Monday, November 21, 2016

Euthanasia might have been necessary fifty years ago

'I believed that euthanasia was the only humane solution. I no longer believe that.'

In 1969, when I was 15 years old, my adored 37-year-old single Auntie Nancy was diagnosed with very advanced, untreatable ovarian cancer. It was a dreadful time in our close extended family's life. She began to deteriorate quickly and to develop severe pain from the tumour masses in her abdomen. She asked to stay at home and to be allowed to die in peace surrounded by her loving family.
There were no visiting palliative care nursing teams then. There was no medical expertise in pain control. Doctors avoided using narcotics until the final hours for fear of addiction and that they would stop working if started too early. As my aunt began to deteriorate, an experienced private day nurse was engaged. My mother, in tandem with my other two aunts, would stay up every third night with my aunt, turning, toileting, massaging and comforting her. She was in agony and regularly cried out in pain. The doctor eventually prescribed a small dose of morphine to be strictly used every four hours. It had no effect.
My aunt slowly became emaciated and developed painful bed sores. The family increased their efforts. They would care for her till the end. Eventually, after months, she became so desperate that she pleaded to be killed. Please? Please? The visiting nurse, a courageous and compassionate woman, promised to help. She had a cache of unused morphine ampoules from previous patients for desperate situations. Unable to obtain appropriate orders from the doctor, she secretly gave them to my aunt. Finally she was freed of her suffering.
It took many years for my mother to tearfully tell me this very painful story. Her guilt, regret and sense of failure were profound. I was convinced that such mercy killing must be made more easily and widely available if it was true that no other treatment options existed.
But since then my views have changed. Thirteen years after my aunt died, I trained in the newly established speciality of medical oncology. I spent any spare time learning pain control and palliative care. I listened to the experts and to my patients.
I began to see newer emerging team-based palliative care treatment options for those like my aunt. Many more of our patients were now dying peacefully. I could see that euthanasia may not be the answer after all.
The advances in the skills, availability and knowledge in palliative care since those days have been phenomenal. The horror stories of doctors telling nurses to close the doors of the patients who were screaming out in pain were fast disappearing.
I have received many euthanasia requests from patients and families over my 34 years in full-time oncology practice, some very passionate, but I have invariably found that they quickly disappear as reassurance and adequate medication doses provide the comfort that is desired and the newly exposed opportunities for patients and families to share deep and poignant moments of bonding and reflection, or nurse a new-born grandchild, or attend a wedding or a graduation.
If a patient and their family needs help for a comfortable and peaceful death, doctors routinely increase the dose of medications, even if the patient dies sooner as a result. As long as the primary goal of this treatment is the relief of suffering and not to cause death, this is permitted.
This "law of double effect" is a legal grey area that allows doctors to provide optimal care short of primarily trying to kill the patient. Some would call it passive euthanasia. Perhaps it is. However, as a secular humanist, it is a subtle but huge difference that allows me to relieve suffering, to share some of the most profound human experiences possible and to sleep comfortably at night.
As an oncologist with 35 years' full-time experience, I have seen palliative care reach the point where the terminally ill can die with equal or more dignity than euthanasia will provide. It is now very effective and increasingly available for two of the three possible ways of dying, outside of sudden unexpected death, which are advanced cancer and chronic relapsing and remitting organ-specific disease such as heart or lung failure.
Palliative care is also available for people with chronic progressive cognitive diseases such as dementia. This is the fourth way of dying and perhaps the most feared of all.
Euthanasia is unlikely to become available for people in such circumstances because their condition prevents truly informed consent.
Only a fully informed detailed advanced care plan done before any decline, where one can prohibit life-saving interventions such as antibiotics and intravenous fluids if certain conditions are met, can easily and safely produce the smooth outcome that many would desire if combined with palliative care.
Like Andrew Denton and others who have observed unbearable suffering in loved ones and the terrible failures of modern medicine in the past, I had once believed that euthanasia was the only humane solution.
I no longer believe that.
The experiences of countless patients and families should be the inspiration for continuing to improve palliative care, for general introduction of advanced care plans and not for euthanasia with its openness to misuse.
If the Victorian government legalises assisted dying for people suffering from serious and incurable conditions, it will be the wrong choice. It is not necessary and, as outlined in the minority report to government, it will inevitably increase the pressure, both stated and perceived, for some chronically ill patients to move on and stop being a burden.
Ian Haines is a medical oncologist.

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