Schiavo Foundation Urges Wife of Disabled Jacksonville Man to Err on the Side of Life

Besides killing pain, I honestly don't know what morphine does to the body. The drugs they gave to dehydrate was lasix.

You'll feel better soon enough.

I don't feel bad..never did...never will.

1. To kill (another human) unlawfully.
2. To kill brutally or inhumanly.
3. To put an end to; destroy: murdered their chances.
4. To spoil by ineptness; mutilate: a speech that murdered the English language.

Its also to kill inhumanely. I consider dehydration and starvation to be INHUMANE, especially when the person wasn't dying prior to that!

Lots of morphine can put you to sleep, PERMANENTLY!

Yes, that too. I don't understand your point. I shouldn't have let them give him large dosages of morphine?

I totally agree. We need to concentrate on how we are going to stop these outrages and just ignore the disruptors.

I think they get kicks out of being perverse.

I seriously haven't met one of the disruptors that has ever said anything pertinent, educational, instructional, or worth reading so I generally ignore their posts. They just attack those who abhor murder of innocents.

Did they put down the cause of death was too much morphine? I doubt it. Morphine, the murder weapon of choice.

My mother in law was in a restaurant when news of Terri's death was broadcast.

The restaurant workers had all their Tv's on full blast listening to what was going on.

They all started talking about how wrong it was to have murdered Terri. The whole restaurant (workers and patrons) exploded in a chorus of outrage at that injustice!

Most Americans are with us.

So, you are saying that I shouldn't have let them give him morphine.

Just pointing out what killed him. Too much morphine. But, some people have no regard for life, including the unborn.

You'd rather people suffer in pain indefinitely?

Did your father have congestive heart failure or pulmonary problems? My mother-in-law was getting lasix in hospice because she was retaining fluid, exacerbating the heart failure and pulmonary problems. Lasix isn't given with the express purpose of dehydrating someone to death, but with helping the patient get rid of excess fluid. It eases the cario-pulmonary congestion. And morphine drips are very common for patients with end stage cancer, and they do get turned up at the end. I don't think screaming in agony would be a particularly pleasant way to die.

You've never seen someone you love be in so much pain and beg you to help them, have you?

Apparently there are some here who do.

Yeah, I have, and the doctors got her family to ok an overdose of morphine for her, too. Her daughter still feels that was wrong, but she was outvoted.

End-of-Life Decisions
B. Lehrer, K. Prager, S. Mayer, J. Quinlan, T. Frymer-Kensky

Columbia University

The panelists debate the merits of living wills and whether doctors or patients' families should have the final say in making end-of-life decisions for patients who can no longer communicate.

Session 1

How Should People Die?

Brian Lehrer
Hello, I'm Brian Lehrer, host of WNYC-AM 820's "On the Line" in New York. We're here at Columbia University for Fathom, to discuss a fundamental question confronting society today: How should we die? Here at the dawn of the twenty-first century, new technology and greater longevity together are enabling human beings to have more of a role in choosing the way we die. However common, though, end-of-life issues are among the most confusing ethical challenges confronting many families, doctors and lawmakers. In this Fathom Forum we will ask where the line is between refusing heroic efforts to prolong people's lives, withholding routine medical treatment, and actually killing people because it's what they, their families, their doctors, the state, even an insurance company might choose.

With me today are Dr. Kenneth Prager, a pulmonologist and the chairman of the Medical Ethics Committee at Columbia-Presbyterian Medical Center; Dr. Stephan Mayer, a neurologist and the director of the Neurological Intensive Care Unit at Columbia-Presbyterian Medical Center; Julia Quinlan, co-founder of the Karen Ann Quinlan Hospice and the mother of Karen Ann Quinlan, a young woman whose name has become a byword for the legal and ethical dilemmas surrounding the treatment of terminally ill patients; and Tikva Frymer-Kensky, a professor at the Divinity School and the Law School at the University of Chicago and an expert in religious ethics, biblical studies, Jewish studies and women's studies. Let's start with you, Stephan Mayer. What is the problem, if indeed there is a problem, in end-of-life issues today?

Stephan Mayer
I think indeed there is a problem, and it begins with the fact that if you ask most people, "How would you like to die? How would you imagine this happening?" most people would say, "Oh, I think I'd like to be at home, in a state of peace and comfort surrounded by family members in a familiar environment." But the reality is that most Americans end up dying in intensive care units. Frequently, in that step toward the end, there are interventions, people are put on life support machines, and these things are done sometimes when it's clear it's not going to change the outcome. It can create pain and suffering, and worst of all it happens when people have already made it relatively clear that they would never want this to happen. It's well known from large clinical studies that many people at the end of life receive high-tech care that they never would have wanted, and I think that the main problem is that sometimes what individuals say they would want is, in the practical reality, not what they're getting when crunch time comes.

Brian Lehrer
Why don't they get what they want?

Stephan Mayer
A lot of reasons. There are a lot of societal and cultural barriers toward letting go, giving up, letting people go on their own terms.

Julia Quinlan
I think one of the reasons is that we don't listen to the patient. We just want to extend that patient's life without input from the patient as to how he would like to die and the treatment, or non-treatment, that he would want to receive.

Tikva Frymer-Kensky
I think there is another aspect to this issue, which is that we have drawn a distinction between not starting a treatment, withholding treatment and withdrawing it once it's begun. People who have begun life support where there's still hope that it could be of benefit for a patient feel that they don't know how to withdraw it, how to pull the plug--that somehow treatment is a problem, that somehow it's wrong. We haven't really made a distinction between using heroic efforts when they can help and taking them back when they're no more than palliatives for our own conscience.

Brian Lehrer
What is the distinction? Can you define it?

Tikva Frymer-Kensky
I think when it becomes clear that there is no benefit to the patient--benefit meaning either hope for cure or a relief for suffering or a meaningful addition to life, like dialysis, where there's not going to be a cure but there's going to be an extension of real life. So when there is any of those three, then there's a good reason to do everything we can to benefit the patient. But when that passes, we have to be able to reach a decision that death is taking over, and not have this image of combat (which we do), that we are fighting all the time.

Brian Lehrer
Dr. Prager, are those the kinds of questions you ask at the Medical Ethics Committee?

Kenneth Prager
These are some of the issues that we deal with. But, if I may, I'd like to go off a little bit from what is very often the party line, if I may use the term, to the problem of end-of-life issues in America. I think that doctors get a bad rap more often than is appropriate, at least in my experience. Part of the problem is that our own societal values and our own education have not kept up with the technology. I think, as Stephan said, yes, it's true that everybody would like to die peacefully, but the question is, when is it time to die? There's always the hope that something else may be done that may help the patient, so we don't know exactly when we've crossed the line between prolonging dying and prolonging life. That's number one.

Number two, I think that there is still a problem with people elucidating their desires. People still have a lot of hang-ups about thinking about their own death; they have a fuzzy idea that they don't want to be a vegetable on a respirator. It's not very helpful, though, to physicians when they're dealing with complicated issues at the end of life. All of what has been said is true, but I think that there's got to be more education of the public. There has to be greater interaction indeed between patients and their physicians. As I say, I don't think we're keeping up with the technology; it's just exploding, and we're left behind to have to catch up.

Brian Lehrer
Dr. Mayer, is it your experience that patients are not communicating and that living wills or advance directives, as they're called, for when they would like treatment withheld don't supply specific enough information to help you in the situations you actually see?

Stephan Mayer

I do neurological intensive care. The joke is that if you're my patient it's the worst thing that's ever happened to you. You've had some kind of devastating brain hemorrhage or stroke or traumatic injury to the brain. They're the cases where you know you can do a lot to pull somebody through. They can recover. But then there are the cases where there is just going to be profound and permanent and serious brain damage or death--take your pick. On these most critical types of cases, only 15 percent of patients have some kind of living will or various directives or health-care proxy; the majority don't. A large majority of these other individuals have at previous times with their family expressed their wishes to some extent or another. But I do think that it really is a dialogue between the doctor and the family and in this setting the patient is off the table now. He can't participate. Everything that's happening is happening to him, but he's not an active participant, so it's up to the family members, the people who love the patient, and the doctors to begin a dialogue to find out what the patient would really want, given this bad situation. I agree with Dr. Prager--I think that the hang-ups are on both sides. Doctors have not been trained how to pull back. We're always trained historically to go, go, go, save life, save life. A lot of doctors aren't even aware that you can legally turn off a respirator. They're afraid it may set them up for some kind of legal liability, which is not the case. With this free-floating anxiety, what you don't know just adds to the fear. Similarly, the family members are sometimes in a state of shock, and it's hard for them to come forward. So I think the physicians really have to engage the families and get the discussions rolling, and try to discuss the issues in a dispassionate way and find out what this patient would really want.

Brian Lehrer
Julia Quinlan, the case of your daughter and the fight that you waged to have her taken off a respirator really put the term "living will" in front of the American people for the first time 25 years ago. Are you disappointed to hear that statistic that only 15 percent of the people who wind up in that position seeing Dr. Mayer have anything like that?

Julia Quinlan
I'm not disappointed, because I knew what these figures were. It is sad that people do not complete a living will, because in that they can explain exactly what they do want and what treatments they want. But there are very few people who fill out a living will. My husband had one, and I have one, but my children don't even have one, and as someone here said, it's difficult for us to face the fact that we are going to die. It's difficult for us to explain the treatment that we would like to receive.

But you said something about there being more choices out there for patients today, which presents another problem, because we find in the hospice, with cancer patients, that there are so many more choices for them, and they are willing to try different treatments. These give them the hope that they will be successful--but they aren't always. That's why I think what you said is so important, Dr. Mayer, that we need the doctor to be able to explain to the patient that, yes, it may be helpful, but it's not going to extend your life to be a meaningful life, and perhaps it is time that we just cease treatment. It's so important for them to have this communication, but I do find a lack of it.

Tikva Frymer-Kensky
I think that that's because it's almost too late. The doctors and the families are caught on the front lines of an issue that really needs to be discussed socially. We need as a community to think about dying as a part of life, to think about where we stop fighting the inevitable. How can we face death? What can we do once we accept the fact--for instance, with a cancer patient--that new treatments aren't going to help, and that there may be only months of life left? We have nothing in our society to guide a person to help them follow through to their own death once they've stopped fighting it medically. I think it's that absence that is the problem. We have nothing with which to, not embrace death, but incorporate the idea of it into our life. Because of that absence, the only thing we have are rituals of medicine beyond the point where they are really therapeutic.

Kenneth Prager
I also think that we as a society expect too much of living wills. I often challenge physicians who know all about these issues. I say, "Sit down and write me out a living will of precisely what you do and don't want done for you at the end of your life." And it's a lot more difficult than you think. You get involved in details, you get involved in all sorts of permutations and combinations. It's extremely difficult, even for the initiated, even for the physicians to be able to consider what every conceivable situation will be and what I do or don't want. I've almost come to the point where I think that the best thing is for an individual to pick out a health-care proxy who they trust, have general discussions with that person about the sorts of things they do and don't want done, and leave the details up to the proxy. I've seen some health-care living wills that are ridiculous. They are so incredibly complicated, with checklists saying, "If I have this I want this done, but I do want antibiotics. I don't want a ventilator; I want a little bit of a ventilator." It's almost like a Jackie Mason routine. It's just too complicated. I'm not saying, of course, that thinking about one's eventual demise and what we do and don't want is not important. It's very important, but the critical thing is to pick out an individual with whom you can have a discussion, and then entrust that individual with the decisions when you're no longer able to make them. Living wills are important, but I think we tend to expect a bit too much of them.

Brian Lehrer
Julia Quinlan, is that maybe a better way than a living will that goes into detail about what somebody wants and what somebody doesn't want? To just designate a person you trust?

Julia Quinlan
I think it's important to have a living will, and in the living will you should designate a person that you can trust. When my husband was dying, of course he had designated me as a proxy, and he knew that I would carry out his wishes, whatever they would be. To have it legal is very, very important, but it's important to sit with your family and to discuss death, so that they know what your wishes are. It's going to happen to all of us.
It's important to designate a proxy before you become ill, while you are still able to make choices. You need to have a family member or a friend who will carry out your wishes. Sometimes problems can arise. For example, when the patient is suddenly dying and the whole family gets together and you have a relative come in from California that hasn't seen the loved one in years, and suddenly they're upset because they don't want you to carry out that patient's wishes. That's why it is very important to have it done legally, so that you can follow up the patient's wishes.

Brian Lehrer
Dr. Prager, you get caught sometimes between conflicting family members on your ethics committee tasks, don't you?

Kenneth Prager
Yes, we do. There are times when push comes to shove, when members of the family find it too painful to let go, when there will be a conflict within a family in terms of carrying out the patient's wishes. Sometimes when the patient's wishes are not specifically and precisely known, when there is room for difference in interpreting what the patient would want, we try to be of service in those cases. I think the ethics committee, in sitting down and talking things out, tries to arrive at consensus, but yes, there are definitely instances when the family themselves may not know. I should just mention one other thing, Brian, and that is that, generally, discussions like this are configured in such a way that it's presumed that it's the doctors who are, again, the bad guys keeping patients alive beyond what is "reasonable," or beyond the patient's wishes. Just as often in our committee work, we see scenarios where the family wishes to keep a patient alive when we would consider it futile in the sense of having that patient survive hospitalization and leave the hospital alive. I'm interpreting the term "futility" here in the very narrow sense that the patient won't live to survival. And I think that this happens, in my experience, at least as often as the other scenario. Doctors are frustrated because they feel cornered by family members, by a spouse, by a son, or a child, saying, "Continue, continue," and the doctor knows it's hopeless in terms of the patient's survival.

Brian Lehrer
Professor Frymer-Kensky, what about the ethics of a doctor trying to convince family members to let a loved one die?

Tikva Frymer-Kensky
I think in this case a doctor is an expert witness. The doctor is the one who says, "This is futile; this patient is not going to live to survival." And we place too much on the doctor if we want them also to make the ethical decision for the family. It's theirs to make, but I don't think the family should be left alone. I think society should be discussing certain guidelines about what is appropriate to do and what is not appropriate. And certainly the idea of survival to leave the hospital is a real criterion that should be generally accepted and known. The doctors, after all, are there to heal. And when they testify that healing is impossible, then the burden should be off their shoulders.

Kenneth Prager
However, when push comes to shove again, we rarely if ever go against family's wishes in those circumstances, and I can tell you that it happens with regularity, that nurses and physicians feel very badly about some cases where they feel they are simply prolonging the death of a patient, doing invasive things to this patient because the family is insistent. I don't think we have a great way of dealing with this problem.

Tikva Frymer-Kensky
No, that's why I said we need some nonmedical things that a family can do, so that they feel they're doing something to help the person face death. Because, at this point, demanding increased medical care really only helps the family think that they are looking out for the patient's interest. They're trying to do a last favor, and it's not a good one.

Brian Lehrer
What kind of thing do you think they could do?

Tikva Frymer-Kensky
I don't know, because we really haven't faced dying as a part of life. As a society, we haven't put our brains to what helps a person die, what doesn't help a person, what helps a person attain peace. We have this image--you know, "rage, rage against the dying of the light"--which isn't very helpful for a lot of people. On the other hand, a lot of my friends have died in denial and never gotten a chance to make peace with it.

Session 2

Pulling the Plug

http://www.fathom.com/course/10701024/session2.html

Session 3

Weighing Life: Quantity and Quality

http://www.fathom.com/course/10701024/session3.html

This is an interesting read.

Many of these posters might be too young to remember the great national debate on this subject after the Quinlan case. A national concensus resulted from that debate that led to the laws we now have on the books in All the States and which have been upheld all the way up to the Supreme Court. No one snuck these laws into place and the shrill ones know this...so they will try other means to impose their will on all. The ballot box slaps them down every time. Still, they squeal loudly.

Very interesting. Of course, the majority here won't even read it, and that's a shame.

Abortion is legal, too. Doesn't make it right! Some people don't even feel remorse after murdering their own child, go figure. That is perhaps the most reprehensible act.

Besides killing pain, I honestly don't know what morphine does to the body.

Morphine is a narcotic, so it can suppress respiration.

"I consider dehydration and starvation to be INHUMANE"

On the contrary. I consider the removal of a feeding tube from a person in a PVS who had previously requested not to live that way to be very humane.

Leaving it there out of some misguided and insane "right-to-life" crusade, despite the patient's wishes, is my idea of selfish cruelty.