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Wednesday, October 14, 2015

Doctors, death and dignity: the semantics of 'suicide'

Inevitably, death comes to be seen as the enemy in medical care. A resuscitation effort ends with success, or death. Death is the antithesis of triumph in medicine. It is where options run out, where treatments end, where the final desperations of hope surrender. It is failure.

Nor are we in medicine unique in this tendency. Poets, too, have interposed their passions between the failing imperatives of heart, and nerve, and sinew, and the dying of the light.

But of course, death cannot truly be the enemy. It is the common end to every story. We do not own life, we wear it for a while. It does not belong to us permanently; it flows through us. Death is no more enemy to us than autumn is to summer; it is what happens next.

Indignity is the enemy. Pain is the enemy. Suffering, in all its vast vocabulary, is the enemy. Death figures in this, of course, for untimely death is the greatest indignity. Our losses to death as we linger here are the most excruciating pain. Death is the remedy for dying, but the root of ineffable sorrow and suffering for those of us it leaves behind.

Death is the enemy, and it is not. Death is simple and inevitable, and inexplicably complicated.

So it is that when a notice from the American College of Physicians, in which I am a fellow, turned up in my inbox telling me that “we” were advising the Governor of California to veto the “End of Life Option Act“ just passed by the California State Assembly, I was a little upset. The bill in question would allow physicians in California to help patients end their lives willfully. This right is already established as law in Oregon, as it is in other countries.

I favor such legislation for the most visceral of reasons. I can imagine, and have, scenarios in which the surcease of my own life would confer more comfort and preserve more dignity than any manner of preserving it. I have been goaded into just such morbid imaginings by the real-world miseries I have witnessed over the course of my medical career. I have long felt that if I could envision a scenario in which bringing my own life to a close would be the preferred option, then denying that option to others was hypocritical at best.

So, my immediate response to my organization's letter was a bristling resistance. But I stifled that impulse long enough to read the letter in its entirety, and I have to say, I was impressed. ACP has a long track record of devotion to the best interests of patients that has made me proud to belong. This is distinct from the AMA, for instance, which largely prioritizes the interests of its physician members. One might like to think these are invariably confluent, but of course it is not so, or the whole patient-centered-care movement would be moot. It is not moot; it is much needed.

I respect ACP, and read their letter accordingly. It persuasively situates their objections to the bill in California in the context of their established code of ethics. It argues that the willful pursuit of death is at odds with the imperatives of medicine, but that extreme devotion to comfort and relief of all varieties of pain is not.

ACP acknowledges that at times, the relief of pain may, ineluctably, accelerate death- and this is ethical. Death as a by-product of pursuing comfort is permissible; the pursuit of death is not. The case is passionate, thoughtful, internally consistent, and poignantly, human. The ACP argument relieved my initial resistance, and replaced it with ambivalence.

As a physician, it is not my place to tell my patient what to do; it is my job to tell my patient what's what. The patient decides; the patient is the boss. It is my job to be an adviser, a teacher, a coach. In that role, I have always paused before offering any important guidance, based on training and knowledge, and run it through a filter of raw emotion: what would I do if it were about me? What would I recommend if this were about the person I love most in the world? I have applied that measure consistently across 25 years of patient care. I have always felt that the trappings of medical expertise that make doctor and patient a bit different were most securely situated on the bedrock of the humanity that makes us profoundly the same.

If it were me, I could well imagine those situations where life is no longer liveably intact. I could well imagine scenarios where the best recourse for the relief of pain in its maddening chorus of many voices, is to relinquish the tattered remains of life, to silence the din, to let go. I could well imagine a final, evanescent gratitude for those helping to gentle me into that night, good or otherwise.

For having imagined my own way into that dark corner, while fully sound of mind and body, I have long felt that others could do the same. I have thus long felt that all should have recourse to the way out I would want for myself.

The difference, then, between the ACP's well-argued position and the personal conviction I have long held reduces to something much like, though a bit distinct from, semantics: the semantics of suicide. Approaching from one side, there is the overt allowance for scissors in the hands of the clinician who willfully applies them to sever the exhausted tether. Approaching from the other, the ministrations of that hand in the service of final comfort may cause that tether to fray a bit faster, and without regret, but also without that specific intention.

Facilitating death to provide comfort, or fostering comfort that facilitates death are alike enough to evoke musings on semantics, yet, apparently, different enough to argue for an executive veto affecting the rights of the 30 million souls who call California home. The difference is, paradoxically, reducible to nearly triviality, yet redolent with terrible portents.

I am ambivalent about the proposed veto. Such are the semantics of suicide. However we define the intention, much depends on its execution. Much depends on the applications of that hand, reaching through the shadows, to find us in that final corner.

Perhaps, then, the approach to this most ultimate of human need is a distraction from what matters most. Perhaps it matters less whether a hand devoted to comfort causes a life line to fray, or a hand inadvertently parts the haggard, final strands of that line in the service of elusive comfort. Maybe all that matters is the comfort, and the fidelity and fervor with which it is rendered, the ethical imperatives it unfailingly serves. In this, the ACP and I seemingly agree.

There is comfort in that. Veto, or no veto, should we find ourselves in that darkest of corners, a hand should reach out to us, and provide the solace we need.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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