End-of-Life Choice, Death with Dignity, Palliative Care and Counseling

Among Doctors, Fierce Reluctance to Let Goby Jay

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By Paula Span
The New York Times
March 29 ,2012

The conversation took place two years ago, but Dr. Daniel Matlock still recalls it quite vividly. You tend to remember when a physician colleague essentially brands you a Nazi.

Dr. Matlock, a geriatrician who specializes in palliative care, had been called in to consult when a woman in her 70s arrived at the University of Colorado Hospital, unresponsive after a major stroke.

She’d done what we’re forever chiding people for not doing: She’d drafted a very specific advance directive and had even taken the trouble to have it notarized. It unambiguously said: no life support, no artificial nutrition or hydration, no nursing home.

The ambulance crew had put her on a ventilator — standard procedure. After the palliative team removed it, she was able to breathe on her own, which isn’t uncommon. She even opened her eyes, though she couldn’t track or follow objects and remained unresponsive. That’s when the prominent surgeon directing her care ordered intravenous fluids.

Dr. Matlock, alarmed at this direct contradiction of her preferences, tells the rest of the story in a post on the GeriPal blog, published by geriatricians and palliative care docs at the University of California, San Francisco. After talking with the patient’s sister, who held her medical power of attorney, he called the surgeon to suggest stopping the IV.

“You would have been hung in World War II for doing what you are doing now,” the surgeon said.

Let’s pause to think about that for a moment.

Within a few days, the woman was transferred to a hospice unit, where the IV was removed and she was permitted to die. But Dr. Matlock’s anger at his colleague and his sorrow at the woman’s treatment, or mistreatment, have persisted. “You work so hard to do what’s right for the patient,” he told me.

And he was sure he was right. Administering fluids to a dying patient increases the person’s secretions and makes breathing more difficult, palliative care doctors are taught. “Dehydration is a gentler death, with less agitation,” he said. But quite apart from that, the woman had done everything but stencil “no IV” across her forehead.

A palliative care consultant, however, couldn’t overrule the surgical team whose patient she was. “I went home that night feeling really bad,” Dr. Matlock said.

What prompted his account of this unpleasant exchange, all these months later, was a startling study recently published in The Journal of Palliative Medicine. After surveying nearly 700 physician-members of a national hospice and palliative medicine organization, the authors report that more than half had had at least one experience in the past five years of another physician or health care professional referring to their treatments as “euthanasia,” “killing” or “murder.”

This, despite palliative practices being broadly accepted as legal and ethical, as reducing suffering while honoring patients’ autonomy.

About a quarter of the respondents had heard similar accusations from a personal friend or family member, the study found. And 25 doctors (4 percent of the respondents) had been formally investigated on the question of whether they had hastened a patient’s death.

“It was cathartic for me” to read the study, Dr. Matlock said. “It was helpful to know I wasn’t alone.” But it’s not exactly reassuring news for the rest of us.

We’ve had frequent discussions here of end-of-life care and why the “good death” so many people want proves so elusive. We can, with ample reason, blame physicians who don’t want to talk or think about dying. (A favorite joke among hospice workers, who tend toward a dark sense of humor: Why are coffins nailed shut? To keep oncologists from administering more chemotherapy.)

And physicians have often responded with their own stories of family members who won’t accept that further treatment is futile and urge another operation, another drug, another something.

But here’s another part of the dynamic, apparently: Even when the system works as it’s supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers.

It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that’s intended to reduce suffering, to point out that the patient’s own wishes are paramount. Perhaps they have to be stronger than we know.

“The culture is changing,” Dr. Matlock told me. “But it’s not changed yet.”