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 solution—despite 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.

Hurting My Patients

An email to Doctor D:

What does it feel like to cause pain or disfigurement to a patient? Is it troubling or do doctors not let it affect them?

Believe it or not, most doctors are not sadists.

Hurting patients is distasteful to those of us who went to medical school because we wanted to "help people."

But the fact is that the really cool gadget that Dr. McCoy waves over sick people to fix them hasn't been invented yet. "Dammit Jim, I'm a doctor not a butcher!" Unfortunately, for the foreseeable future even high-tech medicine will involve some butchering.

People come to Doctor D feeling rotten and I sometimes stick them with needles, electrodes, blades, and tubes which at least in the short run makes them feel worse.

Sorry, I know, it sucks.

Doctor D fully realized the cruelty of his profession as an intern when he was performing a lumbar puncture on a squirming, screaming 2 year old with meningitis. The terrified kid couldn't understand why sticking a needle into his spine was required. He just thought we were torturing him. It sucked. That day D wished he had chosen another profession.

But young Doctor D got over the trauma he caused. The fact was that the lumbar puncture helped save the kid's life. Many of the painful things we do save lives, so we grin and bear it.

After a while we get used to hurting you:

It doesn't help patients for doctors to get emotionally distraught every time we cause pain. You want me thinking clearly so I can do procedures quickly and efficiently, with as little pain as possible. The doctor who hesitates to do an urgent painful procedure can be dangerous to patients.

Empathy must kept in check by necessity.

But occasionally the doctor gets too hard... forgetting your pain altogether and focusing only on the job.

Or even worse, we enjoy hurting you. It's easy to feel for a helpless toddler we have to hurt, but a whiny grown up who asks to be "knocked out" just to get an IV and has more tattoos than skin is a lot harder to feel for. Patients who thrash around can be dangerous to work on because needles and scalpels get knocked all over the place. "STFU and be still!" We sometimes even fantasize about performing painful procedures on belligerent patients.

Our work in proximity to so much suffering has a natural hardening effect. Doctors must constantly be wary lest we become cruel.

I believe that we can find a middle ground in which we perform the difficult task of hurting to heal without losing our compassion.

If I must cause pain adding kindness and understanding can sometimes be more therapeutic than morphine.

Doctor D always enjoys hearing your stories and perspectives in the comments.

What are your experiences with doctors causing pain? What was done well? What was handled wrong? Have you ever felt a doctor was being intentionally cruel in a painful procedure?

Pills and Suspicions (Controlled Drugs)

A question Doctor D gets asked a lot:

Why are doctors so stingy with medicines that make me feel better?

Yeah, I have to admit doctors are totally difficult when it comes to certain pain and anxiety medicines. You show up in a doctor's office and request a medicine that has worked for you in the past and suddenly you get read the riot act and treated like a criminal. Weird isn't it?

Doctor D admits that he does this too. It's not because he doesn't care. D went into medicine because he cares. He has just learned to be cautious over the years.

These medicines are very powerful. Some people really do require them when other meds just won't work, but they can also get you high or even make you stop breathing. Every MD has seen these medicines destroy people's lives.

Heath Ledger and Michael Jackson kicked the bucket because of medicines like this, and Doctor D can guess what's probably gonna show up in Brittney Murphy's toxicology report.

But forget about celebrities, these medicines harm regular folks every day. There was the young mother that broke down in Doctor D's office saying she can't make it though a day without buying pills off the street, and the high school freshman that died of an overdose after spending her birthday money on pills to party with her friends. You don't forget patients like those.

It's one thing to see somebody hopelessly addicted to alcohol or die of a cocaine overdose. It is really sad.

But with prescription drugs it's different. I'm the supplier of drugs that are killing local kids and ruining families. You can see why I get nervous about every prescription for a controlled substance I write.

I totally want to help people in pain. Unfortunately that compassion makes me a sucker for manipulative people. I wish that I could believe what every patient says they need, but if I gave everything that was requested of me I would most certainly end up killing someone. Therefore Doctor D uses very conservative prescribing practices to make sure he has obvious medical reasons for every prescription he writes.

This sucks for patients with legitimate needs who use these medicines responsibly. The behavior of the bad apples causes good people with real needs to be treated like criminals.

Sorry! Doctors hate to act like cops, too, but the very serious drug problem puts us all in positions we don't like.

Please be patient with us. Doctors really want to help people, so if you are honest, patient, straightforward, and work with the system you will usually be taken care of. But doctors are edgy about these meds so please don't react with anger or game the system. I understand your frustration, but acting out won't help you. It will send up red flags that may get you banned from every getting strong medicines.

What do you think? Are doctors too hard on patients who need controlled drugs, or do you find the restrictions reasonable? Have you ever been mistreated when you asked for medicines? ...or known someone who was addicted to pills? Doctor D would love to hear your thoughts in the comments!

The Purpose of Pain (Why the Painscale Doesn't Work)

Last week I answered a question by explaining the trouble with how doctors interpret your painscale. Doctor D confessed that he doesn't like the painscale at all. Today I will tell you why even if used perfectly the painscale still just won't work:

The 1 to 10 painscale ignores the way the human body uses pain in the first place. The scale assumes that we can observe the sensation of pain and then compare and contrast it to other pains we know or imagine. Your analysis of pain is supposed to produce a number that doctors and researchers can use to make calculations. There are a lot of things the human mind does a great job analyzing, but pain isn't one of them.

The purpose of pain is to get your attention. Pain is your body screaming, “Something is wrong!” It doesn't take much pain to completely capture your mind's focus. Pain functions as a useful warning system. It tells you to pull your hand out of the fire or not to walk on that broken ankle. Your brain pays close attention to pain and obeys its commands. So what if being burned at the stake is a 10 and your broken leg is only a 7? Trust me the broken leg will get and keep your attention till the bone is set.

Asking the mind to quantify pain is like asking it to assign a number to love or fear. It simply doesn't work that way. This is the reason that so many patient's say their pain is 10 of 10. No they aren't feeling the worst imaginable pain, but the pain does have their full attention.

Doctors want hard facts from painscales. We scoff at patients who say things like, “My pain is still a 10, but it's better than the 10 I felt before,” or “It's a 10, but not as bad as when I delivered my baby!” We demand hard facts and we get irritated when patients give us flawed and subjective data.

The worst pain Doctor D ever felt was probably about a 6, but subjectively it was miserable enough to get my attention and keep me from hitting my finger with the hammer ever again. We should listen to patients' descriptions of pain and seek to relieve it, but we shouldn't demand they to turn their pain into a number. The human experience of pain just doesn't work that way!

Doctor D is always talking about the natural purpose of things like hunger, laziness, anxiety, and pain. His theory is that understanding the natural functions of the feelings helps us respond when these feelings give us trouble. What do you think? Would understanding the useful warning function of pain help those of you that suffer from pain problems?

Never Say 10! (How Doctors Interpret the Painscale)

A question from a reader:

My doctors all use that 1 to 10 pain scale. Could you explain why? It seems so crude. Is a doctor equating my "6" to someone else's "6"? I always figure that "10" should be left for when a wolverine is gnawing off my face while my lower extremities are on fire, but other people may use "10" more casually.

The painscale is one of Doctor D's biggest pet peeves! The “powers that be” in medicine prefer looking at data rather than real people. And by data I mean numbers. Academics, researchers, and bureaucrats love numbers! They add them up to make treatment or policy recommendations. I often appreciate these bean counters that help clinical doctors, but it gets problematic when we try to pull hard numbers out of subjective human experience.

Medical people are now all commanded to record a numerical pain level on each patient. 0 means no pain at all and 10 means the greatest pain humanly possible (such as fiery wolverines.) They tell us to record this number like a vital sign, but while a fever of 102° F is the same temperature in every person, 8/10 pain may be a very different experience for different people. And lots of hospitals are making policies like "No one can be sent home from the ER until their pain is less than a 5."

Doctor D sees lots of people every day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale. Doctor D suspects that some people might be exaggerating a bit when they answer “Ten” while texting and complaining about the lack of pretzels in the waiting room vending machine. I've seen a few people I was certain had 10 of 10 pain and it seems like disrespect to those people to classify bruises and upset stomachs in the same category. But pain is subjective, so who is to say a mildly sprained ankle isn't more horrific to this individual than the fires of Hell?

Obviously there are some addicts who lie about pain to get drugs, but I think more commonly people say 10 because they lack the imagination to conceptualize greater pains or they hope that a 10 will cause doctors and nurses to take their discomfort more seriously.

While the painscale is supposed to empower patients to define their own pain, it ends up tricking people into an answer that gets them nowhere. Anyone who says 10, who doctors don't think looks like a 10, is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F.

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.” Your doctor will recognize that if you understand how bad 10 is then your 7 is really horrible, so your doctor will work hard to alleviate your misery.

But trust me, never say 10! Even if it you had to set your self on fire to get the wolverines to stop eating you say 9. Ten on the painscale is a Catch-22; answer “10” and the doctor immediately thinks you are about a level 4.

What is the worst pain you every felt? Doctor D's worst pain of his life was about a 6. Did a doctor believe you went you complained of the pain? Do you think the painscale was helpful for getting your pain treated?

Follow-up post: The Purpose Of Pain: Why the painscale doesn't work