Euthanasia is a very touchy subject, especially within the medical field. As a healthcare advocate, it is our job as professionals to better the lives of our patients. What happens when there is nothing more you can do?
I understand, being a Home Health Aide that works a lot with Hospice, that comfort care is important. But truly, when a suffering patient looks to you to ease the pain what do you do? Should you apologize and say their is nothing more I can do?
I can hardly say no more treats to my cat when he gives puppy dog eyes, much less a patient dying alone of cancer. In my opinion, for what it is worth, Euthanasia is most certainly not murder and should never be referred to as such.
If Euthanasia was legal, but very strict in regulations and rules, it would be very beneficial to many terminally ill patients. This may be the only healthcare decision a patient makes within their life, and they should be allowed to make such a decision when conditions permit. We all have choices in this world, what gives you or I the right to take such choices away from someone in such a situation.
What is your opinion? Do you agree or disagree? Do you have a story, personal or not that pertains to this topic?
I get the impression that much of your views revolve around how patients come to experience the adverse effects of medications used in end-of-life care.
you refer to the principle of double of effect, where we accept adverse effects for the purpose of treating distress in the dying patient, and contest the need for double effect to exist at all since "their is overwhelming evidence that the appropriate use of opioids at the end of life does not hasten death". The wording of the conclusions of these studies is very misleading, because you have to consider what they mean by "appropriate"; ie "appropriate" for what kind of patient. What these studies show is that when dosed in manner consistent with a patient who is not choosing comfort over longevity, it does not hasten death. But one of the major differences in the goals of someone who is choosing to be comfortable is that we specifically don't limit pain control to what won't cause adverse effects, we accept adverse effects if it's necessary in the process of treating pain.
In other words, the basic premise of "regular" patient care is that we don't tolerate adverse effects and we adjust the medication regimen as needed to avoid adverse effects while tolerating continued pain if necessary, in comfort care/EOL care we don't tolerate excessive pain, and adjust the medication regimen to treat that, and tolerate the adverse effects only if they're necessary in adequately treating pain and distress.
"The Liverpool Care Pathway [in the U.K." was developed to support patients as they near death. But the reality for patients and families has been mixed.
The system, which can involve withdrawal of medication, food and fluids, was developed at the Royal Liverpool University Hospital and the city's Marie Curie HOSPICE [emphasis added here] in the 1990s to provide a model of best practice in the care of dying patients."
"Liverpool Care Pathway: 'They told my family I was dying'" August 15, 2013, BBC News.
"There are problems with a controversial regime that allows doctors to withdraw treatment in the last days of life, doctors have admitted.
"Members of the British Medical Association said dying patients may have been put on the Liverpool Care Pathway when it was not appropriate because hospitals were offered financial incentives to use it." article by Nick Triggle, at the BBC
also:
Steve Doughty, "Top doctor's chilling claim: The NHS kills off 130,000 elderly patients every year," June 20, 2012, The DailyMail, U.K.
The NHS kills off 130,000 elderly patients every year,
doctors use 'death pathway' to euthenasia of the elderly,
treatment on average brings a patient to death in 33 hours,
around 29 per cent of patients that die in hospital are on controversial 'care pathway'
----------------
This Liverpool Care Pathway is exactly the same misuse of terminal sedation (applied when there is no terminal agitation, no psychosis or delirium and no intractable physical pain) combined with voluntary (or involuntary) stopping eating and drinking (you can't take food/fluids in when you're being terminally-sedated, obviously.
This application of terminal sedation has been long promoted by stakeholders, policymakers and physicians including the Hastings Center, and the current successors to the Euthansia Society of America/Society for the Right to Die/Choice in Dying (name changes - all same organization) which merged into Partnership for Caring, the HOSPICE coalition and then merged with Last Acts, the Hospice coalition, to become Last Acts Partnership which was absorbed into the National Hospice & Palliative Care Organization and marketed as their "Caring Connections" program (from the NHPCO website itself).
Ira Byock, MD, one of the foremost modern hospice leaders openly discusses how he terminally sedates patients who are not suffering from terminal agitation, no psychosis or delirium and no intractable physical pain - and describes how he interacts with patients when suggesting this way of ending their life in a hospice setting. It is also called "slow euthanasia" by many in the palliative care community (or "stealth euthanasia")
If no realistic and objective conversation is allowed, and name-calling, which is beneath this forum, is your only response, then you demonstrate the cult-like qualities of those who can't even countenance that any wrong at all is done by hospice or that there are widespread problems.
"Hospice can do no wrong" you say? So you use ad hominem arguments and mockery when you can't take the heat.
Facts and history show the reality. There has always been two major branches of hospice in the US and U.K. .. that demonstrated by Dr. Cicely Saunders and that demonstrated by Florence Wald, MSN who was a supporter of assisted suicide and euthanasia and certainly had no problem with sedating patients into death, even if not clinically appropriate.
Dust off the history books and learn something about the industry you apparently work in but know nothing about.
"If a nurse really does witness other nurses purposefully sedating an alert and oriented hospice patient, and then administer excessive morphine in order to "kill" them, that nurse better darn well call the police asap."
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Saying that such incidents should be reported to the police or "authorities" only shows that you have not had experience in these matters. People have actually reported to the police and the police will not investigate deaths in hospice settings. Thousands of people have tried, nurses and physicians.
The police state uniformly that these matters are "expected deaths" and that the complaints should go the state departments of health investigators (who are almost worthless when it comes to substantiating fact-based allegations that are submitted to them).
Not all hospices are killing patients. That would be a ridiculous statement. Neither are all staff, but some are, and when it happens to one's loved one, it is tragic, and the anguish these family members experience haunts them for the rest of their lives. These are not people who always ignorant about good end-of-life care in hospice. Some had good experiences, wonderful experiences in hospice, and then later had a terrible experience with a hastened death (various sorts of means can be used).
If you work in hospice, you would immediately know that the scenario you describe is ridiculous in a home care setting. There are no doctors and other nurses standing around when such a hastened death would occur. Nurses in hospice have comparatively the most independence in their work, compared to other niches of health care.
In addition, many palliative care physicians often use terminal sedation when there is no intractable physical pain, no delirium and no terminal agitation (which are the clinically appropriate criteria for using terminal sedation).
Why hospice agencies would want to end the lives of their patients could have more than one answer:
many hospice agencies especially for-profit ones, have been brought up on charges by the U.S. Justice Dept. for taking in absolutely NON-terminal patients who simply stable, chronically-ill patients and using them to pad their revenue stream. Many articles and government reports have come out about these schemes.
The current Medicare hospice benefit (however much you may not like how it is set up) requires certification that the patient is statistically likely to die in 6 months (but allows of course for re-certs again and again if clinical conditions demonstrate that the patient is still "terminal" by their definition).
To avoid discovery by Medicare fiscal intermediaries, some patients may be hastened to death to "prove" that they were terminal (if they died, then they must have been terminal it would seem ... they reason).
Some hospices have plenty of patients and need to clear out facility beds for new patients. that could be another reason. Of course, if census is low, they're not going to end the lives of those patients that are not terminal; they'll keep them. The influx of for-profit hospice corporations into the industry has been striking, and now there are more of them than the nonprofit corporations. Some are just in it for the money, not the mission!
Specializes in NICU, PICU, Transport, L&D, Hospice.
If no realistic and objective conversation is allowed, and name-calling, which is beneath this forum, is your only response, then you demonstrate the cult-like qualities of those who can't even countenance that any wrong at all is done by hospice or that there are widespread problems.
"Hospice can do no wrong" you say? So you use ad hominem arguments and mockery when you can't take the heat.
Facts and history show the reality. There has always been two major branches of hospice in the US and U.K. .. that demonstrated by Dr. Cicely Saunders and that demonstrated by Florence Wald, MSN who was a supporter of assisted suicide and euthanasia and certainly had no problem with sedating patients into death, even if not clinically appropriate.
Dust off the history books and learn something about the industry you apparently work in but know nothing about.
bah
no person here has suggested that hospice "can do no wrong".
We are simply not interested in your conspiracy theories and fear mongering relative to hospice care in the USA. It seems that your objective is not to improve hospice care, but rather, to frighten the socks off of vulnerable and frightened people who are reeling from knowlege that they or someone they love has a terminal or life limiting condition.
You are an arrogant ass if you assume that those of us who work in this industry have no knowledge of the history of the specialty. It is especially aggravating that someone who apparently has very limited experience in the actual specialty considers himself an expert because he has looked some information up on the internet and has self published a book critical of hospice care.
Yes, Florence Wald was a pioneer in American Hospice and yes she supported euthanasia as a possible option for suffering people. Still, you seem to not understand that hospice and euthanasia are two separate things and that hospice care is NOT synoymous with euthanasia. It seems that you have a need to convince us that they are the same, why?
no person here has suggested that hospice "can do no wrong".
We are simply not interested in your conspiracy theories and fear mongering relative to hospice care in the USA. It seems that your objective is not to improve hospice care, but rather, to frighten the socks off of vulnerable and frightened people who are reeling from knowlege that they or someone they love has a terminal or life limiting condition.
You are an arrogant ass if you assume that those of us who work in this industry have no knowledge of the history of the specialty. It is especially aggravating that someone who apparently has very limited experience in the actual specialty considers himself an expert because he has looked some information up on the internet and has self published a book critical of hospice care.
Yes, Florence Wald was a pioneer in American Hospice and yes she supported euthanasia as a possible option for suffering people. Still, you seem to not understand that hospice and euthanasia are two separate things and that hospice care is NOT synoymous with euthanasia. It seems that you have a need to convince us that they are the same, why?
You didn't read carefully what I have written. I have never equated hospice and euthanasia. That doesn't meant that the euthanasia movement has not influenced the hospice industry. The history clearly shows that it has and is part of the covert euthanasia movement as contrasted with the overt euthanasia movement that is represented by the likes of Compassion & Choices that work for legalization of assisted-suicide/ and or euthanasia.
I have worked with hospice and home health for 18 years and have been in touch with hospice professionals with doctorates in nursing and also professors of palliative medicine (MDs and DNPs) who confirm there are serious problems in the industry.
There is no "conspiracy theory." There is good hospice and tainted hospice. If you can't admit that there are some who do not follow the criteria for terminal sedation that Dr. Cicely Saunders and many other physicians in the palliative care industry have established, then I can't help you.
They have issued formal statements and clearly condemned the misuse of terminal sedation to end lives when there is no intractable physical pain, no delirium, no psychosis and no terminal agitation.
I get the impression that much of your views revolve around how patients come to experience the adverse effects of medications used in end-of-life care.
you refer to the principle of double of effect, where we accept adverse effects for the purpose of treating distress in the dying patient, and contest the need for double effect to exist at all since "their is overwhelming evidence that the appropriate use of opioids at the end of life does not hasten death". The wording of the conclusions of these studies is very misleading, because you have to consider what they mean by "appropriate"; ie "appropriate" for what kind of patient. What these studies show is that when dosed in manner consistent with a patient who is not choosing comfort over longevity, it does not hasten death. But one of the major differences in the goals of someone who is choosing to be comfortable is that we specifically don't limit pain control to what won't cause adverse effects, we accept adverse effects if it's necessary in the process of treating pain.
In other words, the basic premise of "regular" patient care is that we don't tolerate adverse effects and we adjust the medication regimen as needed to avoid adverse effects while tolerating continued pain if necessary, in comfort care/EOL care we don't tolerate excessive pain, and adjust the medication regimen to treat that, and tolerate the adverse effects only if they're necessary in adequately treating pain and distress.
Clearly, the approach in hospice or palliative care settings is different from "regular" healthcare and I support the specialized branch of medicine known as palliative care, practiced by Dr. Saunders and many others. Certainly, one can increase the dosage, titrating for comfort as needed to establish patient comfort levels, and that is a wonderful thing to do!
Don't mis-quote or twist what was written. Good EOL care is a blessing. However, Dr. Saunders and hundreds of other palliative care physicians have condemned the misuse of terminal sedation to intend the ending of life (when there is no intractable pain, no delirium, psychosis or true clinical terminal agitation). The brief statement on this subject of the European Assoc of Palliative Care is below and was approved by Dr. Cicely Saunders
"Abuse of palliative sedation: Abuse of sedation occurs when clinicians sedate patients approaching the end of life with the primary goal of hastening the patient's death. This has been called ‘slow euthanasia'."
see:
Nathan I Cherney, Lukas Radbruch, and The Board of the European Association for Palliative Care, "European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care," 2009 updated version, European Association for Palliative Care.
ronpanzer, what are your credentials? You created the Hospice Patients Alliance, and you self-published a "book" on the website. You say you have friends in the hospice industry, and they agree you about the issues. (Not really good evidence there.) An excerpt from your "book":
You googled a seminar agenda on bioethics in Canada, and you use that as a basis that evidence-based medicine is somehow...not evidenced-based? Did you attend the seminar? Do you even understand how standards of care are developed and the levels of evidence to determine the standards of care?
You might be a master googler, but an expert in hospice you are not.
It seems you are capable of googling as well, but if you are not aware that evidenced-based medicine or what "goes by" that label, can be used in various ways by those with different agendas or especially, financial concerns, then that would be unfortunate.
For just one example of how "evidence-based" medicine may be misused, let's look at what professors of geriatrics at the U of Rochester had to say about it at a conference of the American Geriatrics Society in Seattle, WA in 2007. They confirm exactly what I wrote:
For example, just as one example, in a presentation entitled,
"END-OF-LIFE CARE FOR NURSING HOME RESIDENTS WITH ADVANCED DEMENTIA
AND FEEDING PROBLEMS: A COST-CONSEQUENCE ANALYSIS" by
T. V. Caprio, R. G. Holloway, R. McCann
University of Rochester Medical Center, Monroe Community Hospital, Strong Memorial Hospital,
Highland Hospital, Rochester, NY, USA.
###########
END-OF-LIFE CARE FOR NURSING HOME RESIDENTS WITH ADVANCED DEMENTIA
AND FEEDING PROBLEMS: A COST-CONSEQUENCE ANALYSIS
Thomas V. Caprio, MD Prof of Geriatrics & Aging, et al., Univ of Rochester Medical Center, Monroe Community Hospital, Strong Memorial Hospital, Highland Hospital, Rochester, NY, USA.
In this presentation the following conclusion was presented:
"external financial aspects may provide subtle influences on treatment decisions beyond that of evidence-based outcomes and value-based preferences of decision-makers."
their findings were summarized as following:
"Introduction: Advanced dementia may involve eating problems, swallowing difficulties, or loss of interest in food.
Families and nursing homes are often faced with a difficult decision-making process regarding medical care including administration of artificial nutrition/hydration and continued hospitalization for complicating illnesses.
This project performs a comprehensive cost-consequence analysis of different treatment pathways for nursing home residents with advanced dementia and feeding problems.
Methods: A two-component cost-consequence model was developed using TreeAge Pro 2006 software. The first component compared the costs associated with percutaneous endoscopic gastrostomy (PEG) feeding tube placement verses hand-feeding by staff. The second component compares costs associated with management of a single episode of aspiration pneumonia in the nursing home verses acute hospitalization. Cost estimates were obtained from published peer-reviewed literature. The mortality and risk of developing aspiration pneumonia was assumed to be uniform throughout the model.
Results: Total societal costs appear to be equivalent between tube feeding and hand feeding at approximately $18,000 including treatment of aspiration pneumonia in the hospital, and a range $10,000 - $11,000 for treatment in the nursing home. The costs from payer perspectives of Medicare, Medicaid, and nursing home show considerable differences. Medicare has the highest costs with PEG tube placement and hospitalizations for pneumonia at nearly $13,000. Medicaid costs for tube feeding is less than $5,000 and this compares to over $6,000-$7,000 for hand feeding. The nursing home experiences the highest costs associated with hand feeding and pneumonia treatment onsite,
due to increased staff costs exceeding $8,000. Nursing homes overall receive higher reimbursements and have lower costs with PEG tubes.
Conclusions: This provides further evidence that conflicting financial incentives may result from chosen treatment pathways for advanced dementia in the nursing home. It must be considered that these external financial aspects may provide subtle influences on treatment decisions beyond that of evidence-based outcomes and value-based preferences of decision-makers."
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That there may be other considerations that influence the delivery of care even when based upon "evidence based" medicine is my point, and that is exactly what these physician researchers have stated.
So much for the polite, enlightening, and engaging thread regarding the ethics of euthanasia itself. I feel like I need a tin foil hat to be here, and a scalding how shower + vanco on my way out.
Ron, you stated none of is engaging in an objective conversation regarding this topic, and yet every post prior to you joining the conversation WAS all of those things and more.
What you left out of your anecdote-laden comments was whether the people who were "killed" consented to and/or requested their deaths.
MunoRN, RN
8,058 Posts
RonPanzer,
I get the impression that much of your views revolve around how patients come to experience the adverse effects of medications used in end-of-life care.
In your article (http://www.ooanet.org/aws/MCA/asset_manager/get_file/64594/the_rise_of_stealth_euthanasia_ethics__medics_june_2013.pdf)
you refer to the principle of double of effect, where we accept adverse effects for the purpose of treating distress in the dying patient, and contest the need for double effect to exist at all since "their is overwhelming evidence that the appropriate use of opioids at the end of life does not hasten death". The wording of the conclusions of these studies is very misleading, because you have to consider what they mean by "appropriate"; ie "appropriate" for what kind of patient. What these studies show is that when dosed in manner consistent with a patient who is not choosing comfort over longevity, it does not hasten death. But one of the major differences in the goals of someone who is choosing to be comfortable is that we specifically don't limit pain control to what won't cause adverse effects, we accept adverse effects if it's necessary in the process of treating pain.
In other words, the basic premise of "regular" patient care is that we don't tolerate adverse effects and we adjust the medication regimen as needed to avoid adverse effects while tolerating continued pain if necessary, in comfort care/EOL care we don't tolerate excessive pain, and adjust the medication regimen to treat that, and tolerate the adverse effects only if they're necessary in adequately treating pain and distress.