Friday, September 13, 2013

My Brush with Euthanasia: Forget Not Love

This post conforms to the blog rules.Euthanasia is a terrible thing. I had a brush with it about a month ago while on a geriatric ward. This might surprise and scare you. Just to clarify, this actually happened. I am exaggerating nothing.

I was reviewing an older patient's chart at the nursing station before rounds. This person was on dozens of medications. The home medication list was three pages long. Everything was carefully listed by doses, times, and routes (oral, otic, ophthalmic, topical, nasal...), but the sheer volume was overwhelming. On top of the drugs for medical and mental problems, there were various  prescriptions and OTC remedies to cover side effects of the first drugs.

(If polypharmacy is new to you, then let me explain how these lists grow. A man of 64 on no medicines has some chest pain and goes to his doctor. He leaves with instructions to take a baby aspirin every day. And, because his blood pressure was high, he also leaves with a prescription for a water pill and a blood pressure medicine.

(Fast forward four years. Despite his daily three drugs, the man ends up in the hospital with a heart attack. He leaves with a stent, an antiplatelet agent, a pill for cholesterol, and an ACE inhibitor.

(Fast forward another eight years. Our man seems to be getting lost around the house and can't balance the checkbook very well any more. He's put on two drugs for dementia. Thyroid replacement is added because a thyroid test was high. His wife added a multivitamin, CoQ10, and glucosamine to keep him healthy after that fall he had last Christmas, and he also has nitroglycerin on hand, for that chest pain that started all this. He's now up to a dozen drugs, not counting any OTC painkillers, eye drops, or occasional antibiotics.)

Back to my story: I looked at the three page list of medicines in my hand, aghast. How burdensome this regimen had become for the patient and caretakers! What was this person's quality of life like, with so much intervention? This all seemed like artifice to replace the functions of a failing body. It seemed like torture to prolong a life. And for what?

I looked up from the page out to the patients beyond the nursing station counter. Half of the patients on this ward seemed over-medicated to me. They sat in their wheelchairs unaware of their surroundings. Other professionals I had learned from, including very compassionate hospice nurses, liberally took patients off medicines toward the end of life. I liked this palliative, simplifying approach. Too much medicine is a cloying thing, a clinging to numbers or days. I thought to myself, "why not just take this patient off everything and let her go peacefully?" No more surprise bruises from aspirin, no more dizziness from the blood pressure pills. No more bother with all these pills and suppositories and drops.

But today I looked at her three page list, I saw one problem with the remove-the-medicines approach. Two of this patient's medications were high-potency antipsychotics in high doses. And the rest of the regimen was like a teetering game of Jenga: remove one thing, no matter how extraneous, and the rest collapses. I groaned inwardly. We could not let this person off her would not be peaceful or safe, and it would not improve her quality of life. If medication withdrawal couldn't be done, what could? How could this patient and her caregivers be relieved of all this?

"What if," I thought, "What if we just gave a little too much of something?"

Immediately I was alarmed. Where did that thought come from? Did I just suggest to myself that I should euthanize a person? I had. I was thinking about giving something (e.g. a benzodiazepine) to let her just slip away. I was horrified at the thought I had just produced.

How did I get to that point? I was thinking about burdens and quality of life! How did I go so far astray?

Looking back, I realized that in the few days I'd worked on that ward, I had taken on the attitude of the attendants there. They shouted at the patients from their chairs in the nurse's station and loudly talked and laughed about them like children or animals. Giving medications in such big and complex regimens was a chore. They didn't love. And although I detested this and really couldn't wait to be off that ward, it rubbed off on me! Writing so many orders--what a chore! Working on this ward--what a burden! So, as I was looking at that medication list, I was not loving the person, even though I was pitying them.

And as soon as I forgot about love, I forgot about the meaning of life, the dignity of persons, the mystery of each soul's holy journey, and the importance of suffering in salvation. Who knows whether that person on three pages of medication was becoming a great saint or mystic? Beneath the shroud of dementia and crippled limbs, under the veil of an incontinent, flailing old woman, perhaps God was adorning an exquisite saint. Perhaps in heaven her beauty and nobility will be breathtaking. And moreover, what if her suffering was saving my soul? Yours? Our country, our world? How could I dare to know? (Job 38 comes to mind.) Certainly, simplifying her regimen with palliation in mind isn't a bad idea, but I only safely stay in that mindset when I remember love.

So forget not love. It's a deadly mistake.

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