Category Archives: Euthanasia

DEPRESSION AND CANCER

Hi DR Ryan here, medical oncologist AND PROFESSOR AND RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer.

I am sure you are familiar with our opening song   from chariots  of fire. A man has a plan and in a day it is crushed…… so it is when you have been told you have cancer ,thoughts of loss of control, soul sucking anxiety, what about your family and the list goes on as it hits  you like a ton of bricks.

He rose above it in the film  and so you to will be a hero ………I have seen no exception no matter how afraid you are, and that is what we are going to talk about today …your attitude when first diagnosed and through your course of therapy.. What about Depression

 

. We will take our time so feel free to write in your questions or comments at www.w4cs.com and i will try to get to them

Depression and Anxiety Disorders in Patients With Cancer

 

OVERVIEW

Over 15.5 million cancer survivors are alive today in the US, which is similar to the populations of New York City, Los Angeles, and Chicago combined.

 

The number of survivors continues to grow, not just because of earlier detection and treatment AND AGING OF THE POPULATION , but because of revolutionary new therapies that have been emerging over the past decade.

Now, patients with poor-prognosis metastatic cancers such as lung cancer and melanoma can live many years with good quality of life while on active treatment. For many individuals, this changes the landscape from a terminal illness to more of a chronic illness.

 

Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. In 2008, the Institute of Medicine published Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which documented under-detection and failure to optimally manage psychiatric disorders and psychosocial needs in patients with cancer and their families.

 

Unmet needs can have negative consequences for quality of life, treatment adherence, and survival. Subsequently, the American College of Surgeons Commission on Cancer started requiring cancer centers to screen patients for psychosocial distress as part of accreditation, and the American Society of Clinical Oncology developed practice guidelines for managing depression and anxiety.

 

THEY ARE NOT ALWAYS FOLLOWED OR SCREENING DONE SORRY BUT THAT IS REALITY AND RESEARCH SUPPORTS THAT

 

 

Although most cancer centers provide some psychosocial services, increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals . Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management.

 

Studies have documented that a cancer diagnosis results in high levels of emotional distress. Patients go through an adjustment period for about 4 to 6 weeks after diagnosis. SOME LONGER AND EXPECT THAT Cancer for many patients is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions—all while continuing to manage family, work, and other responsibilities.

 

However, for the majority of patients, once they receive a plan of action and begin treatment, their emotions tend to level out. Yet, cancer should not be considered as one discrete crisis, but rather as a series of crises that may occur at any time in the disease trajectory from diagnosis, treatment, cycles of recurrences and remissions, post-treatment, and sometimes palliative care.

 

In terms of psychiatric disorders among cancer patients, there is significant variability in the prevalence rates reported due to different assessment methods (clinical interview versus standardized measures), diagnostic criteria, type of cancer, and stage of disease among other variables. Recently, Mehnert and colleagues reported a 31% prevalence rate for any psychiatric disorder in cancer patients. Adjustment disorders tend to be the most commonly diagnosed, with the rates ranging from 11% to 35%. Rates for depression vary from 11% to 37%, and anxiety disorders show rates from 2.6% to 19.4%. The rate for depression in the general population is 7%—and thus lower than among cancer patients—but the rates for overall anxiety disorders seem to be comparable WHICH I DO NOT BELIEVE IT IS UNDER REPORTED.

 

 

Assessment and treatment

The Case Vignette presents specific issues important for psychiatrists to consider when treating patients with cancer.

CASE VIGNETTE

Mrs. T is a 53-year-old postmenopausal married woman with 2 teenage daughters who recently received a diagnosis of stage IV breast cancer metastatic to pelvic bone. Up until 2 months ago, she had been working full-time as an attorney but had to stop because of severe pain that progressively worsened. A medical workup showed an HIGHLY TREATABLE BUT INCURABLE LONG TEERM POSSIBLE SURVIVAL CANCER.

She does not have a psychiatric history or comorbid illnesses. Soon after starting THERAPY, she began to feel very sad, anxious, irritable, and fatigued; cried easily; and had trouble sleeping because of hot flashes. She ruminates on dying and leaving her daughters. She denies hopelessness and suicidal ideation, and quite the contrary she very much wants to live.

 

Depression and Anxiety Disorders in Patients With Cancer: Page 2 of 3

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

 

Coordinating with the oncology team. With the patient’s permission, consulting and informing the oncology team of your involvement is critical. As mentioned earlier, psychiatrists need to understand the patient’s cancer diagnosis, staging, treatments, adverse effects of treatment, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life. Medical concerns can cause or exacerbate depression and anxiety.

 

For example, in this case, knowing that survival with metastatic breast cancer can be years is critical in providing psychiatric care for the patient. Remaining silent as the patient expresses fear of death within the next few months can be taken by the patient as agreement and can exacerbate anxiety. Psychiatrists contribute to oncology care by providing information to the oncology team regarding the patient’s emotional status and potential barriers to care and treatment adherence.

 

 

Pharmacotherapy. While there may be overlap between symptoms of depression and anxiety and cancer- and treatment-related adverse effects (fatigue, changes in sleep and appetite), treatment of the psychiatric disorder is primary rather than a focus on differentiating the causes of the symptoms. The most prescribed antide­pressants in cancer patients are SSRIs, At times the choice of an antidepressant is made based on the antidepressant adverse-effect profile.

 

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Some psychiatric medications may adversely affect the efficacy of commonly used systemic cancer therapies.

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Be aware that some systemic cancer treatments are associated with psychiatric adverse effects. DRUGS TO TREAT leukemia and some lymphomas, may cause depression. Interferon at high doses can cause depression and even suicidal ideation. SOME CAN CAUSE can cause lethargy, depression, mania, confusion, and hallucinations. THEY can potentiate the effects of alcohol, opioids, and tricyclic antidepressants.

 

Glucocorticosteroids such as prednisone and dexamethasone are widely used in cancer care. They can cause a range of psychiatric symptoms, from emotional lability, depression, anxiety, restlessness, irritability, and insomnia to paranoia, delusions, and hallucinations. Symptoms may develop within a couple of days of the start of treatment and are also common if the dose is rapidly tapered off. But psychiatric symptoms can develop even on a stable dose.

Mindfulness Practice Reduces Cortisol Blunting During Chemo

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Mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published online April 7 in Cancer.

) — Mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published online April 7 in Cancer.

David S. Black, Ph.D., M.P.H., from University of Southern California in Los Angeles, and colleagues assigned 57 English- or Spanish-speaking colorectal cancer patients to either mindfulness, attention-control, or resting exposure at the start of chemotherapy. Four saliva samples were collected at the start of chemotherapy and at 20-minute intervals during the first 60 minutes of chemotherapy. Self-reported biobehavioral assessments after chemotherapy included distress, fatigue, and mindfulness

An area-under-the-curve analysis showed a relative increase in cortisol reactivity in the mindfulness group, after adjustments for biological and clinical measures (P = 0.03). From baseline to 20 minutes, more than twice as many patients in the mindfulness group displayed a cortisol rise, compared to controls (69 versus 34 percent; P = 0.02). Mindfulness scores were inversely correlated with fatigue and DEPRESSION (P < 0.01) and distress scores (P < 0.01).

 

 

 

 

Pain management. Suffering from uncontrollable pain is one of the most common fears of cancer patients. Unfortunately, pain is under-recognized and undertreated in patients with cancer. Bone pain experienced by cancer patients can be excruciating, and explaining to the patient that at times she may need to use opioids under the care of her oncologist without fearing addiction can prevent the patient from suffering unnecessarily. Poorly managed pain can lead to depression and anxiety. Once pain is appropriately managed, depressive and anxiety symptoms often diminish or resolve.

While some psychiatrists and oncologists have expertise in pain management, others may not and are reluctant to prescribe the necessary medications at the appropriate doses. AND SOME OVERPRESCRIBE Speaking with the oncology team and helping to get appropriate referral to a cancer pain specialist or palliative care team is crucial to the quality of life of cancer patients, especially those with advanced disease.

 

 

Before the patient’s visit with the pain specialist, it is helpful for the psychiatrist to provide education and correct some common misconceptions. The following 3 key issues should be considered regarding referral for pain management:

1) A majority of cancer patients do not have a history of addiction and actually fear becoming addicted to pain medications

2) Patients view the taking of pain medications as associated with death and dying: “Only a patient who is dying takes morphine”

3) Patients may need education on the difference between addiction and tolerance, in order to comply with prescribed pain medications

 

Psychiatry appointments

The traditional paradigm for psychiatric treatment may require a more flexible approach to scheduling to adjust to the reality of the patient’s needs during treatment. Patients may initially need more frequent appointments as they are adjusting to the diagnosis. New patients may be unsure when to make follow-up appointments because they have many upcoming oncology visits. Letting the patient know that scheduling psychiatry visits shortly after the oncology visits provides an opportunity to review the new medical information during the session.

 

 

During treatment, patients may need to cancel or reschedule appointments because of the adverse effects of treatment. Depending on the specific patient’s clinical situation, exceptions may need to be made to policies about late cancellations and no-shows. As the disease advances, patients may become hospitalized and are too weak to make office visits. Accommodating shorter inpatient visits may be indicated for continuity of care.

 

Patients often include their family in oncology visits, and some assume that this practice also occurs in psychiatric visits. Psychiatrists in cancer centers frequently see patients with their family members in the room. It would not have been out of the ordinary for Mrs. T to have her husband or another family member join her for her psychiatric evaluation. Providing effective support and treatment of patients with cancer will often entail providing support and education to their spouses, children, and significant others. Family members may need support in coping with their own concerns and often need education in how best to support the cancer patient.

 

 

Concluding OVERVIEW thoughts

 

Cancer care will continue to change over the next several years, sometimes rapidly. While psychiatrists cannot be expected to stay up to date with all of the emerging cancer treatments, they do need to learn about the ones that their patients might be receiving. Many resources are available for learning more about the psychiatric care of individuals with cancer. The American Psychosocial Oncology Society (www.apos-society.org) has published quick reference handbooks on psychosocial care for adults, children, and elderly adults with cancer and produces webinars on particular topics, such as sexual health and cancer.

 

7 Physical Clues You Could Have Depression

 

Many people who suffer from chronic illnesses also suffer from depression. Depression isn’t something that should be overlooked; it should be brought to your doctor’s attention so that it can be treated. But how do you spot depression?  With help from prevention.com, we’ve put together a list of some of the most common physical signs that someone is suffering from depression.

 

Aches and Pains

Although many chronic illnesses have their share of aches and pains, depression can also make muscles and joints feel sore or exacerbate the problem. People who are happy or content generally feel pain less than those who have depression.

 

Difficulty Sleeping or Waking Through the Night

Not being able to relax enough to fall asleep or frequently waking up during the night and finding it difficult to go back to sleep could both be signs of depression. Lack of sleep or disturbed sleep can have a profound effect on mood and the ability to concentrate.

 

Changes in Weight

Loss of appetite or comfort eating are both associated with depression, but you may not realize you have either until you step on the scale and notice a difference. In addition, if you’re not sleeping well because you’re anxious or depressed, this can also mess with your appetite leading to weight loss or gain.

 

Skin Complaints

Because depression affects hormones, this often becomes apparent in our skin. Depression can lead to skin complaints like acne, psoriasis, and eczema and treating the depression can help with the skin complaint.

 

Stomach Problems

Mood definitely affects the gut, and people with depression may suffer from symptoms like nausea, constipation, diarrhea, heartburn and indigestion.

 

Headaches and Migraines

People with depression are more likely to experience frequent headaches or migraines. Although this could also be a side effect of medication or treatments you take for your chronic illness.

 

Oral Problems

Dentists in Australia have found people with depression are more likely to need dental work such as tooth extractions and cavities than those who don’t. The thought behind this is that if you’re depressed, you’re less likely to be as diligent about oral health.

 

Depression questionqaire IS KEY

 

Suicide

 

 

LONDON, England, AND I MENTIONED THIS BEFORE – British researchers have found that people who are frequently depressed or anxious may run a higher risk of dying from certain types of cancer. THERE ARE SEVERE PROBLEMS WITHIS STUDY AND IT HAS NOT BEEN REPLICATED LOOK AT COMLIANCE, SYMTOM COMPLAINING, ALCOHOL, QUALITY OF LIFE ISSUES, AND SUCH

In THIS study published in the BMJ medical journal, the scientists were cautious in their conclusions, pointing out that a statistical link does not necessarily signify a cause-and-effect relationship between mood and cancer.

Their findings nevertheless added to the growing body of evidence that mental and physical health do not function on separate planes, and that one can influence the other.

While earlier research had shown that chronic depression and anxiety could help trigger heart disease and stroke, attempts to forge similar links between states of mind and cancer have yielded mixed results.

 

It has already been established that depression can disrupt hormonal balance to the extent of boosting natural cortisone concentrations and inhibiting DNA repair mechanisms – both of which weaken defences to cancer.

 

It is also well known that emotionally distressed people are more likely to smoke, drink and become obese – all of which are associated with a higher cancer risk.

 

.

The scientists could not discount the possibility that depression could be a result, rather than the cause of cancer, however.

 

“Distress might be a consequence of the early stages of the malignancy rather than a potential predictor,” they said.

 

THE AUTHORS noted that further research was needed to confirm the link and tease out the causal connections.

 

 

 

Seeing Cancer Through a Sibling’s Eyes: What We Don’t Know Can Hurt Them

SO LETS DRILL DOWN TO WHAT WE HAVE LEARNED

 

Depression and Anxiety Disorders in Patients With Cancer

AGAIN

7 Physical Clues You Could Have Depression

 

Many people who suffer from chronic illnesses also suffer from depression. Depression isn’t something that should be overlooked; it should be brought to your doctor’s attention so that it can be treated. But how do you spot depression?  With help from prevention.com, we’ve put together a list of some of the most common physical signs that someone is suffering from depression.

 

Aches and Pains

Although many chronic illnesses have their share of aches and pains, depression can also make muscles and joints feel sore or exacerbate the problem. People who are happy or content generally feel pain less than those who have depression.

 

Difficulty Sleeping or Waking Through the Night

Not being able to relax enough to fall asleep or frequently waking up during the night and finding it difficult to go back to sleep could both be signs of depression. Lack of sleep or disturbed sleep can have a profound effect on mood and the ability to concentrate.

 

Changes in Weight

Loss of appetite or comfort eating are both associated with depression, but you may not realize you have either until you step on the scale and notice a difference. In addition, if you’re not sleeping well because you’re anxious or depressed, this can also mess with your appetite leading to weight loss or gain.

 

Skin Complaints

Because depression affects hormones, this often becomes apparent in our skin. Depression can lead to skin complaints like acne, psoriasis, and eczema and treating the depression can help with the skin complaint.

 

Stomach Problems

Mood definitely affects the gut, and people with depression may suffer from symptoms like nausea, constipation, diarrhea, heartburn and indigestion.

 

Headaches and Migraines

People with depression are more likely to experience frequent headaches or migraines. Although this could also be a side effect of medication or treatments you take for your chronic illness.

 

Oral Problems

Dentists in Australia have found people with depression are more likely to need dental work such as tooth extractions and cavities than those who don’t. The thought behind this is that if you’re depressed, you’re less likely to be as diligent about oral health.

 

Depression questionqaire IS CRUCIAL

 

Suicide TWICE THE RATE

Elderly patients with cancer

 

are far less likely to be diagnosed with depression than patients in any other age group for two primary reasons: There is an overlap between cancer symptoms/treatment side effects and the diagnostic criteria for depression, and older adults are more likely to present with anhedonic “depression without sadness,” according to Chris Nelson, PhD, Associate Attending Psychologist at Memorial Sloan Kettering Cancer Center in New York.

 

 

According to Dr. Nelson, self-report instruments tend to underestimate the severity of depressive symptoms, and many depressed older patients with cancer are completely overlooked. “There is clearly a need to better understand, quantify, and treat depression in older cancer patients,” he said at the 2017 American Psychosocial Oncology Society (APOS) Annual Conference in Orlando, Florida.1 “This represents a significant public health concern that will grow in importance as the U.S. population continues to age.”

 

Diagnosing Depression

Common symptoms of depression—fatigue, diminished concentration, thoughts of death/suicide, weight loss/gain—are confounded with side effects from cancer treatments or, potentially, the cancer itself.

 

The literature suggests that two gateway symptoms—depressed mood and loss of interest—are most valuable in diagnosing depression in cancer, but according to Dr. Nelson, identifying these symptoms is not necessarily useful in older adults.

“The gateway questions come off the table as less than usefull useful diagnostic criteria when we combine cancer and aging,” he said. “So we’ve been trying to identify additional symptoms that are useful for diagnosing depression in older adults with cancer.”

 

He and his colleagues conducted a study aimed at identifying the phenomenology of depression in older cancer patients and developing a set of indicators to identify, assess, and treat depression in this population. They performed a literature review and interviewed eight experts in the fields of oncology, social work, psychiatry, and psychology to assist in identifying important constructs.

 

Based on input from the experts and findings from the literature review, the researchers conducted qualitative interviews with 12 depressed and 12 nondepressed cancer patients older than age 70. Depressed patients were identified by referral and subsequently interviewed by the panel of experts to confirm their depression.

 

Major and Minor Themes

The researchers identified four major themes in distinguishing depression in older cancer patients: anhedonia depressed mood without sadness , reduction in social relationships/loneliness, loss of meaning and purpose, and lack of usefulness and sense of being a burden.

 

Four minor themes also emerged: attitude toward treatment, mood, regret and guilt, and physical symptoms and limitations.

 

 

In the patient interviews, the experience of anhedonia was nuanced and involved a lack of initiation of new activities in addition to difficulty maintaining existing activities, he reported.

 

Another central issue was, reduction in social relationships and loneliness, varied based on the range and depth of patients’ social engagement, but depressed patients tended to have limited meaningful relationships and were socially isolated and withdrawn.

 

Loss of meaning and purpose in life was salient in the depressed group, and they displayed an inability to adjust to their new limitations. “Patients in the nondepressed group didn’t need to be engaging in anything particularly purposeful, but what they did in the past carried over and was still important to them,” he noted. THIS IS CRITICAL AND THEY GO BACK TO IT OVER AND OBVER AGAIN Lack of usefulness and sense of being a burden was also displayed in all depressed participants.

There was no difference between depressed and nondepressed participants in terms of their willingness to engage in treatment, but their attitude toward treatment was the nuanced difference. “

 

The nondepressed were much more proactive regarding their treatment, whereas the depressed were resentful, angry, and upset about their treatment,” he said. Mood also varied more in the depressed group, with some patients citing worse mood in the morning, when the demands of the day were in front of them.

 

Both groups looked back at their lives and experienced some level of regret, but the amount of guilt experienced was the differentiating factor between the nondepressed and the depressed. “The depressed patients seemed to ruminate on their regrets, whereas the nondepressed were able to put their regrets in a tolerable perspective,” he said.

 

No actual difference in physical limitations was observed between the two groups, but a difference was noted in how they coped with those limitations. Two aspects of coping were deemed to be specifically useful to older cancer patients: acceptance of the limitations associated with aging; and adaptation—changing and modifying one’s lifestyle and activities—to adjust to those limitations.

 

Of the four major and four minor themes recognized by the researchers, only two—the major theme of anhedonia DEPRESSION WITHOUT SADNESS and the minor theme of mood—are identified in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for depression. Based on their findings, the researchers conclude that the DSM-5 criteria might not apply in identification of depression in older patients with cancer. We missed the boat perhaps According to Dr. Nelson, a new patient-reported outcome based on these symptoms we have talked about may be beneficial in identifying depression. ■

 

Cancer survivors show patients how to overcome the ordeal WITH COMPEMATRY AND ALTERNATIVE MEDICINE FOR WHICH THERE IS SCANT TO NO PROOF REMEMBER ANECDOTE DOES NOT MEAN ANTIDOTE

THESE ARE CLAIMED HEAD FOODS

Diet may a huge role in Depression. There are a number of lifestyle factors that contribute to Depression but one cannot overlook what you put in your mouth. The following foods are THOUGHT to lift the mood by working at the cellular level:

Chamomile Tea: One of the most recommended bedtime soothers. Pennsylvania university tested chamomile supplements on 57 participants suffering from Depression for eight weeks and found that it led to a significant drop in symptoms. Pour a cup of boiling water over 2 to 3 heaping tablespoons of the dried flowers (you can buy chamomile either loose or in tea bags at health food stores) and steep for 10 minutes. Try having a cup every night: Turn off the TV, computer, and phone and settle down for a peaceful end to the day. It’s nice iced, too.THIS WAS POOORLY DONE STUDY AND NOT CORROBORATED

 

Chocolate: Therapy for Depression, especially if it is dark chocolate. The antioxidants boost up not just the heart health but PERHAPS the mood. Dark chocolate is known to lower blood pressure, adding calmness. It contains MORE polyphenols and flavonols than some fruit juices. WHAT THAT MEANS IS UNCLEAR

 

Garlic: Surprised?. But garlic is packed with antioxidants which neutralise free radicals (particles that damage cells). It has allicin, said to fend off heart disease, cancer and common cold.AGAIN NOT PROVEN Depression weakens our immune system, but garlic IS CLAIMED TO mend it back. Have raw in the morning, saute it in broth, or add to all the meals, it is an enemy of depression.

Green Tea: Yes there’s caffeine but green tea also has theanine, an important amino acid IS THOUGHT TO fights Depression. in addition to ALLEGEDLY protecting against cancer, this slimming food is a brain booster as well, enhancing mental performance. Have two cups a day.

 

Oatmeal: The humble oat is actually a complex carbohydrate which compels the brain to produce serotonin, a feel-good chemical. Children on oatmeal breakfast stay sharper through the morning. AGAIN NOT FULLY CORROBORATED IN CONTROLLED STUDIES Beta-glucan, a soluble fibre in oatmeal, promotes satiety. THAT IS TRUE The whole grains release the glucose slowly in the blood stream hence keeping the blood sugars levels optimum. Stabilised blood sugar help the person to have a stable mood too PERHAPS BUT NO [ROVEN ROLE IN DEPRESSION.

 

Tomatoes: Contain folic acid and alpha-lipoic acid, both of which are good for fighting Depression. AGAIN SAME ANSWER NOT PROVEN

According to a paper in the Journal of Psychiatry and Neuroscience, an elevated incidence of folate deficiency is shown in patients suffering from Depression. About one-third Depression patients are deficient in folate. AGAIN NOT PROVEN TO HAVE ANY CAUSE AND AFFECT

 

Fatty Fish: When it comes to omega-3 fatty acids, no food source is better than fatty fish like mackerel, bluefish, wild salmon and tuna. The fatty acids found in these fish not only have ALLEGED UN PROVEN specific brain-boosting properties AND WHAT DOES THAT MEAN to fight depression, but also are good for overall health TRUE. They REDUCErisk of heart disease. For those who cannot or do not consume fish should have dietary supplements of fatty fish of high quality.

Berries: All the berries like strawberries, raspberries and blackberries BUT ESPECIALLY DARK BERRIES are the high antioxidants sources. These antioxidants are also called as DNA repairmen AGAIN UNPROVEN. They ward off the free radicals which are toxic and affect our mood UNPROVEN and the sense of well-being THEY TASTE GOOD AS WELL. These food products go around fixing your cells and prevent them from getting illnesses. AGAIN NOT REALLY PROVEN BEYOND GENERAL HEALTH

Mushrooms & Onions: ARE ALLEGED AND AGAIN UNSTUDIED REPOSIBLY AND UNPROVEN TO promote healthy gut bacterium. Nerve cells in our gut manufacture 80-90% of our body’s serotonin the neurotransmitter NOT REALLY which keeps us sane & happy.A WHOE BUNCH OF INTERACTIONS AND TRANSMITTERS ARE U INVOLVED AND SEROTONIN ALONE IS NOT ENOUGH

Dark Green leafy vegetables ARE HEA;THY FOR YOU Spinach and kale are THOUGHT TO FIGHT DEPRESSION Depression and cancer. GBOMBS stands for greens, berries, onion, mushroom, beans & seeds.

Apple: Is a rich source of antioxidants NOT THAT RICH and helps prevent and repair oxidation damage NOT PROVEN and cellular inflammation WHAT DOES THAT MEAN

 

THE KEY IS DO NOT BELIEVE ALL YOU HEAR. YES DIET HAS VARIOUS ROLES BUT DO NOT DO NOT DO NOT DEPEND ON THEM FOR TREATMENT OF SEVERE DEPRESSION IT CAN END WITH SUICIDE IT MAY NEED COUNSELING AND MANY OTHER PROVEN MODALITIES [PEOPLE WANT THIS TO WORK BUT STUDIES TO PROVE THEY HELP IGNORE THE 13& PPLACEBO EFFECT AND TREATING MILD TRANSIENT MOOD DEPRESSION NOT CLINICAL DEPRESSION. CALIMS ABOUT MEDICAL SPECIFIC MECHANISMS OF ACTION ARE ALMOST ALWAYS CA CA AND UNPROVEN CRITICALLY

 

I promised you stories and this one is filled with depression, hope and my only miracle—believing in miracles is miraculous enough for me

The Gift

 

 

It was as if her soul was branded cruelly at birth, “Kick Here”. It was not that she was dealt bad cards so much as she never had much of a prayer to be in the game of life. Alcoholic and abusive parents spawned this only child almost three decades ago and rendered havoc on her congenitally frail spirit and teetering health. Not surprisingly, she was cursed from the beginning as a severe diabetic. This had withered away her adolescence in angry diabetic comas  and multiple illnesses  as her family rambled helter-skelter across the country lashed to the whims of a drunken, oft-unemployed father.

Now a mother herself, Maria was at most a trembling waif of a young woman. She was murderously robbed of childhood innocence, weaned on despair, suckled on disappointment. Against the odds for severe diabetics she had amazingly survived pregnancy with very healthy twins.

She had escaped her hell of a family only to find herself in a ramshackle marriage to a pestilence, not a man. Wife beater and child abuser, her enlisted military husband was a belligerent brooding hulk for which fatherhood was a grave inconvenience and blot on his life.

I have come to believe that it was not by chance that one of our sage senior physicians happened to pull E.R. duty the day she walked the miles to our hospital carrying her precious cargo shivering in her arms. Both of her babies had fevers and to the discerning eye, it was clear that evil had pitched its tent in their home. Incessant apologies from a terrified tearful mother, scarred blistered skin from burning cigarettes pressed into innocent skin and classic fractures wailed as a wounded plaintiff cry for a savior, for justice.  Clearly both she and her children had been abused. She collapsed out of catharsis and  at least a momentary reprieve from fear and overwhelming grief when the emergency room team were marshaled to gather them all into our protective bosom. Simultaneously the search was set for her stain of a husband.

In short order, it was painfully clear that the tragedy had no bounds. It was soon obvious that Maria was ill. Evaluation in the emergency room showed that she had rapidly worsening kidney failure from what was soon learned to be malignant masses in her abdomen choking off her kidneys and eating voraciously through her pelvis.

I was drawn to this wounded pup. The ache of seeing such unfairness from a world which offers no guarantee of freedom from suffering  was a constant companion for many of us tending to her care. Our clinical bond and trust falteringly evolved. Leveraging the lifeboat of her children, I painstakingly strained to encourage in her a glimmer of hope and perhaps flame the fading flicker of fighting for her life, for her children.

We all have bucket lists of dreams unfulfilled and longed for. Her dream was common enough. She longed to have simply played with her children, to frolic with fantasy, unburdened by dread. Now she was resigned to a painful death; it was all she expected. Only the irrepressible devotion to her babies and the possibility of their future being so uncertain carried her on. However, it quickly became clear that the cancer would agonizingly strain the last beats of life from her.

We had raced through the diagnostic evaluation and the hurried dash to save her kidneys and numb what had to be blinding pain. There was never the slightest whimper, the faintest flinch from her. Through wounded eyes she watched disaffected, rallying only when her babies were safe and near. It was for them she allowed the tubes into her kidneys, for them she tolerated the invasion of her belly to knit together her perforated strangulated bowels, for them she bloodlessly whispered a vacant “yes” to chemotherapy. If only she could have just a moments peace.

A few years ago, I suffered through the disaster of a rental condominium in Orlando while visiting the magical mouse that only Irma Bombeck could rightly do justice. It was absolute architectural anarchy. If water should have passed through it, it did not, if designed to support weight, it would not, if it controlled the environment, it could not. It was simply a massive disappoint and grand inconvenience.

Therefore, one day the stuff of fairy tales landed in my mind. I fashioned a story and made the calls. Perhaps I was serving my need to somehow save her, perhaps not. By the time the smoke cleared, it was all arranged, clearly by the hand of a force far greater than mine; Airfare, a rental car, lodging and Disney World admission was waiting, free of charge for Maria and her babes.

Yet she was  giving up and dying. I eagerly told her of the scheme to whisk her away to fantasyland. I was stupefied by her visceral response. Life beamed in her eyes and for the first time of what was to become an adorable habit, Maria smiled. I could almost hear her soul snap into action barking orders to finally fight the beast eating her body. Her husband safely spirited away, a battered and bruised young, very alive mommy made it home for a long weekend for the first time. Irrespective of my personal faith, I was ill prepared for what lay ahead for Maria and her children.

A few Mondays later my nurse hovered in my doorway, seemingly buoyed by joy, wet eyed and spiritually transfigured. Stammering, she parsed out “It is Maria, Maria, she, ah, she is so alive “. I am sure I fumbled out something only to have my nurse return, “No, it’s Maria, You don’t understand what’s happened.” In an instant, she was gone and I was confused.

Then I saw the glow of life as never I have seen before. Guided by grace this beautiful woman glided into my office and settled into the chair. I was steeped in the warmth issuing from this vision. It looked like the Maria God would have fashioned were he to meddle mercifully in her miseries. She spoke serenely, “I stopped taking the narcotics, they made me sleepy and I have no more pain. I am eating everything in sight and my sugars seem okay. Dr.? Dr.? Are you okay?” Aghast and afraid that I might burst the bubble I beckoned her in to the exam room. It was normal, unbelievably normal.

A lump was growing in my throat and my voice grew strangely hushed. I vaguely remember calling the chief of radiology for the urgent CAT scan but I do remember his return call after it was done He was incredulous, questioning me. “I do not know what you pulled, but the scan I have here, well its normal – no tumor, and healing bone”. Gone too was the bowel obstruction, the blocked kidneys, all of it gone. The physical exams, CAT scan, blood tests; all were normal. Softly, before I could gather myself, she spoke as if the hand of God was gently stroking my disbelief, “I know”, and then silence. I was in the presence of grace.

I had no problem getting through on the phone to make all the arrangements final and in moments, it was done. She would leave for Orlando that weekend. The sweat of my soul slid down my face to  as my nurse handed me a tissue and floated out with our miracle.

On a Monday, some weeks after the joy of a lifetime with her children in Orlando, she appeared in my office. She was gaunt, wasted and desperately pleading “Tell me my babies will be OK; tell me what will happen to them. Tell me.” We spoke until the ache lifted from her spirit and she reached some manner of closure with the cancer that had so quickly returned to ravage her body. Abruptly she stopped, rose to face me  and gently put her arms around my neck without a word. I saw that she knew it was over and her children would be safe.

There was no sorrow that Friday in the hospital. Her babies lay besides her in her arms, sleeping, as God called his angel home.

 

This is Dr Kevin Ryan author of the book when tumor is the rumor and cancer is the answer, a comprehensive text for newly diagnosed patients and their families signing off radio www.w4cs.com and iheart  the cancer support radio program

See you Next Tuesday at noon PST when we will look at depression and cancer

 

Now for any questions

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Cancer Anxiety

Anxiety ( blog) and iheart)

Hi DR Ryan here, medical oncologist AND PROFESSOR AND RETIRED COLONEL AND CANCER SURVIVOR and this is when tumor is the rumor and cancer is the answer.

I am sure you are familiar with our opening song   from chariots  of fire. A man has a plan and in a day it is crushed…… so it is when you have been told you have cancer ,thoughts of loss of control, soul sucking anxiety, what about your family and the list goes on as it hits  you like a ton of bricks.

He rose above it in the film  and so you to will be a hero ………I have seen no exception no matter how afraid you are, and that is what we are going to talk about today …your attitude when first diagnosed and through your course of therapy.. What about ANXIETY

. We will take our time so feel free to write in your questions or comments at www.w4cs.com and i will try to get to them

Anxiety and fear

it is anxiety that is the killer, NOT FEAR. We humans suffer most when not knowing all that needs known, especially when there is so much to fear. I choose, as do many dictionaries and as have countless great religious leaders and philosophers, to define anxiety as fear of the unknown.

I frequently relate a parable to my patients on this crucial subject. Let us travel back in time to the clan of the proverbial cave man. In one cave, somewhat safe from the elements and huddled about a fire, is a family fraught with anxiety towards the savage carnivores outside. These beasts only know this clan as prey. The clan shrinks under the weight of this knowledge, convinced that the predators will most assuredly find and devour them. The clan huddles all the closer, shaken by every foreign sound and every dimming of the fire. They dare not move. They are not ready to battle for their next meal or to survive. That is the primordial example of paralysis by analysis– as old as man is. That is anxiety.

in the hillside just to the east, another clan of warriors huddle. They know well the dangers that lurk and are ready to pounce as the fire dims and the sounds draw near. Fearful of what they know, and armed, they set forth into what will now be the known. History has shown us that this clan survives. That is the liberating power of fear inciting action.

Both anxiety and fear evoke the same visceral and pressing emotional urgings. However, for the first clan, the unknown fuels their feelings. That is anxiety and that is the end of that clan. However, the second clan knows that the bigger enemy is anxiety, fear of the unknown. It is fear of anxiety that drives them to action. Anxiety is the road to paralysis. Fear can ignite action without guarantee of success, but action nevertheless.

anxiety disorders in patients and their relationship to the quality of life have been the subject of legions of studies in the medical literature. Their conclusion is universal. Anxiety is as much a killer as is living in constant bodily pain. What is life worth, one wonders, when the icy soul sucking grip of the never and forever lie holds you tight to its bosom. This lie screams into your psyche saying, “it will never change and it will forever be the same”.

anxiety is not abnormal and may in fact be an emotion that leads to a positive outcome. Nonetheless, it is almost the kiss of death when it too easily evolves into the loosely defined term morbid anxiety causing panic, irrationality and paralysis. There is little doubt that morbid anxiety has negative consequences in many regards for the cancer patient as well as their family.

Granted, some malignancies with a less ominous prognosis will not elicit as much morbid anxiety. Once again, the key is that the patient knows that the prognosis is less ominous. It is knowledge that is the oncologists’ first and most precious gift to the patient. It is knowledge that the patient and family must demand. Knowledge delivered through teaching that must be thorough, comprehensible, and empathetic. The flow of information must never stop. Physicians must teach patients how to deal with family, friends, sources on the internet, the staging procedures and their meaning, the treatment and the value of second opinions. Patients must learn well that they will not be alone, that thousands have handled this and that others were no less anxious and no braver.

physicians must speak to their patients of the odds of cure, remission and durability of remission. They must not shy away from discussing spirituality, life’s goals, and the effects of treatment on normal bodily function. Common anxiety-laden patient questions, as “what functions or abilities will I lose” as well as “what will I keep” are essential front burner issues. Discussions must be frank regarding the specter that pain, nausea and vomiting often represent to patients. Moreover, physicians will find the more empathetic time spent the greater the patient’s trust and quality of life.

Patients need to know if research studies hold out a realistic promise. Oncologists must explain the amazing armamentarium of medications they have, the psychological assistance patients will be given and potentially, the beautiful role which hospice may play. Most of all, patients must be put in charge by being given repeated slow but thorough helpings of knowledge. That is the key to killing anxiety. Caretakers must indeed take great care to embrace the god given, hero-making emotion of fear, break the paralyzing bonds of anxiety and guide patients and families onward to face the future.

Remember it’s ok to tell someone you are not ok

Lets summarize the overview of anxiety

First page

 

Second page

For example , mindfulness practice during chemotherapy can reduce the blunting of neuroendocrine profiles typically observed in cancer patients, according to a study published in cancer.

Other issues are what some have called scanziety and also the issue of telephone messages.

Scanxiety refers to the fear and worry associated with imaging, both before and after a test is performed, and lasts until the test results are communicated to the patient. As described by cancer survivor Bruce Feiler in a time magazine column, “scans are like revolving doors, emotional roulette wheels that spin us around for a few days and spit us out the other side. Land on red, we’re in for another trip to cancerland; land on black, we have a few more months of freedom.”  The root of this anxiety is  related to the uncertainty of the test results and the amount of time that elapses between when the test is performed and the results known. Not surprisingly, most patients report an escalation of anxiety that correlates with longer wait times.

In an ideal world, scanxiety could be alleviated by immediate test results. However, test results also need someone qualified to interpret them and explain their implications. When scans show no evidence of disease, or a blood test is within normal limits, the phone calls are easy to make. It’s a different story when the scans or tests are abnormal or indicate disease progression. In these cases, face-to-face conversations about treatment options are usually best.

“phone tag” frustration

So, what can healthcare providers do to reduce scanxiety? Some oncology practices schedule patients for a clinic visit on the same day a scan or test is performed or results known. Of course, this approach only works when there is collaboration between the imaging or laboratory department and oncology providers. “the test results are not back yet” are words no patient wants to hear on a follow-up visit.

Patients who have scans and tests performed in their hometowns need to be informed that test results may or may not be available on the same day. These patients should be instructed to call their oncology providers to obtain results rather than wait for a call with the results.

Every oncology facility should have procedures that reduce the likelihood that patients will “fall through the cracks” and not be followed up. This can happen when return calls to patients go unanswered. The resulting “phone tag” is frustrating for patients and healthcare providers alike.

After-hours calls are particularly challenging, as they are often placed or received via personal cell phones. One option is to block or hide personal cell phone numbers; however, patients may ignore or decline these calls since the callers are not identified. Another option is the doximity dialer, an app that allows healthcare providers to call patients without revealing their personal cell phone numbers. Patients see an office or clinic number instead. The app allows healthcare providers to call patients at any US number, choose the caller id that appears, and send return calls to an office or clinic.

The app can be downloaded for iphone at the app store and for android devices at google play.

What else can be done to reduce scanxiety? Cognitive-behavioral therapy may be helpful in dealing with the thoughts that are at the root of the anxiety. This helps by examining possible outcomes. This leads to a reduction in all or nothing, and catastrophic thinking, which in turn reduces anxiety. The bottom line is that there are a number of strategies to help patients reduce scanxiety and cope with its effects . Being diagnosed with cancer is hard enough; we need to do all we can do to make the journey less stressful. –

The physical changes regarding patient;s anxiety are measurable David s. Black, phd, mph, from university of southern California in los Angeles, and colleagues assigned 57 English- or Spanish-speaking colorectal cancer patients to either mindfulness, attention-control, or resting exposure at the start of chemotherapy. Four saliva samples were collected at the start of chemotherapy and at 20-minute intervals during the first 60 minutes of chemotherapy. Self-reported biobehavioral assessments after chemotherapy included distress, fatigue, and mindfulness

Analysis showed a relative increase in cortisol reactivity in the mindfulness group, more than twice as many patients in the mindfulness group displayed a cortisol rise, compared to controls (69 versus 34 percent; Mindfulness scores were inversely correlated with fatigue and distress scores “implications include support for the use of mindfulness practice in integrative oncology,” the authors wrote.

 

Let’s go back to Yoga

Researchers have put yoga to the scientific test for years, and the results so far have been impressive. The practice has been shown to lower risk for heart disease, type 2 diabetes, depression and hypertension and anxiety.

But yoga can also help those who are already ill feel better. A new study suggests that doing yoga twice a week may improve quality of life for men being treated for prostate cancer and may help reduce the side effects of radiation, which include fatigue, sexual dysfunction and urinary incontinence.

So again if you have any of these tell your doctor, there is help

  • Difficulty concentrating and making decisions
  • Heart palpitations, sweating, shaking
  • Shortness of breath, feeling faint
  • Numbness or tingling in the hands or feet
  • Heightened sense of alertness
  • Anticipating feeling anxious or a persistent worry
  • Feelings of guilt, worthlessness, and/or helplessness
  • Feeling of unreality or detachment from oneself
  • Fear of dying or losing control
  • Irritability, restlessness
  • Dry mouth
  • Muscle tension
  • Nausea
  • Sleep difficulties
  • Cold or sweaty hands
  • Loss of interest in activities or hobbies once pleasurable
  • Withdrawal from normal activities and friends (avoidance)
  • Appetite change or weight change (usually loss)
  • Persistent aches or pains, headaches, cramps, or digestive problems

Lets also give a non scholarly but becoming so, nod to smoked cannabis, the psychoactive form in alleviating anxiety- there are some early trials in the 80’s mostly about control of nauseas and vomiting where it was no better than what was then the standard and inferior to what we have now with exceptions existing on a case by case basis. It being a class 1 drug highly controlled by the FDA has made scholarly work hard but there is a growing body of evidence that supports a possible role in alleviating anxiety, besides improving mood , appetite and pain as well as anticipatory nauseas Mostly we are left with it being no better than standard of care but there are some powerful small studies and of course individual anecdotes. Remember ,anecdote does not equal antidote

None of the above is true for any other herbal substance despite what you think or may have heard

Remember anecdote does not equal antidote

Seeing cancer through a sibling’s eyes: what we don’t know can hurt them an article summarized from the ONS

Family-centered care is crucial to the care of children with cancer, whose disease and treatment are both life-threatening and often prolonged over the course of several years, through survivorship or until death. Family-centered care recognizes the stark reality that cancer is disruptive to the family system. And can cause great anxiety in many family members with children being no exception While acknowledging the value of family-centered care to the ill child and parents in clinical practice, we may overlook other family members who would also benefit from family-centered care, most notably the healthy siblings of the child with cancer.

Indeed, healthy siblings have described wanting more information about their ill brother or sister and the illness; parents have described wanting guidance on how to best meet the needs of the siblings when one child has advanced cancer and to do so across the spectrum of life-threatening illness.
Challenges associated with a cancer diagnosis, treatment, and adaptation impact the entire family. Recent research has demonstrated that families experience altered family function and may face an accumulation of risk for mental health and severe emotional problems including anxiety over the course of illness,

other research reports that the experience of cancer increases family cohesion and family resilience. So it can bond as well as break- it is a case by case , family member by family member SITUATION even within the same family

Through the sibling’s eyes

Perceptions of the impact of cancer on the family often come from the parental perspective. BUT NOT ALWAYS. Each member of a family will assess the impact of the illness differently

Some experience feelings of jealousy, neglect, and bitterness. But almost all experience anxiety. Parents may spend less time emotionally and literally with the healthy child

When a child is diagnosed with cancer, the whole family is disrupted and anxiety initially runs rampant and delayed anxiety after a siblings death is all too common.

The nurse’s role

It starts with awareness. Nurses can promote a broadened scope of family-centered care and recognition of sibling needs in advanced disease and other times of turmoil. In doing so, they may mitigate some negative effects of strained or limited communication. Oncology nurses directly impact families through communication and can model open, compassionate, developmentally appropriate communication with siblings. Moreover, coaching and teaching are inherent to nursing care of families. Thus, oncology nurses role can be 2-fold: communicating with siblings across settings to increase their comfort or to provide education and

coaching to parents in discussing sensitive, emotional topics related to the illness.

Teaching parents to keep lines of communication open across the various fronts on which they parent all their children can diminish anxiety.

Although there are many methodological flaws in the following report it stresses the mind body connection which is never to be ignored.

However we are not saying the diagnosis of anxiety or for that matter, depression causes cancer in all , most or a significant minority nor does it mean you will get cancer if you have those diagnoses . Nonetheless, anxiety does have measurable effects on the immune system and that weaves a complex web

So what did they find in England in a study which I remind you has many limitations.

A BMJ article addressed how depression and psychological distress can increase the chances of dying from cancer. The study revealed a 32 percent cancer risk due to anxiety and depression. Of course something called multivariant analysis biases this dramatically as stated… just having anxiety  of unrevealed duration and severity does not cause cancer in 30 percent of people…. but this is interesting. The authors are clear to point out that Cause and effect are not established clearly.

The study stresses that the correlation between anxiety, depression, and cancer cannot be treated as evidence. In some cases, people with undiagnosed cancer can get anxious and stressed due to the changes happening in their body despite being aware of their sickness.

An expansion of part of this observation must follow

Up to one in ten people will battle anxiety or depression at some point, and this makes people more likely to smoke and drink, and less likely to take exercise and maintain a good diet. But even accounting for this, anxious and depressed people seem to die in greater numbers from cancer

PERHAPS THIS SHOWS that their unhappiness damages the body’s defense systems against the disease. The chicken and egg argument is self apparent however

Some suggest damages in DNA repair in the severely stressed patient but little good data supports this. What we do know is stress can also put people off from attending screenings which could spot cancer early, or prevent them seeking proper treatment when they do fall ill.

.

People who are anxious often stop looking after themselves and this could lead to poor diet and lack of exercise both proven to have a role in cancer cause

AGAIN THE LEAD AUTHOR STATES THE flaws are too deep in the English study to walk away thinking if you are depressed or anxious you will get cancer

Finally what about the internet in all this. Rather than recite every nuance and nonsense ( not all is nonsense) that DR Google spouts….. All the following key phrases will take you to links that are self explanatory and say pretty much the same thing as what we have covered  here

fear of getting cancer

anxiety about having cancer

constant fear of getting cancer

fear of cancer diagnosis

fear of cancer

cancer and anxiety attacks

cancer anxiety symptoms

anxiety after cancer

So, anxiety is soul sucking, it has many forms and presentations, it is harmful and it is treatable in cancer patients and families by MANY approaches

This show will be posted both in script form on www.w4cs.com blog and the book blog reachable through the book web site www.whentumoristherumorandcanceristheanswer.com and the audio will be here as well as on iheart radio in a few days

I urge you to reread and listen critically to what has been said and note what has NOT been said regarding the connection between cancer and anxiety, especially regarding cause and complementary and alternative medicine

Now, as I promised in the first show I would, along the way, read stories I have published independently as well as in the book of actual patients with names changed , to at times illustrate a point. The past few shows have been about attitude- both up and down and what works, Here is a tale of my first and only encounter with a leprechaun…I think you will all get the point

A Leprechauns’ Laser Light Of Life

As I made rounds, lilting laughter punctuated a rag tag vocal ensemble’s singing of “Danny Boy”. It ebbed and flowed from the oncology ward lounge, warmly filling a sterile hallway; but not my heart. It was the twentieth St. Patrick’s Day since small cell lung cancer riddled and devoured my son of Hell’s Kitchen, World War II veteran, tough Irish dad. Although he died during the dreary wet frozen rains of a New England fall, he was etched into my heart’s memory owing to one very magical St. Patrick’s Day.

As I did every St Patrick’s since his death, I was reminiscing a time when I, a newly minted, wet behind everything medical student and a 2nd Lt in the USAF in the Health Professions Scholarship Program, visited my dad at work as  General Electric’s chief labor relations negotiator in Manhattan. The day ended at a midtown Irish bar with me accompanying him on the tavern’s beer soaked upright as he crooned “Danny Boy”. You could feel the century old pub wood weep as a sonorous tenor voice I never knew he had lifted hearts, minds and glasses. Mutually uninhibited but not inebriated, father and son were in tune.

So here I was decades later on another St Patrick’s Day rounding on the Oncology ward, tired and tied to a bittersweet memory. Regaining focus for the duties of the day, I began to thumb through the chart rack. Suddenly, intruding through the funk was the unmistakable sound of a Buck Rogers’s ray gun. It was right behind my left ear, magically mixing with leprechaun like chortling and giggles.

I spun on my heels and was bowled over by the impish grin and theatrical posturing of my toy toting assailant. Hopping and toe dancing as light as a shamrock blown by faerie breath and half naked in hospital regalia with toy cosmic carbine in hand, retired USAF Chief Master Sergeant “O’Reilly” squealed, “Ah-eee, Gotcha Doc”!

O’Reilly had whistled and skipped to an easy truce with his sleepy follicular Non Hodgkin’s lymphoma for sixteen years prior to this admission. His blarney charmed the beast called anxiety. His acceptance of the capriciousness of a life filled with the Damocles Sword of a strong probability of an aggressive transformation of his disease was like a therapeutic balm of Gilead for not only himself, but so many patients he befriended and bolstered.

His checkups were always a happy routine rife with fabulous tale spinning, unabashed limerick singing and other sound medical practices. Clinic visits from the sage retired chief leprechaun of the USAF always ended with a pat on my head, a wink at the nurses and his trademark squeezing off of a couple  laser beams of magic from the now infamous toy gun at whomever he thought needed it most.  It never hurt, it often helped and more than once, it seemed more powerful than my prescription pad. An emeritus professor of mirth and mentorship, O’Reilly was one of the wisest men I knew.

Shortly before this final admission, the limber leprechaun interrupted plans to visit family in Ireland because, as he said, “Me shillelagh’s telling me something ain’t right”.  A thorough history and physical revealed nothing. The complete blood count showed a slight drop in his usually robust hemoglobin and his platelet count had fallen considerably. So did my heart when review of the peripheral blood smear suggested what an immediate bone marrow examination confirmed; myelopthisis. His lymphoma had transformed aggressively and was exploding into banshee like furor. It was replacing his bone marrow. Further staging showed broad lymph node, boney, spleen and meningeal dissemination.  An incredibly bright man, he fully understood the limits of therapy and the grave prognosis.  Typically unafraid and more concerned for his family, he was annoyed at the change in travel plans. He sprightly assured me, “I have a few things yet to do, so let’s have a go at it.”

We did. After a rocky course consisting of intensive systemic and intrathecal brain chemotherapy, massive transfusions and considerable assistance from colony stimulating factors to support his white blood cell count and fight infection and erythropoietin to help him make blood, this knobby kneed leprechaun of a man was zapping my dour spirits. Bald and beaming and headed towards a major clinical response,   he was working his magic on this very special St Patrick’s Day.

That was his family in the lounge warming the ward with lilts of laughter. Spying my doleful drudge as I began ward rounds, he left the comfort of family and friends to fire a laser beam of life my way. Clearly unfazed by the enormous odds of a rapid and refractory to treatment recurrence of his cancer, he often grandly showcased his plastic phaser quipping something to the effect of, “If it comes back, we’ll zap me cancer with this thing; it’s better than those poisons, eh?”

O’Reilly was one of the gifts clinical oncologists can garner in decades of clinical practice, if they are open to receive them. He was one of those wonderful “doctor-patients” put in our path to minister magical wisdoms just when we oncologists need those most. Being touched by such patients’ special zest, zeal and wisdoms is one of those easy medicines to swallow. Souls such as these are precious jewels in the growing treasure chest of a clinicians experience and the luster of the clinical pearls they impart are often both illuminating and transformative. So it was with O’Reilly

Unbeknownst to me, he had more things than fighting his cancer on his agenda. He had taken particular notice of one of my young clinic nurses. She was a seemingly emotionally cold and somewhat intense Second Lieutenant nurse that was “too young to act such a tough nut and too talented not to try and crack”, according to O’Reilly. She had requested transfer to the inpatient Oncology service. This coincidentally put her on the ward and in O’Reilly’s service and sights when the aggressive transformation of his lymphoma occurred. Both I and the senior nursing staff were concerned for her, believing her far more fragile than her implacable demeanor might suggest, but our “tough nut” showed no signs of trouble and sadly, few signs of warmth even when O’Reilly’s improbable  clinical remission occurred.

Shortly after that St Patrick’s Day, the probable occurred. O’Reilly was readmitted with signs and symptoms of a rapid recurrence. He was quick to grasp his situation, calmly and confidently summarizing my lengthy delivering of sad news to a family unwilling to believe the unacceptable, saying gently to all, “It’s been a great run, so now, soon, I’ll be with sod and saints”. In his final days of a rapidly progressing malignancy that would not be denied, he had three simple requests; some intimate uninterrupted time with the Mrs., a steady supply of Guinness Stout and “one last shot at some unfinished business”. Curiously, and without any explanation offered, he decreed that the “tough nut” young nurse be assigned to his care and furthermore she was to be the only medical staff he wanted in his room; no one else, no exceptions.  Somewhat bewildered but always admiring of his wisdom, the charge nurse and I warily agreed. On hearing his request, the young lieutenant almost condescendingly agreed seemingly fashioning it as some sort of dramatic last wish. After all, she thoughtlessly quipped, it was “probably (her) turn anyway”. She would be in his service having no idea how true that would prove.

I was shaken upon news of his passing the next morning. However, deeply appreciative of O’Reilly’s gifts, I was both concerned and curious as to the impact, if any, his passing had on the young “ tough nut” nurse. No worries. I no sooner strode onto the ward than she ran up to me glowing, seemingly transformed and weightless, her eyes brimming with tears of joy. Reaching into her pocket she produced our leprechauns’ little laser gun. Smiling, she told how he called her to his room, eschewing all others. She bubbled joyously of how they chatted for hours about secret things, special things about love and the rich life. She was bursting with the pride and surprise as one who had been picked above all others as something special and lovable. Tugging at my white coat like the impatient exuberant child she then was, she announced triumphantly that she was the last target he leveled a final salvo of saving love at. He then bequeathed his other worldly potion in a pistol to her, assuring her that, “I can go now. You’ll know when to use it and when it’s time to pass it on.”

Death is not always so kind, so graceful in its gifts. When we healers and helpers are absorbed in our sorrows, perhaps lost in the fog of sadness over the limits of our skills or other concerns, we may also be most vulnerable to the laser beams of life from those who by all rights should be sorrowful, yet are not.

This is Dr Kevin Ryan author of the book when tumor is the rumor and cancer is the answer, a comprehensive text for newly diagnosed patients and their families signing off radio www.w4cs.com the cancer support radio program

See you Next Tuesday at noon PST when we will look at depression and cancer

Now for any questions

Should Physicians Help Terminal Patients Die?

Should Physicians Help Terminal Patients Die?

hospitals

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

This is a increasingly common question from the bedside to the jurists bench and beyond. Listen in on some of our best thinkers dissect the topic

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age. Continue Reading We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

| Disclosures | August 25, 2016

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

 

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Add Ethics: Today’s Hot Topics to your email alerts

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds

Should Physicians Help Terminal Patients Die?

Arthur L. Caplan, PhD; Timothy E. Quill, MD; Howard Grossman, MD; Maurie Markman, MD; Farr A. Curlin, MD

Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds.

Dr Caplan: Just to emphasize, it is the reversibility of their psychological state.

Dr Markman: That is correct. Again, this is an example and certainly an example in the cancer domain, which is my experience. A patient could have been taking a tremendous amount of pain medications. They are not working and they say that nothing is working. I accept that. However, it could be that there is a single anatomical lesion that has not been appreciated or has not been approached. An interventional radiology approach or a surgical approach might be able to relieve that pain. If that pain were relieved, that could change the patient’s psychological despair that led them to say, “I want to end my life.”

Dr Caplan: What do you say to the advocates of physician-assisted dying? What do you say to the patient who says, “I understand that you can manipulate this and manipulate that, but I am dying and I do not want to go through all of that. I would rather be in control of how I die. I know that you could do this or sedate me or block this. I do not want to go through all of that.”

Dr Markman: It is their right. It is as simple as that. Again, as a physician, I would see my role as an advisor, no more than that. If someone were to say that to me, I would say, “I accept that. Did you consider this? Did you consider that?” But of course, I am not a psychologist or a psychiatrist. It is also not for me to decide right or wrong. As a physician, I can voice an opinion. I can advise. I can even go to a family member if I think that there may be some element that just doesn’t make sense to me, based on objective data. In your example, the patients want to be in control, but it may be a potentially curable cancer, let’s say. There may be a concern that we are not getting through to them. My role in that is not to tell patients that they are wrong; my role might be to ask whether there is another way of approaching this that they’re not hearing. If the answer is that this is their decision, it is their decision.

Making Death the Goal ‘Is the Antithesis of Medicine’

Dr Caplan: Dr Markman has brought up some very thoughtful and provoking points. Now we will speak with Dr Farr Curlin, a physician and an expert in palliative care at Duke University. He is the Trent Professor of Medical Humanities and also works in the Center for Bioethics, Humanities, and History of Medicine at Duke. He is certainly one of the nation’s leading experts on end-of-life care, and he has done pioneering work in integrating theology and healthcare. Welcome, Farr.

Farr A. Curlin, MD: Thank you.

Dr Caplan: Let me begin by asking you a straightforward question. You-

 

 

  •  Arthur L. Caplan, PhD: Physicians face many contentious issues in their work in hospitals, but none are as divisive or emotionally disturbing as the ethical question: Is it ever right to intentionally accelerate a patient’s death?

webmd.ads2.defineAd({id:’ads-pos-520′,pos: 520}); Hi. I’m Art Caplan, and this is Both Sides Now, a special Medscape program that explores controversial issues that physicians face. Today we will discuss the highly complex question of whether physicians should be allowed to assist patients in ending their lives. This practice, which is often called physician-assisted dying or physician-assisted suicide, has been a divisive issue among not only physicians but also the public at large and their families.

Here is the current state of physician-assisted death in our country at this time. The American Medical Association strongly opposes any bill on physician-assisted suicide or euthanasia, saying that these practices are “incompatible with the physician’s role as healer.”[1] The Death with Dignity Act in Oregon was implemented in 1997.[2] Since then, three other states have passed laws that allow a physician to assist patients in taking their life. In addition to Oregon, there is now Washington, Vermont, and, most recently, California. Montana and New Mexico allow physician-assisted dying on the basis of court opinions in each state.

We are not talking about euthanasia, which is when a physician actually injects a lethal dose of medication into a patient. Today, a physician will prescribe the lethal medication, but the patient must take it or administer it themselves. In states that have legalized this, a patient has to make two separate requests—one orally and one in writing, 15 days apart—to get a lethal prescription. Two physicians have to agree that the patient is terminally ill, meaning less than 6 months to live. The patient must also be mentally competent and over 18 years of age.

We will be talking to two notable physicians who are in favor of physicians helping terminally ill patients to hasten their deaths. Then, we will talk to two others who are adamantly opposed to it.

‘Part of Our Job to Help People Die Better’

Our first guest is Dr Timothy Quill from the University of Rochester School of Medicine. He is the Georgia & Thomas Gosnell Distinguished Professor in Palliative Care and professor of medicine, psychiatry, and medical Humanities. Dr Quill is strongly in favor of physician-assisted dying being available to terminally ill patients as an option. It is a pleasure to welcome you to the program.

Timothy E. Quill, MD: I am glad to be here. Thanks for having me.

Dr Caplan: What is the difference between physician-assisted dying and physician-assisted suicide? Both terms are used. How do you differentiate the two?

webmd.ads2.defineAd({id:’ads-pos-420′,pos: 420}); Dr Quill: Many times, the two terms are conflated. Those who believe that this should be a legal option prefer to use the language “physician-assisted dying” rather than “physician-assisted suicide.” Why is that? Suicide equates the act with mental illness, with people who have other choices. The opponents of physician-assisted death would like it to be called physician-assisted suicide because they want to equate it in some sense with mental illness.

Dr Caplan: When you say “mental illness,” do you mean depression?

Dr Quill: Depression, psychosis, or an act that makes no sense and could be prevented by good medical care. People who are advocates see it as a possible rational approach when suffering gets very difficult and there are not a lot of other good options. We know that it can be rational because we have met people who are in that circumstance who have asked for our help.

Dr Caplan: Your field has evolved a lot over the past couple of decades. We have certainly seen palliative care spread out into American healthcare. It isn’t everywhere, but it is certainly available, starting earlier for many people. Some physicians are going to say, “Why are we even having this discussion about assistance with dying if we have palliative care?”

Dr Quill: Palliative care is the floor in this discussion. If somebody is talking about being ready to die and suffering that is uncontrollable, the first step is to have a conversation about whether they are having pain that we could be relieving. We will be asking them, “What makes it so unacceptable? What is the worst part? Tell me more, tell me more.” Most of the time, you will learn that they were having pain that they were not telling us about or shortness of breath. It might be that they are having some spiritual issues and they need to talk with their rabbi or clergyperson. It may also be that they have reached the end of their tolerance for this process.

 

We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die.

 

Dr Caplan: A very common criticism that swirls in this debate is that physicians should do no harm. That goes all the way back to Hippocrates. How do you answer those who say that doctors shouldn’t commit harm by assisting in dying?

Dr Quill: It would be hard for me to construct addressing the suffering of a terminally ill patient as a harm. It is an obligation. The question is, how we can respond to those kinds of sufferings? Part of our job, in my opinion, is to help people die better. I say that in a direct way because it irks me when we say that doctors should not help people die. We need people who are committed to caring for people all the way through to their death as if they were family members, committed to relieving their suffering. Sometimes that requires helping people to die. It is not a happy day when we are taking people off life support. We do not like to do it. Sometimes we dream about it afterward. But we do it because we have to do it, because the patient is saying that they do not want it anymore. They have had it. We understand. We all talk about it. We make sense of it. We support each other.

Respecting Patient Choice

Dr Caplan: Those are some excellent points about the value and need for physician-assisted dying for terminally ill patients. Now let’s speak with a physician who has been outspoken in his support of physician-assisted dying. Dr Howard Grossman is an internist in New Jersey and New York State and a former plaintiff in a lawsuit to legalize aid in dying in the state of New York. Thanks for joining me today.

Howard Grossman, MD: Thanks for having me.

Dr Caplan: Let’s get right into this. There are a lot of folks who are wondering what the best argument is for permitting physician-assisted dying. What is the single most important reason that you would make this available or legal for your patients?

Dr Grossman: There are a few really big issues. One is that we are talking about mentally competent people who have been given a terminal diagnosis, usually less than 6 months to live, with all the caveats about making those kinds of predictions and letting them make their own decisions about how they do that end-of-life time. We have established the right to withhold hydration, to let people starve themselves to death.

Dr Caplan: You can refuse all life-preserving interventions.

Dr Grossman: Exactly, but we do not let people limit the time for which that happens. The second issue is that doctors are the gatekeepers of medication. We have that responsibility. It has been given to us, and nobody else has it except for nurse practitioners and some PAs.

Dr Caplan: Would you say that the key reason is to respect patient choice?

Dr Grossman: Absolutely, because these are mentally competent people who know what they are doing. They are making a choice.

Dr Caplan: Do you know physicians who have been asked to assist in hastening death? Has that ever happened to you?

Dr Grossman: It definitely happened to me and I think it has happened to most physicians. How people deal with it is a difficult and personal thing. Certainly, working as I do in the HIV field, during the darkest days of the epidemic there were all of these young people who were clearly terminal and on the road to death. Many times they had horrible deaths, not because they were in pain, but because it was horrible to put them into a coma with pain medications in order to keep them pain free.

Dr Caplan: When you talk to critics, what do you think of their opposition, concerns, and ethical worries? We have talked a little bit about palliative care and alternatives, but if you scratch the surface, are we really having a debate about religion?

Dr Grossman: You took the words out of my mouth. When I have this discussion, objections are very often religiously grounded, and that should be respected. They should be able to practice the way that they think is right based on their religious beliefs, but they should not be imposing it on everybody else.

Dr Caplan: Here is something that I hear all the time. You select death, and then it turns out that a cure is just around the corner. You got shortchanged. You didn’t realize that next week, the precision medicine folks are delivering the cure for your bladder cancer or your disseminated lung cancer. How do you respond to that?

Dr Grossman: I think about a patient I had when this came up. In the late ’90s, when HIV therapy changed, I had a patient who had had AIDS since the beginning of the ’80s. By the late ’90s, he was very ill with lymphoma, CMV retinitis, and a bunch of other things. He was on a million drugs, and then the new cocktails came out. He was one of those people who had the Lazarus effect, but he only lived another 5 years. His immune system was far too damaged. I remember saying to him, “John, you came back. You had talked to me about ending your life back in 1995 before all of this came. How would you feel if you had done that?” He said, “If I had chosen to do that at that point, that would have been the right choice and I would have made it anyway. I am glad that I am still here, but that would have been the right choice for me and nobody else gets to decide that.”

‘Despair May Be Temporary, but Death Is Permanent’

Dr Caplan: We have heard some great points about why physician-assisted dying should be an option for patients. Now let’s hear from some physicians who feel quite differently, and they feel that they have compelling reasons for their point of view. Let’s speak with a physician who is right in the forefront of caring for patients who are struggling with the very tough situation of disease and dying. Dr Maurie Markman is president of medicine and science at Cancer Treatment Centers of America. Welcome. Thank you for joining us.

Maurie Markman, MD: Thank you. I am glad to be here.

Dr Caplan: Let’s get right into this tough area. What would you say is the most important reason to worry about physician-assisted dying right now?

Dr Markman: To me, it is rather straightforward. Let me just make it clear that everything I am talking about is my opinion. One of the things we will come into is why people potentially agree or not agree with this concept. I am only speaking for myself. My feeling is that it really comes down to a concern about the reason why somebody may ask for this, which is their right. Death is irreversible. The reason for asking is despair. Despair may be potentially temporary or it may be permanent, but death is permanent. My concern would be that there might be something reversible from the perspective of an individual patient’s despair. I would want to be certain that there is not before I would say that it makes sense for that person. Again, it is always their right to decide what to do, but my role as a physician would be to say to make sure that there isn’t something reversible that would lead them to change their minds.

Dr Caplan: Just to emphasize, it is the reversibility of their psychological state.

Dr Markman: That is correct. Again, this is an example and certainly an example in the cancer domain, which is my experience. A patient could have been taking a tremendous amount of pain medications. They are not working and they say that nothing is working. I accept that. However, it could be that there is a single anatomical lesion that has not been appreciated or has not been approached. An interventional radiology approach or a surgical approach might be able to relieve that pain. If that pain were relieved, that could change the patient’s psychological despair that led them to say, “I want to end my life.”

Dr Caplan: What do you say to the advocates of physician-assisted dying? What do you say to the patient who says, “I understand that you can manipulate this and manipulate that, but I am dying and I do not want to go through all of that. I would rather be in control of how I die. I know that you could do this or sedate me or block this. I do not want to go through all of that.”

Dr Markman: It is their right. It is as simple as that. Again, as a physician, I would see my role as an advisor, no more than that. If someone were to say that to me, I would say, “I accept that. Did you consider this? Did you consider that?” But of course, I am not a psychologist or a psychiatrist. It is also not for me to decide right or wrong. As a physician, I can voice an opinion. I can advise. I can even go to a family member if I think that there may be some element that just doesn’t make sense to me, based on objective data. In your example, the patients want to be in control, but it may be a potentially curable cancer, let’s say. There may be a concern that we are not getting through to them. My role in that is not to tell patients that they are wrong; my role might be to ask whether there is another way of approaching this that they’re not hearing. If the answer is that this is their decision, it is their decision.

Making Death the Goal ‘Is the Antithesis of Medicine’

Dr Caplan: Dr Markman has brought up some very thoughtful and provoking points. Now we will speak with Dr Farr Curlin, a physician and an expert in palliative care at Duke University. He is the Trent Professor of Medical Humanities and also works in the Center for Bioethics, Humanities, and History of Medicine at Duke. He is certainly one of the nation’s leading experts on end-of-life care, and he has done pioneering work in integrating theology and healthcare. Welcome, Farr.

Farr A. Curlin, MD: Thank you.

Dr Caplan: Let me begin by asking you a straightforward question. You have a lot of experience in palliative care. What do you think is the key reason to oppose physician-assisted dying or physician-assisted suicide?

Dr Curlin: The main reason physicians should oppose physician-assisted suicide is that assisted suicide directly contradicts the purpose of medicine. It directly contradicts physicians’ long-standing profession to maintain solidarity with those who are sick and debilitated. It is not just about medicine. I think it is the antithesis of medicine. Continue Reading

Dr Caplan: How do you respond to those who say that part of their mission as a physician is to relieve suffering and that part of their mission is to listen to their terminally ill patients— that if they want assistance in dying, it is consistent with a physician’s ethical obligation both to relieve suffering and to honor their wishes?

Dr Curlin: Relieving suffering is obviously an essential aspect of physicians’ work, but if we have no other objective criteria to decide what suffering we are obligated to relieve and what suffering we are not, then there is literally no boundary on our use of medical technology to achieve things that people want. For any conditions that people suffer from, they can ask that we take them away.

Dr Caplan: We have doctors contacting us with this kind of question. They say that, certainly, we don’t want to be involved with children or psychiatric patients, but for those who are at the far end of dying, in the final throes of death with their MS overcoming them or their parkinsonism overcoming them, those who are in a stage of dying that is imminent, not even 6 months away but days—is there no relief, no mercy to be offered by hastening their death even at that point?

We do not make the death a part of our plan. We make relief of those health-diminishing and health-crushing symptoms our goal.

Dr Curlin: Patients in that situation are taken care of. Scores are in that situation. Without ever making their death our goal, we can treat those symptoms with powerful medications—as much as they need to get the symptoms relieved, whether it is choking on their secretions or gasping for breath or being in pain. If, as a side effect, the medication hastens their death, then of course physicians can still do that, and they have done that for centuries under what has been called the rule of double effect. It has been an important heuristic for guiding us. We do not make the death a part of our plan. We make relief of those health-diminishing and health-crushing symptoms our goal. We work toward it as hard as we need to get it done.

The Key Points

Dr Caplan: So, where is all of this headed and what does it mean for physician-assisted dying? Here are the key points that we have heard in today’s program:

On the pro side, assistance in dying relieves suffering in terminal patients who are in pain. It enables ill patients to have some control over their life and death. Many consider this merciful and a part of what compassionate care is for patients. Patients with little time to live may want their suffering to end on their terms.

On the con side, physicians are enjoined against doing harm. Many believe that assisting in dying is harm. Some worry that there is a slippery slope, that it is going to become too easy for patients to commit suicide, not because they are terminally ill but because of depression or other reasons. Some conditions may actually turn out to be treatable. Death is not reversible, and some religions consider suicide in any manner a sin.

Here is my take. The issue of physician-assisted death is clearly going to remain a divisive topic for the foreseeable future, but I think we are going to see more states move to legalize it. The momentum is there. I think the practice is going to spread around the United States.

I hope that this program has given you some further insight and information so that you can make up your own mind about the subject. I am Art Caplan from the NYU Langone Medical Center on behalf of Medscape. I hope to see you next time on Both Sides Now.