-making. Terri
Schiavo had a troubled marriage and
though it is felt that she had an eating
disorder that caused her potassium to
fall and her heart to stop briefly,
speculation lays murder charges on her
husband. A few years after Terri’s
vegetative state he has a live-in girlfriend
from whom he has two children. That
as Catholics he wants Terri cremated
without an autopsy, rather than buried
makes one wonder all the more. As parental
love is unconditional and apolitical,
perhaps there ought to be a legislative
amendment that in terminally ill cases
with no Advance Directive, the health
care power of attorney should belong
to a parent and not the spouse.
This is not to say that the Schindler’s
frantic desire to reinsert the feeding
tube and prolong her life is necessarily
the correct one. There are times when
it is not life that is being prolonged
but death. Though this is totally premised
on the individual’s personal definition
of life. And there, really, is the rub.
The vast majority of patients that do
execute an Advance Directive choose
discontinuation of life support and
artificial feeding in a situation where
a meaningful recovery has been ruled
out. Facetiously we say that they don’t
want to be part of the vegetable patch.
Very importantly if the religious affiliation
of these individuals that do execute
an Advance Directive is taken, a full
spectrum will be seen, from atheist
to Evangelical Christians. Why then
do we not apply the same yardstick to
our loved one? Why would they want to
lie in a non-dignified state in a nursing
home, dependent on others, mindless
and drooling?
“In a serious diagnosis we should
always err on the side of life”
said President Bush. The sanctity of
life is not the only tenet in Christianity
even though Evangelicals delude themselves
into believing that it is. It is sad
that President Bush and his brother
Jeb Bush, Governor of Florida, have
used the Schiavo case for political
mileage. A legal snub from the Florida
courts and the Florida Supreme Court
is well deserved mainly because the
President’s blatant dichotomy
about the definition of life and who
is expendable and whose life ought to
be preserved.
(Dr. Mahjabeen Islam is medical director
of the Palliative Care Unit at St. Vincent
Mercy Medical Center in Toledo Ohio.
Her email address is mahjabeenislam@hotmail.com)
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