Jul 22, 2010

Dr. D's Guide to Killing Your Loved Ones

A very different question this week:

"What can I put in someone's IV that will kill them fast?"
Now don't start judging yet...

This person was writing out of compassion not hate. Someone they love has a terminal illness and asked them to do this if the pain got too bad. (Think: Clint Eastwood in Million Dollar Baby)

It is a hard question. I feel for the person who wrote because I have been in this situation many times.

The Moment of Truth
There is the moment when doctors say, "I'm sorry, but there is nothing we have that will stop your illness. The disease will win shortly and you will die."

We are all going to die one day—many of us from illnesses that are long and painful. Everyone mentally acknowledges this as a concept, but when you are on the receiving end of such news it still hits you like a ton of bricks.

It is not uncommon for people to get in a very dark place after this news. Despair, fear, and hopelessness are understandable emotions given the circumstances.
Doctor D is by no means the final word on such a heavy topic, but perhaps I can offer some perspective from a doctor who has accompanied many patients on that difficult final path...
A Cry for Help
Depression is miserable. Anyone who has depression can attest that the mental anguish of hopelessness can be just as terrible as the worst physical pain. Often depression is triggered by traumatic life events.

The good news is that depression is not the end. Most people recover from depression, especially depression that is due to horrible news.

We all work very hard to convince a suicidal but otherwise healthy 20 year old that life can be better and their depression can be treated. Why should we not similarly address the depression of terminally ill patients? Whether someone's life will be decades or days they can live to the fullest when supported by people who love them.
Often when a dying person asks someone to kill them it is a cry for help. In their despair they are asking, "Am I worth anything anymore?"

The answer they need to hear is, "Yes, you are still worth everything to me! I may not be able to save your life, but I will cherish and honor you to the very end."
Every terminal patient that ever asked me to die, they later expressed to me their joy in life and how much they value their time once they had made peace with what was happening. Depression can be treated allowing people to pass with a peaceful heart.

Do not doubt the value of a human spirit, even during the final hours! Doctor D once watched a dying woman do more good during her last day of life in a hospital bed than he has done in all his years of practice.

Fear of Pain
Hurting sucks. We all hate pain and want to avoid it. The thought of dying in pain is intolerable even to consider. And a lot of fatal conditions are also very painful. Many people who otherwise are at peace with dying might contemplate suicide to avoid the pain at the end.

I believe that the field of Hospice is perhaps the finest breakthrough medicine has made in recent decades. Hospice is care for those with terminal illnesses.

Hospice is the art and science of comfort, and as a discipline they have made amazing discoveries in the treatment of people in the dying process.
There is no reason that anyone with terminal illness needs to die alone and in pain these days.
It is sad, but many people still don't know about Hospice. (I guess it's because they don't have their own TV dramas like every other field of medicine. I suppose the ratings wouldn't be good for a medical drama when the patient dies every episode.) Many patients seem shocked when I tell them there are teams of medical professionals that are skilled at managing every aspect of care at the end of life.

Not only do they insure you don't physically suffer, but they address the emotional and spiritual pain of facing death as well. Hospice patients are able to pass in peaceful environments or even in their home. There is support for the family as well. And yes, insurance does cover it.

Many patients are skeptical if Hospice can really deliver.
People figure that if fighting an illness was miserable, then loosing to it must be torture. Back in the old days that may have been the case, however, hospice has an advantage: they aren't trying to cure you. The very thing that seems like the problem they use to create solutions. Without needing to cure anything they can avoid any procedure that causes pain, and they don't have to avoid treatments that might not be good for your illness because fixing your illness is no longer the goal. Your comfort becomes the ultimate goal.

I have never seen a hospice patient die in pain.

Some patients wonder if they can trust the doctors and nurses involved with Hospice to really care about their pain. "Aren't a lot of doctors jerks who enjoy hurting patients who complain too much?" I admit, there are some callous doctors, but I have yet to see a single one involved in the hospice system that wasn't about as kind as a human can be.
Please don't touch the IV!
So in response to the question: Your loved one is asking for your help, but it is important to recognize help they need. Putting down your loved one like a dog is not the solutiondespite what Clint Eastwood says.

Love, support, respect, and connecting them to resources that can help them through this difficult time is the right and humane approach.

Doctor D always loves to hear your thoughts. Have you ever had someone you care about feel this way? Have medical professionals ever wanted to help someone die?

Anyone have any experiences with Hospice?

I realize that suicide is a difficult topic with lots of emotion on all sides. Please share opinions and discuss with respect.


Anonymous said...

Thank you so much for posting this. It is powerful.

As a patient who is dying in my mind faster than my body- I want my family to let me go when it is time. I would opt for euthanasia when the time comes only to save my family from dealing with a person who is not "in there" any more for years before my body finally lets go. I will be here until "I" am not anymore. I wish to have a say in my own death too. I realize at some point "I" must give up control - but illness is not fair. I am not depressed or insane. I just don't want my family to have to deal with the guilt and ramifications of "killing" me either.

If I figure out a good time and place- when the last vestiges of "me" have slipped away-- I find no wrong in that. Thank you for this post.

Parin Stormlaughter said...

My father was under home hospice during the final 3 months of his life. My mother was his primary caregiver. He died from metastasized prostate cancer. It was in his hips, spine, arm bones, and lungs that we know of.

The last 24 hours that he was with us, the hospice nurse was like an angel from heaven. My father was not in pain - God removed his pain 3 weeks before he died - but had he been, I feel absolutely certain that the nurse would have moved heaven and earth to ease it.

She stayed with my mother, talked to her, explained everything that was happening, and was like the still river that runs deep.

God bless hospices and those called to that merciful work!

Anonymous said...

Hospices are more medical care for people with things like money and insurance. Those who are poor with extremely limited health care get to slowly die alone in the corner, suffering in pain because the free medical clinic does not prescribe narcotics. Depressed? It's hard not to be depressed when the pain is a 8 on the 1-10 scale and doesn't let up, except when it spikes to about a 25. Yet the last doctor I saw first chided me on the amount of Advil I take, refused to prescribe Tramadol because "We're not allowed to prescribe DEA scheduled drugs" [yes, I know, tramadol is not scheduled] and then refused to prescribe an anti-depressant because "I don't believe in those."

It's very easy to take the high road of "look what's available out there!" except that those of us living on scraps don't even get that level of dignity.

DrSnit said...

This is right in my area! Been doing this for years. When it comes to the end - the dying are almost never afraid (in pain, yes, but not afraid) - it is those of us watching us face OUR FEARS.

This really struck me: "Doctor D once watched a dying woman do more good during her last day of life in a hospital bed than he has done in all his years of practice." YES! I'm always amazed - always profoundly moved- to see how much beauty and gifts people have to give out in their last days. All the old crap seems to fade away. I always feel as though I am being given GIFTS to be there - GIFTS to see it.

It is hard to face our fears - all of our fears - especially culturally- about fears, death, loss, dying, grieving, pain. Great post. Provoking - moving - and challenging to many depending on where we are at in our health AND where we are at in our lives.


Anonymous said...

I think a lot of us would like to know how that dying woman accomplished so much good on the last day of her life while lying in a hospital bed. It's hard enough to know how to spend an ordinary day well, much less a day under those conditions.

Doctor D said...

Anonymous 8:29, are you referring to a chronic painful condition or a terminal illness?

The resources available for these two different situations vary quite a bit.

I have volunteered in quite a few Free Clinics and we have never been responsible for a patient on hospice. I've never had trouble getting hospice covered even with uninsured illegal immigrants. Everybody in the states in which I have worked pretty much agrees that caring for the dying is the least we can do. (And these are red states.)

Do you mind letting us know what state you are in and what condition you have?

Doctor D said...

By the way:

I know it sucks, but there is a really good reason that Free Clinics don't prescribe narcotics.

I'll do a post on it someday if you guys are curious.

Anonymous said...

Sometimes, like now, the pain of depression, the hopelessness, the never-ending despair are not surmountable. I see this as a terminal illness and it would be a kindness to let me die.

Anonymous said...

I will always use he/she or they or them to keep from pinpointing what sex the friend of mine is :O)

Hello Dr. D and thank you so much for addressing this question. I must correct one part of the question that I believe I did not explain myself right. The loved one did NOT ask me to do it for them, he/she was wanting to make sure that if he/she would push insulin directly into their IV port - would they die instantly. Thus being the reason: there is nothing more that can be done to help he/she to get better.

As a Christian I do not condone his/her desire to do this, but yet my compassion for their pain is real. Every day since the day I first met this individual, I knew about this dreaded disease and that eventually I would lose a great friend. As the months has passed, I make sure that I ck on him/her daily with a text or call. Mainly a text as sometimes he/she is so groggy they cannot speak where I can understand. Each day I get a reply telling me how thier day or morning had gone. But when I speak to him/her whether on the phone or text, I tell them that I am always praying for them and that I love them.

This individual asked me one day WHY I would even take the time to befriend him/her and always to check on them. I said You are my brother/sister in Christ and GOD expects us to always love one another, support and pray for each other. This person was wowed and every day thanks me for being their friend.

I must say when I first got the question I freaked out, begged them not to do it to go to the hospital, etc.. He/she already has Hospice to come when its almost time for them to go. He/she explained that the question was posed not to say he/she was going to do it, but to use it as a LAST resort if the pain worsened.

Im not sure whats going to happen, but I do know this. I am becoming a better person because of this individual and will dearly miss them when they pass.

Anonymous said...
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Anonymous said...

When a friend of mine was dying of cancer, he did not want to use hospice services because he said it would place too much of a burden on his family to have to care for him. (Family members WERE with him, helping out in all kinds of ways---I'm not sure what more a hospice program might have asked of them.) He also hated to take many narcotics because they left him feeling fuzzy-headed. So he was often in a great deal of pain; he described it as "pure hell." He had a private agreement with his oncologist that if he did not die by a certain date, he would be admitted under the guise of pain management and be given a lethal dose of narcotics. He died a few days before the date he had picked. I am so sorry that he could not find a way to get help from hospice and palliative care professionals.

Thank you for this post. It is certainly reassuring to those of us with terminal illnesses.

Anonymous said...

My grandfather was in hospice care during his last days. They were very accommodating, even allowing my family to throw him a birthday party in one of their lounges. I was only a kid at the time, but I've always had the impression that hospice care is of the highest level.

Thanks again for a wonderful post.

Anonymous said...

I am an intern in Family Medicine (just a month and change in!) and so far I've helped two families choose hospice care for their parent. They both happened in the same day in the same room even, just hours apart. I woke up that day kind of dreading the family meetings, not knowing how they would react, but man, I finished the day feeling better than I had all month. I really feel like hospice was the right choice for both of these patients, and I'm glad the families also thought it was the right decision.

As a different note, I like to think about, and present hospice care this way: Perhaps it's time we start thinking about shifting our goals. Instead of doing everything we possibly can TO you, to maximize your time on earth, maybe we should consider maximizing your comfort for the time you have left. We'll stop sticking you with needles, we'll stop bothering you with tons of beeping machines, we'll let you go to wherever the most comfortable place is (Home or inpatient hospice or nursing home, depending) and do our absolute best to relieve your pain and make you feel as good as you can feel until it's time to go.

When I think about it that way, as a goal shift, it seems extremely reasonable and in some cases, vastly superior.

tracy said...

First Anon,
i understand what it is like to feel this way, as i do too. it is a painful Hell and one that only another person who has been there can know. i am so sorry you feel this way. Having been recently "fired" by my Psych didn't exactly help. Please don't die.

tracy said...

i apologize. i ment my message for the 4th Anon.

Anonymous said...

I'd still be afraid. I've seen two people die under hospice care, and yes, they still suffered. Hearing a child cry out in pain for days on end is not something I'll ever forget. Shouldn't have been that way, but it was.
If I was going to die soon, and starting to be in pain, I'd rather just end it.

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