What is a life worth?
Posted on Thursday, May 30th, 2013 at 2:38 pm by Life Matters Media
Geriatrician argues against bias against the aged and ill
Physicians caring for the elderly and for those nearing the end of life cannot be effective patient advocates until they confront their own deep and widespread prejudices, said geriatrician James Wright at the University of Chicago’s Conference on Medicine and Religion Wednesday.
Wright’s presentation, “The Courage to be a Geriatrician,” examined the bias held by many towards those lacking in independence, particularly those residents of nursing homes. “Most of us share the same prejudice, that life is of less value when lived in dependency,” Wright explained. “We are in a tradition that cultivates freedom, independence and productivity, and that is what we give value.”
“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” Wright said.
This prejudice thus serves as a blockade to administering comprehensive care to some of society’s most vulnerable- the oldest and most infirm. Medical professionals, those in geriatrics especially, must experience a shift in mindset from valuing life based on independence and instead towards seeing innate human value. The oldest and sickest are long divorced by age and ability from past functions, Wright said, but their lives remain valuable. That value does not stem from any thing they once did.
Prejudices manifest, Wright said, when doctors make quality of life assessments. His research demonstrates that when simultaneous assessments of life quality are made by both physician and patient, the patient almost always scores his or her quality far higher than the physician. “These devaluations matter,” he said.
The discrepancy, Wright argued, arises out of the drive of younger, working people towards self-affirmation. We often think, he said ‘‘I am not only alive, but my existence has meaning.’’ This quest for meaning is why the able-bodied join larger movements- political, civic or social. These movements give us worth.
“We live in an era of meaningless- now that we no longer fear the sword, plague, even hell, we fear meaningless,” he said, and this fear inhibits proper care of those we judge to have none.
Wright pointed towards the leaders of the Protestant Reformation as ones who can teach medical providers intrinsic human value. “All beings have equal value not because they earned it, but they were made that way by God, the source of all value,” Wright said. Both Martin Luther and John Calvin agreed that all of us, as humans, are not good enough, and fall short of our own expectations. However, God who loves without condition.
“We are enough as is,” Wright said, “and that gives us courage to be not as something greater.” The most successful providers see all life as equally acceptable and valuable, simply because that life is human.
“All people are created equal and remain equal throughout the course of their lives,” Wright concluded. “Only with this conviction, can we truly be trusted to value and care for the elderly in a way we all deserve.”
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Vermont votes to allow "Death with Dignity"
Posted on Tuesday, May 14th, 2013 at 5:10 pm by Life Matters Media
The Vermont House approved a measure allowing physicians the ability to prescribe life-ending medications to some terminally ill patients seeking to end their lives. Vermont is set to become the fourth state allowing the legislation known as ”Death with Dignity,” following Oregon, Washington and Montana.
The Patient Choice and Control at End of Life Act awaits approval from Gov. Peter Shumlin, a Democrat and supporter of the bill.
“By a 75-65 roll call vote, the House approved a bill largely that copies a law passed by Oregon voters in 1997 for three years and then shifts to a system with less government monitoring,” The Associated Press reports.
This marks the first time this type of legislation has been moved to passage by a legislature. With safeguards similar to the Oregon bill, patients seeking the prescription barbiturates must first state their intentions three times- once in writing. A second opinion from a physician indicating a patient has less than six months to live and proof of sanity, are mandatory. Patients must wait 48 hours before filling the prescriptions.
“It’s an important step for terminally ill Vermont patients,” Dick Walters, president of Patient Choices-Vermont, said after the vote. “It’s a big step forward for the region and for the country as a whole,” the AP reports.
Come 2016, changes advocated by some of the state senators seeking less government involvement during the process will go into effect, including less monitoring from physicians.
“It’s huge,” said lobbyist Michael Sirotkin, who for years has been involved with the issue in Vermont. “I think it’s going to have a major effect on other states’ willingness to vote on this,” he told USA Today.
But not all lawmakers approved of the bill’s passage. ”There can never be a dignified death using a handful of pills or a lethal cocktail,” said Rep. Carolyn Branagan, a Republican from Georgia, VT.
Other opponents were concerned about the radical changes the bill underwent while in the Senate. ”We are passing a bill that has not been vetted,” said Rep. Paul Poirier, an Independent from Barre. “Do we want to pass a bill … just accepting 100 percent what the Senate did overnight?”
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Montana HB505: Outlawing assisted suicide
Posted on Thursday, February 21st, 2013 at 10:09 am by Life Matters Media
Montana lawmakers are considering a controversial bill to outlaw physician-assisted suicide, a decision that opponents say would punish doctors for honoring their dying patients’ wishes. If the bill passes, physicians who provide life-ending drugs could face 10 years in prison and a $50,000 fine.
Introduced by Rep. Krayton Kerns, a Republican, HB505 seeks to clarify “the offense of assisting in suicide,” after a 2009 Montana Supreme Court decision left many confused about the issue.
Known as the Baxter Decision, the court ruled physicians that prescribe life-ending drugs are safe from prosecution, because “nothing in Montana Supreme Court precedent or Montana statutes [indicates] that physician aid in dying is against public policy.” However, the decision did not address whether assisted suicide is a right guaranteed under the state Constitution.
Kerns insists the ruling needs clarification. ”The Baxter Decision did not establish legal assisted suicide in Montana, and this has remained a gray area,” Kerns told the Great Falls Tribune. ”This bill would be a legislative declaration saying it is illegal based on constitution principles.”
According to the bill, “A person who purposely aids or solicits another person to commit suicide, including physician-assisted suicide, commits the offense of aiding or soliciting suicide.” Consent of the patient would not be a defense. However, withholding life-sustaining treatments from terminally ill patients would remain legal.
Critics argue the bill would curtail patients’ end of life choices. Opponent Bonnie Warne of Billings told the Billings Gazette that doctors who provide life-ending drugs to their patients would be unfairly attacked. “Death is inevitable and private. We do not need the state interfering with aid in dying,” she said.
Dan Lourie, from Bozeman, wrote a letter to the Montana Standard arguing that if the bill passes, he would be forced to forfeit his doctor-patient privacy. “My position is that my end-of life choices should be between me and my doctor, and the Montana Supreme Court agrees with me,” he wrote. “It should be my right, and certainly will be my desire, to discuss all of my choices with my doctor — treatment options, my choice to refuse treatment, pursuit of comfort care and assistance in dying.”
Compassion and Choices, a non-profit that serves to expand end of life options, maintains the bill would “roll-back” end of life legislation.
“HB505 goes beyond just prohibiting aid in dying by putting a physician at risk of prosecution for answering a patient’s questions about any of a variety of death hastening options, such as directing deactivation of a cardiac device, directing withdrawal of a ventilator or feeding tube, or provision of palliative sedation; and a spouse, child or friend could be prosecuted for driving the patient to the doctor’s office for the discussion,” a statement posted on their Web site read.
If the bill were to pass, palliative care would still be allowed for terminally ill patients, because palliative care serves to manage pain and ease suffering.
Hearings about the bill began this week.
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Spirituality at end of life: Practitioners remain hesitant
Posted on Friday, December 28th, 2012 at 5:07 pm by Life Matters Media
Physicians and nurses at Boston medical centers cited a lack of training as the main reason why they rarely provided spiritual care for their terminally ill cancer patients, even though most patients considered it important to their end of life care.
A new study published in the Journal of Clinical Oncology reports that out of the 204 physicians from four medical centers who participated in the three year study, just 24 percent reported providing spiritual care. Among the 118 nurses, only 31 percent reported providing care.
“I was quite surprised that it was really just lack of training that dominated the reasons why,” senior author Dr. Tracy Balboni, an oncologist at the Dana-Farber Cancer Institute in Boston and researcher of spirituality, told Reuters Health.
Spiritual care may range from prayer with a physician or nurse to recommendations for a hospital chaplain.
Spiritual care “is considered by patients to be an important aspect of end of life care and is also associated with key patient outcomes, including patient quality of life, satisfaction with hospital care, increased hospice use, decreased aggressive medical interventions, and medical costs,” Balboni said.
Even though current palliative care guidelines encourage medical practitioners to mind religious and spiritual needs that arise during a patient’s end of life care, most medical practitioners remain silent. Ninety-four percent of patients with advanced cancer had never received any form of spiritual care from physicians.
Spiritual care may become more common in the future, however. “There was a time when nurses and physicians may have said, ‘That’s not my job,’ but I think the tides are changing,” said palliative care researcher Betty Ferrell of City of Hope, a cancer research center in Duarte, California.
“I think we are realizing we can no longer ignore this aspect of care,” Ferrell told Reuters. She’s a professor of nursing who was not involved in the new study.
Study researchers suggest more spiritual care training for physicians and nurses. The study found only 13 percent of doctors and nurses reported having such training. However, those who received training were almost 11 times more likely to provide spiritual care to their patients than those who had not.
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How POLST forms clarify wishes: Three scenarios
Posted on Monday, December 10th, 2012 at 2:39 pm by Life Matters Media
The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve end of life care in Illinois, is on its way to implementation. Health care professionals met at Rush University Medical Center this week to discuss the form’s development and strategies for raising public awareness.
Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center, provided the audience with hypothetical scenarios the POLST program form could remedy.
POLST program forms are more detailed than conventional living wills or other advance directives. They allow people to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for people who are likely in their last year of life. They can follow patients across in-state care settings and direct doctors to provide or withhold life-sustaining treatment in emergency situations.
The forms aim to more quickly direct doctors to a person’s wishes and eliminate confusion about what patients would want in the case that they are medically incapacitated and unable to communicate their wishes. The forms provide instructions in the case of a cardiopulmonary arrest (the person has no pulse and is not breathing), the degree of medical intervention they would want in a pre-arrest situation (the person has a pulse and/or is breathing), and whether or not they would want artificial nutrition if their medical illness prevented them from taking in adequate oral nutrition.
How a POLST form could help
A 67-year-old man is sent to the emergency room with chest pain and shortness of breath. He is also confused. The cardiologist says that a cardiac catheterization with angiogram and a stent are needed. The nurse tells the physician that there is a DNR order on his chart. Should the physician send the patient for an angiogram? It’s not clear.
If that patient had a POLST form that indicates DNR in case of full cardiac arrest but an order for full treatment in a pre-arrest emergency, the physician would immediately know what to do. The patient would be sent for the angiogram.
An 85-year-old man is admitted to the emergency room with severe pneumonia. He’s hypoxic, confused and refusing the ventilator. There is a DNR order on the charts. The physician feels that DNR doesn’t apply to this potentially reversible condition but the nurses disagree. He receives full resuscitation.
If that same patient had a POLST form indicating no CPR in the case of arrest and a preference for comfort care, the physician and nurses would have clear instructions. He would not have undergone full resuscitation, but would have been maintained in comfort with noninvasive maneuvers. .
A 59-year-old woman who is being treated for breast cancer is admitted to the emergency room for sepsis. She is transferred to intensive care and receives oxygen and maximum vasopressors. She has a DNR order on the charts. The staff are concerned that they are violating her wishes.
If she had a POLST form indicating no CPR in the case of arrest but limited interventions in addition to comfort measures, the staff may feel more comfortable treating her as they are doing and spend less time deliberating.
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