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Embracing life, accepting limits

A physician's position is unique when a loved one faces death

Peter A. Setness, MD

VOL 114 / NO 2 / AUGUST 2003 / POSTGRADUATE MEDICINE

The poet Dylan Thomas wrestled with the death of his father through his writings, specifically the poem "Do not go gentle into that good night" (1). I am not a gifted poet, but I, too, have wrestled with the same issue as of late. My own father slowly died over the past 3 months. Although he was 86 years old and had lived a rich and fruitful life, watching this man I loved and respected pass away was indescribably painful at times.

In a matter of months, the tumor in his brain transformed him from an alert and active octogenarian to a weak, fragile shell who no longer recognized our family. We had to face deciding, with the aid of his physician, when prolonging his life through the use of science ended and prolonging his death began. We used terms such as supportive care and comfort measures and discussed what each meant in my father's case. And unlike Dylan Thomas, I found myself wishing to see my father pass peacefully and comfortably, rather than having to "rage, rage against the dying of the light" (1).

This experience has caused me to reflect on the role we physicians play when our patients become terminally ill. We practice in a time when a wide range of options are available for those nearing the end of life. Modern medicine offers medication and technology capable of keeping the terminally ill alive for much longer than ever thought possible. Concurrently, debates rage in our society over whether the hopelessly ill have a right to passive or active euthanasia.

Life-sustaining measures

Medical science now offers us the ability to sustain life under remarkably adverse conditions. Patients whose prognosis would have been deemed hopeless just a decade or two ago now routinely receive lifesaving and life-prolonging care. There is no doubt that these advances in technology offer a much-appreciated second chance to those who are critically injured or suffering from debilitating diseases. Even patients with terminal conditions can experience longer lives, thanks to our ability to support the body in the face of overwhelming odds. Advances in transplant therapy, chemotherapy, medication management, surgical intervention, and mechanical support all offer patients a chance at extended survival.

However, potential drawbacks to these medical miracles exist. Seizing every opportunity to stave off death may result in prolonged suffering for the patient. Families may cling to unrealistic hopes that medical science can offer a last-minute cure or reprieve. Conscientious physicians may be reluctant to abandon the fight without exhausting every weapon in their arsenal.

The "death with dignity" movement

On the other end of the spectrum, the Hemlock Society advocates that "every hopelessly ill, mentally competent American should have access to the full range of end-of-life choices, including the option of hastening one's death . . ." (2). The society and other groups like it support and actively lobby for enforceable laws that protect doctors who wish to aid patients in ending their life. Thus far, only Oregon has passed such legislation, but initiatives have been brought before the legislatures in four other states. (The US Department of Justice has challenged the Oregon law as a violation of the federal Controlled Substances Act, and the federal courts have yet to decide the matter (3).)

The Netherlands became the first country to legalize mercy killing when a controversial euthanasia law took effect in 2002 (4). The law allows patients who have extreme suffering to request euthanasia and lets doctors carry out mercy killing in these cases without fear of prosecution. Specifics of the law require that the patients be of sound mind when making the request and face a future of "unbearable, interminable suffering," although their condition need not be terminal or life-threatening. The request to die must be voluntary and originate with the patient.

Countries such as France, Belgium, and Australia are exploring similar measures. In the Netherlands, there already is talk of widening the scope of the law. However, public opinion around the world remains largely opposed to legalized euthanasia. The United Nations Human Rights Committee has gone on record saying it is not convinced that the Dutch system can prevent abuses such as pressure to request euthanasia being exerted on the patient (4).

"And you, my father, there on the sad height . . ." (1)

In an address last year to a scientific congress of physicians, Pope John Paul II urged them to pursue scientific research but reminded them, "There are limits which cannot be humanly overcome" (5). He further noted that resorting to extreme measures to keep the terminally ill alive does not respect the patient. He stated, "Certainly one cannot forget that man is a limited and mortal being."

Throughout my career I have leaned toward providing supportive care in the terminal phases of life. When a patient nears death because of a terminal condition, I believe there comes a time when it is appropriate to set aside heroic measures so that the dying process may proceed. Watching my father slip away only served to strengthen my belief that this middle ground is the best course.

As much as I loved and respected my father, I was prepared to let him go when the time came. Birth and death are part of the cycle of our earthly existence, and both have their appointed time. As a matter of fact, within days of my father's passing, my daughter delivered our first grandchild--a healthy baby boy named Samuel. Life and death . . . the cycle continues.

References

1. Thomas D. The selected poems of Dylan Thomas 1934-1952. Rev ed. New York: New Directions, 2003:122
2. Hemlock Society USA. What Hemlock believes. Available at: http://www.hemlock.org/about/beliefs.asp. Accessed May 29, 2003
3. Carson T. Oregon, US battle in court over assisted suicide. Available at: http://www.dwd.org/fss/news/reut.05.07.03.asp. Accessed May 29, 2003
4. Dutch legalise euthanasia. Available at: http://news.bbc.co.uk/1/hi/world/europe/1904789.stm. Accessed May 29, 2003
5. Pope: excess treatment disrespects terminally ill. Star Tribune Mar 24, 2002

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