Skip to comments.End-of-life care: Pain control carries risk of being called a killer
Posted on 04/29/2012 4:46:29 PM PDT by Dr. Brian Kopp
By Kevin B. O'Reilly, amednews staff. Posted April 16, 2012.
Three decades after hospice emerged as the standard of care for terminally ill patients, the end-of-life treatments that palliative medicine physicians provide are frequently referred to as murder, euthanasia and killing.
More than half of hospice and palliative medicine physicians say patients, family members and even other health professionals have used those terms to describe care they recommended or implemented within the last five years, according to a nationwide survey of 663 palliative care doctors in the March Journal of Palliative Medicine.
Common palliative care treatments such as the use of opiates, sedatives and barbiturates to control pain and other symptoms are enough to draw accusations of murder and euthanasia, the study said. The troubling survey results come nearly six years after the American Board of Medical Specialties approved the hospice and palliative medicine subspecialty certification, and 30 years after the creation of the Medicare hospice benefit.
Nearly 1.6 million Americans received hospice care in 2010, up from about 25,000 in 1982, said the National Hospice and Palliative Care Organization. And palliative medicine has made its presence felt in hospitals, with 85% of 300-plus bed hospitals boasting palliative care teams, according to the New York City-based Center to Advance Palliative Care.
Yet the growing use of hospice and palliative care is creating more opportunities for misunderstandings, experts said. New developments in end-of-life care aggressive pain and symptom management (even to the point of unconsciousness), along with a greater willingness to withdraw advanced, life-sustaining treatments such as mechanical ventilation, dialysis, and artificial hydration and nutrition still strike many people as wrong.
The surveys findings highlight the gap between the well-established ethical and legal boundaries that demarcate acceptable end-of-life care and the understanding of patients, families and other members of the health care team, experts said.
Its alarming, said H. Rex Greene, MD, a practicing oncologist and palliative medicine specialist in Lima, Ohio. To accuse legitimate palliative care physicians of euthanasia and murder is a horrible mischaracterization of whats done to relieve symptoms at the end of life.
Twenty-five of the physicians surveyed said they were formally investigated by their institutions, state medical boards or prosecutors, with about half of those cases related to the use of opiates to manage dying patients pain. Nearly a quarter of the investigations were related to the use of palliative and sedative medications when discontinuing mechanical ventilation. An additional 8% of the investigations were for palliative sedation the practice of sedating to unconsciousness terminally ill patients who have severe, refractory pain.
All of these treatments when conducted with the consent of patients or surrogate decision-makers and implemented with the intent of alleviating pain or other symptoms in terminally ill patients are broadly accepted as ethically and legally appropriate, even if they have the secondary effect of speeding the dying process.
Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care, says the American Medical Association Code of Medical Ethics. This includes providing effective palliative treatment even though it may foreseeably hasten death.
Although none of the physicians investigated was found at fault, most reported worry, anger, anxiety, isolation, depression and difficulty working as a result of the ordeal. Euthanasia accusations whether voiced in the patients room or in the courtroom could have a chilling effect on physicians treatment of dying patients symptoms, said John G. Carney, CEO of the Center for Practical Bioethics, a Kansas City, Mo., think tank that works to improve end-of-life care.
Im deeply concerned that if we dont pay attention to the message in this article, we are going to be dealing with this issue of physicians who are reluctant to do what they know to be right because they are afraid of what people will say or that someones going to investigate, said Carney, a former hospice executive director.
The distinction between aggressive pain control or the withdrawal of life-sustaining treatments and euthanasia is still lost on many patients and families, physicians said.
These misperceptions are really pretty hard-wired and difficult to eliminate, said David Casarett, MD, chief medical officer of the University of Pennsylvania Health Systems hospice program in the Philadelphia area. Believe me, if there were an easy way to communicate these issues, then we wouldnt have highly qualified physicians called before medical boards to explain their actions. To some degree, this is a cultural change. Were far ahead of where we used to be 20 years ago. On the other hand, we cant wait another 20 years for these things to go away.
Doctors who care care for dying patients should take into account the publics lagging understanding of end-of-life treatments, take time to explain their intricacies and make use of ethics consultation services, said Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.
When I started training in this area 30 years ago, it was a rare thing to remove a feeding tube because nobody lived long enough to get that sick, said Dr. Storey, who practices outpatient palliative care in Boulder, Colo. Now many people are living until they are extremely debilitated on life support. And if you work in an ICU, you want to sit down and take time and talk to people, but when its happening every day, its hard to remember sometimes that the public didnt get informed that things have changed.
Yet confusion about end-of-life care is not limited to patients and families. A majority of the doctors surveyed said that other physicians or health professionals at times characterized their palliative care treatments as murder, euthanasia or killing.
As end-of-life care has become more specialized, the gap between what palliative care specialists see as appropriate care and other doctors perception of those treatments has grown, physicians said.
Those of us in palliative care and hospice dont think that much about putting a patient on a large dose of an opioid like morphine. We do it all the time, and we see patients do well, said Dr. Casarett, associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania.
Recently, a patient dying of cancer enrolled in Dr. Casaretts hospice program after deciding to stop chemotherapy treatment. The oncologist caring for the patient was upset and talked with Dr. Casarett, saying that the combination of stopping curative treatment and using high doses of opiates was wrong.
He said, We might as well just be walking away, and we might as well just shoot [the patient] now, Dr. Casarett recalled.
It still stings to hear that, he said. But Dr. Casarett takes solace in knowing that he is doing right by his patients. I tell other physicians that this is the standard of care, and that these sorts of medications and interventions are safe and effective.
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More than half of palliative care doctors have been told the care they recommended or provided is murder, euthanasia or killing. The frequency of such accusations varies by source and at times includes other doctors.
Patients friend or relative: 59%
Physicians friend or relative: 25%
Another physician: 56%
Another health professional: 57%
Source: Prevalence of Formal Accusations of Murder and Euthanasia against Physicians, Journal of Palliative Medicine, March (ncbi.nlm.nih.gov/pubmed/22401355/)
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I’m sorry for your recent loss. Your experience is very similar to ours when we lost my MIL 2 years ago. She had Parkinson’s. Her doctor suggested Hospice about 5 months before she passed, not to shorten her life, but because there were additional benefits she received that helped her live longer. The Hospice nurses did daily massages, helped feed her when she could no longer lift a spoon, got her an inflatable air mattress that was on a timer, which inflated different sections in sequence to stop bed sores from forming. She did well for a few months, but at the end, we had been warned she would no longer be able to swallow, and that’s what happened. Her DNR read no feeding tubes, no feeding through IV, so we knew it was time. The nurses showed us how to use the mouth swabs, but we couldn’t even use ice chips for fear she would aspirate and start choking, not even able to cough. They gave her minimal amounts of morphine, as she was unable to swallow, just what little could be dissolved under the tongue, nothing by IV or injection. She was with us another 5 days, before she passed. She slept a lot, but when she was awake, her eyes were clear, and she’d listen to Hubby and me talk to her. Not once did I hear anyone from Hospice suggest she should be given more morphine or other meds to speed the process up.
It saddens me that others have had more traumatic experiences, especially during such trying times in their lives.
So you are fixing to open an assisted living center and Hospice? I think that is fantastic! Your in for a lot of hard work and virtually no time off but do what’s in your heart.
I’m assuming you’ll be following Medicare guidelines but will you be able to run it without taking Medicare/ Medicaid pts?
I worked for a not for Hospice once but they still received Medicare benefits. Wasn’t sure how that worked.
So the guy who was nurse for years witnessed this li.d of abuse towards pts? I can’t imagine it. Maybe I’ve been fortunate being in the South. The rare times I’ve dealt with abuse was neglect by families.
Absolutely you always find out the pts religious beliefs at the beginning of care. My point was that people, if they are believers, make their peace with God while they’re still lucid and pain control does not effect that.
This will just be home hospice care, not inpatient or assisted living. We will contract with local assisted living and nursing homes as well as the local hospital for respite care. Someday is we are successful, we’ll build a free standing hospice unit.
We will be a participating provider with Medicare and all the major insurances. Non profit or for profit status does not affect Medicare or insurance participation.
If your loved one has COPD, is 83 and is being admitted to the hospital for the 4th time in 6 months, should heroic life-saving measures be considered appropriate or simply delaying the inevitable?
Finally, there are studies that show patients who are on hospice actually live longer than patients with similar prognoses not on hospice.
Lots of uninformed nonsense in this thread.
There are plenty of people posting their anecdotal experience on this thread, Dr. Kropp among them. I’ll not you did not denote his anecdotal posts as such. Even it up and you’ll have more credibility.
There are plenty of people posting their anecdotal experience on this thread, Dr. Kropp among them. I’ll not you did not denote his anecdotal posts as such. Even it up and you’ll have more credibility.
Thank you for your opinion.
You have been misinformed by someone. Hospice has no deadline, only requalification points. If a patient is still terminal at the qualification date, hospice care continues.
You are quite welcome.
I have seen doctors argue patients are not hospice appropriate and refuse to sign a hospice order only to have the patient die without hospice care less than 24 hours later. Additionally, even when the doctors know the patient is terminal, they frequently do not wish to have the conversation with the patient and simply wait for a hospital case manager to talk the family or patient into it after multiple hospitalizations in a brief period of time.
So had did that incentivized hospice thing work out for Terri Schiavo?
I don't think you've had experiences which comprise a representative sampling of hospice companies. JMO
My dad is 76, smoked for 40 years, has COPD, and is on oxygen 24/7. He had 7 admissions in 9 months, and the doctors told him he had only 3 to 6 months to live.
That was twelve months ago.
And he has had no admissions since, and is in the process or retaking his driver's license, which he let lapse when the doctors told him he was "terminal."
I get real jaundiced towards people who throw around charges over the appropriateness of "heroic" life saving measures and "simply delaying the inevitable." You know what I'm saying?
Where did I argue that?
On the other hand, are you going to seriously argue that peoples lives are not being ended prematurely in hospice and palliative care by premature withdrawal of water and food, the discomfort of which is subsequently masked with morphine and/or haldol and/or benzos?
The problem with Terri Schiavo’s end of life was the interference by lawyers and judges, not hospice. Judges can’t write medical orders, but they can - and did - order Sheriffs’ deputies to restrain nurses and doctors from providing care.
I was trying to find what the medicare payment for hospice care policies were for 2001, which is when my friend's husband utilized in home hospice care.
Jim, thank you for your action dealing with this euthanasia issue.
I lost my mother due to withholding of food and water that I could not stop due to issues whose details I'm not going to discuss publicly on the internet. Much has already been said on this thread with which I fully agree, and there's no need to repeat my own story which is all too similar.
I learned two things from that incident.
One was the importance of getting a good lawyer who shares pro-life convictions and understands the potential loopholes which doctors can exploit in “living wills,” and even then, reading every single word of anything that gets signed.
The other was a greatly increased respect for the role of Roman Catholic hospitals in end-of-life issues. My mother trusted her once-evangelical denomination, and when she woke up from a coma, without understanding what would happen, left the intensive care unit of a Roman Catholic hospital and fell into the hands of a hospice founded by one of the worst liberal professors at the official college of her denomination, a man whose evil theology I had fought against for nearly a decade. She thought she was going into a nursing home with care comparable to the hospital if needed, but once she lost consciousness, she was starved to death and nothing could be done because of what she had signed, despite very clear verbal statements made in the presence of several witnesses including me and an elder’s wife.
Not going to say more details here, Jim, but I want to commend you for what you wrote. Theology has consequences, and when it comes to abortion and euthanasia, those consequences can easily be fatal.
We simply cannot trust our doctors or our lawyers to have our best interests at heart; even if they mean well, they don't necessarily share our values, and lawyers may not understand loopholes in areas outside their ordinary scope of professional practice. The documents we sign could be our own death warrants if we're not careful.
For those of you who are Roman Catholics on this thread — keep demanding that your church enforce its doctrine at your hospitals. I am confessionally required to believe some very strong things about the Roman Catholic Church, just as the Council of Trent requires you to believe some very strong things about Protestants, but abortion and euthanasia are good examples of where conservative Roman Catholics and evangelical Protestants can and should work together. At least for now, we can typically trust Roman Catholic hospitals and unfortunately I cannot always say that about Protestant hospitals and nursing homes, even if they're supposedly evangelical.
Death is not unChristian. And facing it without fear is completely appropriate, religiously and psychologically. Putting 80 year olds on vents 4 or 5 times doesn't make us more of a culture of life.
I share your concern over the tendencies towards euthanasia in our elite's teachings and philosophies. I do not find them practiced with any sort of frequency in my area. I find the opposite. Oncologists doing chemo up to the patient's last breath. Internists hoping the cardiologist tells the patient there is no more that they can do for their CHF while the cardiologist believes that's the internists' job. Ditto for COPD and the pulms. And it is precisely of the secularity of our culture, not the religiousness, that they fear having "the talk" with their patients.
The average stay on hospice is around a week.
For whatever it's worth, Lil Flower, my mother is an additional example of a case where a hospice said they could not maintain a feeding tube. You say the hospice should immediately be reported. That's quite interesting, and I sure wish I'd known I could do that. I've been pro-life for well over two decades, but my focus has always been on the abortion issue, not end-of-life issues, and your post and that of Dr. Kopp have helped me a great deal in understanding things that I knew were wrong years ago but which I could not effectively argue against from a legal perspective.
I'm omitting some key details here for personal reasons, but am including what is legally and ethically relevant for making end-of-life decisions.
My mother died in her mid-sixties. Her history was that she had been a three-pack-per-day smoker for most of her life, resulting in COPD. She reported having completely stopped smoking a few years before her death, but years of heavy smoking had already done permanent damage. Some of that damage included severe low blood pressure causing weakness in her legs and arms that prevented her from walking, and eventually got so bad that she could no longer grip objects with her hands. The cause of this weakness was misdiagnosed and not recognized as being due to low blood pressure for an extended period, and that resulted in inadequate food and water since she couldn't eat by herself, leading to a declining health spiral with repeated emergency room visits due to fainting and other loss of consciousness until the COPD was finally properly diagnosed. Because she could not eat properly due to lack of ability to handle silverware at home, she suffered from extreme weight loss over a period of perhaps half a year, eventually went into a more serious coma, and was transported to an emergency room where she was expected to die. I was called from halfway across the country to participate in a family decision on withdrawing life support; when I discovered that meant withholding food and water, I absolutely refused, and fortunately she was in the intensive care unit of a Roman Catholic hospital where the staff understood my objections and called in additional staff members to try to deal with the situation.
During the argument over whether to remove her feeding tube, my mother continued to receive necessary nutrition and hydration to the point that she unexpectedly recovered, became fully conscious, and became very upset by what was happening. She ended up living several more weeks, but knew she'd probably die in the relatively near future, so rather than dying in a hospital, she wanted to go to a nursing home associated with her denomination, which was once evangelical but was quickly lapsing into liberalism.
The end result is she was placed into a hospice associated with the nursing home rather than the nursing home itself, lapsed into unconsciousness over the weekend when she couldn't eat or drink enough to sustain herself, and I discovered to my horror that she could not be put back on the feeding tube because of the institution's rules on the matter which, among other things, meant she couldn't be transferred to the part of the nursing home where feeding tubes could be restored.
I could do nothing under the circumstances because of documents my mother had signed much earlier in her living will which, once she woke up out of her coma, she clearly and repeatedly contradicted verbally in my presence and that of several witnesses. Once she lapsed back into unconsciousness, I could do nothing because of the living will.
I sure wish I had known at the time that I could report the hospice for what happened with her feeding tube. I have absolutely no doubt in my mind that my mother agreed to leave the hospital thinking she could be put back on a feeding tube if necessary, but once she lapsed into unconsciousness because she couldn't control her hands well enough to eat and drink by mouth, there was nothing more I could do.
Bottom line: people who say these things don't happen are simply wrong. Get your legal documents governing medical care written by a lawyer who is pro-life and understands the loopholes. If you can, choose a doctor, a hospital, and a nursing home that share your values. If you can't, make absolutely certain you have someone to advocate for you and make decisions on your behalf who understands what you want, and has the legal authority to follow your wishes.
The consequences of failure in situations like this could be fatal.
This discussion has been provided much enlightening information. I also appreciate those who have bravely shared their experiences on both sides. Thank you.
I wish that I, too, could relay a positive hospice experience, but unfortunately I can’t. Neither as a fill-in hospice caregiver (via a visiting burse agency), nor as a friend and family member of two patients in hospice care.
In your humble opinion, I'm sure.
I may not agree with your humble opinion however. I am in a geriatric specialty too though it's far from pulmonology or internal medicine. Nonetheless treating on average 80 geriatric patients a week I know better than to believe my dad's case is "the exception."
You work as a fill-in for a hospice company and you’ve had no positive experiences? It seems odd that your continue to work with them.
So what percentage of patients diagnosed as terminal do not die within 6 months?
And what percentage of patients in a similar condition as your father’s condition make it another 6 months?
Or they have an agenda.
What’s your agenda? (see my last post. )
My “agenda” is presenting clear information on hospice.
I sought a nurse on the floor to discuss this with....and asked she go off the record. She of course hesitated but eventually understood. As I had suspected the medication was indeed too strong and the cause of her problem. I asked the nurse if she would please ask the Dr. to decrease it, even if it might mean she'd have some discomfort. I would learn he did just that...and the hallucinations stopped and she was in no discomfort at all for lessening it.
The problem as I saw this was the family member was far too dependent on the Doctors..and my mother for that matter. As the nurse explained to me the Doctors see the patient for only a ‘very short’ time....it's ‘the nurses’ who care for them who ‘see’ the progress or the opposite throughout the day. Having this information I spoke often with the nurses who let me know the real comfort level of my mother....and I went thru them.. who then went to the Dr. if I thought something might be done differently.
Additionally my daughter in-law is an outstanding ER trauma nurse as well as worked on the floors and headed them. She has said the same thing.....get to know the nurses even though they change shifts....and it helps because you can then structure your visits when you know a particular one is on shift. I did and for that my mom was comfortable until time to go with the Lord.
I understand, from a religious perspective, that when the "body" is dying the "soul" is preparing for flight, if you will, and has no need for food or water. That the patient has a sense about this and why they request less and less water and don't want either food or drink.
I saw this occcur with my mother, who was a nurses aid for many years, and she knew how the nails start to change color as the body dies....I saw her checking hers often the last two weeks. In the last two or three days she would only ask for ice chips...to wet her lip... and then not even that.
So I have to agree fully with cancer patients when in the last mile there is no need...they're getting ready to go to their heavenly home.
Yep..that's exactly what my mom did...I was shocked when I got there to visit and she was chit-chatting and laughing with family members..sitting up in bed no less...but the nurse explained to me, when I inquired about this happening, that it is very common.
To me it just seemd like God was giving the family a last 'family moment' before she left..and she did die two days later.
trisham said:”Anecdotal evidence is simply not very reliable”
Anecdotal evidence is one thing but lil Flower was speaking of her personal experiences that she had to document as part of being a case manager for a Hospice company...documentation that could be used against her if not properly followed thru.
The legal premise when used in court cases against nurses is “If it wasn’t documented, it wasn’t done.”
Michael Mathis RN(26 years and counting)
What conclusions have you come to about hospice based upon your experience and this thread, specifically?
My religious beliefs are different from yours. Your statement would nullify any conversation with a good Baptist or an atheist.
You've never read about or don't believe in deathbed conversions such as in Luke 23?
40 But the other criminal rebuked him. Dont you fear God, he said, since you are under the same sentence? 41 We are punished justly, for we are getting what our deeds deserve. But this man has done nothing wrong. 42 Then he said, Jesus, remember me when you come into your kingdom.[d] 43 Jesus answered him, Truly I tell you, today you will be with me in paradise.How could Dismas have converted in the midst of the agony of crucifixion if your first statement is true?
If your first statement is false, how many deathbed conversions are thwarted by terminal sedation?
Between 4 traumatizing experiences with 3 different hospice care providers & an experimental cancer treatment program, (the details of which I will not share), the horror of the Terry Schaivo incident, and the "peek behind the curtain" at who is funding the "evolution" of hospice care, I personally have a very negative opinion of hospice. However, out of respect for others here who are dealing with the raw grief of recent loss, I'm not going to salt their wounds by enumerating my grievances. My own grief is too fresh for me to be objective. However, I'm sincerely glad for those who have had good hospice experiences or who have provided exemplary hospice care.
We know that none of the men on the cross that morning were in so much pain that they were unable to worship. And One had no need for conversion. (And who’s to say that the man who asked Jesus to remember him had not been converted and even baptized before. That’s the argument of many Church of Christ preachers.)
Nevertheless, different people have different pain and even different pain tolerances.
My own mother, on the way into the hospital for her last admission, chirped up at admissions with, “I have the best insurance there is: Jesus Christ!” On the day she died, the sheets hurt her legs, a breeze caused her to cry out in pain and we couldn’t get her pain under control at all, even with doses that should have knocked her out. In addition to (probably because of) paraneoplastic neuropathies, she had a series of lacunar infarcts that made her brain CT look like Swiss cheese. She was barely thinking and talking nonsense.
(She died of another stroke while in the MRI machine, with me at her head, singing to her. Even though our family had made our wishes that she not be resuscitated, the neurologist wanted this one last test, the paper work wasn’t finished, the hospitalist hadn’t signed the order and I had to interfere to prevent a full code.)
Perhaps if you’d studied in San Antonio, you’d have more first-hand experience. The Family Medicine residency program where I trained took the Podiatry residents for a few months of training on the in patient medicine service.
Thanks for sharing this.
And Yes, San Antonio is a highly regarded Podiatry residency in our specialty, for good reason.
I stayed close to home and completed my residency locally.
>If your first statement is false, how many deathbed conversions are thwarted by terminal sedation?<
Why are you having difficulty understanding that giving a person morphine at the end of their life is not “terminal sedation?” Why do you want people to hurt and be uncomfortable when they don’t have to be? I find those who are so opposed to pain meds haven’t had enough pain to need them, yet.
Morphine is not some boogy man drug. It is very effective at quick pain relief, but it is also short lived. Within 2-3 hrs it has worn off and you have to administer it again.
My husband worked, drove, etc. for 8 months taking a higher dose than average of oxycontin. He had a broken hip due to the disease avascular necrosis and due to family issues had to postpone his surgery. I think its cruel not to at least try to relieve someones suffering just because a family member or caretaker has some unfounded fear of pain meds. Do you know how many times I’ve been told by family members they don’t want their dying loved one to have a narcotic for pain because they fear their loved one will become addicted to it! It leaves me scratching my head but some people really have a hard time dealing with death so they cling to ideas that somehow help them avoid the elephant in the room: that their loved one is dying.
I assure you, I know the difference between proper pain control and terminal sedation. Morphine can be used for proper pain control. It can be and is used in conjunction with other meds for terminal sedation, and it can be and is used to mask the symptoms of pain and discomfort when water and food are prematurely withdrawn to bring about a premature death.
Why are you having difficulty grasping that these latter incidents are well documented and going on in segments of the hospice and palliative care industry?
Why do you want people to hurt and be uncomfortable when they dont have to be?
Where have I said I want people to hurt and be uncomfortable? That is the false rhetoric of those who are trying to push the euthanasia agenda, if you weren't aware. Careful falsely employing their rhetoric. Folks might start to question your motives when you employ the tactics of the euthanasia promoters.
>Careful falsely employing their rhetoric. Folks might start to question your motives when you employ the tactics of the euthanasia promoters.<
Well I don’t give a shit what other people think of me. I also don’t give a shit what tactics euthanasia promoters use , either. I’m just telling you that you can use morphine, ativan, and other medications to control restlessness and pain without it becoming terminal. However, keep in mind that the person in question is in fact dying. And I really think some people are so frightened by that fact, that they grasp at straws to make some sense of it all.
Just so long as they really are in the process of dying, we’re in agreement.
The problem we’re talking about in this thread is when it’s employed to facilitate a premature death.
I don’t think you grasp or admit that this is going on, or how prevalent it is becoming.
You’re right I cannot grasp it. You have only heard these things happen. You have personally never seen it yourself. I have first hand knowledge and experience in Hospice and have never seen, nor heard of from other colleagues, what is claimed here. I will go with what my own eyes have seen vs something you have heard second hand.
If I’m shown otherwise with facts, then I will certainly acknowledge it.
I did mention earlier in this thread that I can certainly picture this evil administration turning Hospice into something evil, because they are evil.
Have you even read this thread?
I've sat down and talked to Terri Schiavo's brother, sister, and mom. Their foundation fields calls about cases like the ones I'm describing every day. So does Ron Panzer of the Hospice Patients Alliance, who I talk to on a regular basis. Are you calling them liars?
I'm glad you had the opportunity to work in a good hospice where these things apparently weren't happening.
But you are in denial about the reality going on elsewhere in some segments of the hospice and palliative care industry.
How bizarre that that the medical community which espouses euthanasia resists giving enough pain medication to make someone comfortable because it might kill them.
I guess by denying the pain medication, they think they can build a better case for euthanasia so people don’t suffer unnecessarily.