Wednesday, December 26, 2007

More Random Thoughts on Futile Therapy and Euthanasia

Last week, I wrote about a sad end-of-life case brewing in Canada. Today, I'd like to add a few more thoughts on it.

You can read them here.
Last week, I wrote about a sad end-of-life case brewing in Canada. Today, I'd like to add a few more thoughts on it.

This case is about a critically ill, elderly man and his family who are orthodox Jews. The family's orthodoxy is one of the reasons they are reluctant to allow the heroic life support measures currently being employed to be withdrawn. Their position is that it is against basic tenets of their religion to do so. They have an attorney whose position is that such withdrawal of care is no less than assault and battery. The family goes a step further calling it murder.

I myself am Jewish though far from orthodox. While I don't profess to be an expert on Jewish law (halacha), one thing i do know is that like secular law, much of it is in the eye of the beholder. There is very little under halacha that is truly, irrevocably settled.

Jewish law is based upon the Torah, the first five books of the Jewish Bible (what non-Jews call the Old Testament). The Torah, like all things biblical, is so shrouded in mystery that Jewish scholars have engaged in centuries of debate as to its meaning. By "meaning" is meant the Torah's relevance both spiritually but also as a code of ethics and behavior. This debate was transcribed and codified as a commentary to the Torah known as the Talmud.

Halacha is based on rabbinical scholars' understanding and interpretation of the Torah and the Talmud and is always changing to meet current ethical and legal dilemmas. There is no shortage of thought directed to end-of-life issues in halachic law.

Like so many issues of Jewish law, the orthodox position on withdrawal of life support is far from settled. That being the case, it may be simplistic or a misinterpretation to call such withdrawal murder as the family described in the link above is apparently doing.

In fact, there is a reference in the Talmud (B. Ab Zarah 17b-18a) regarding the execution of Rabbi Chanina ben Teradyon. When he was burned to death by the Romans, they wrapped him in a moist blanket to prolong his suffering. Responding to an appeal for compassion from his family, the executioner was permitted to remove the blanket thus hastening his death. This reference has been invoked in halachic arguments to justify the withdrawal of life support when its use will only prolong patient suffering.

I thought this might interest some readers both as providing an insight into some of the views Jews hold on this topic but also as an example of how halachic arguments are set up. The whole subject is fascinating though again, I'm no expert but merely a dilettante.

I'd also like to mention that when I was a medical student in my preclinical years, I read an article in the New England Journal of Medicine called Must We Always Use CPR?. Leslie Blackhall, the author posed the title question, the answer of which I had always taken for granted: one always offers a patient or his surrogate the option of CPR. In other words, the decision to be a "full code" or not always resides with the patient.

Blackhall questioned the wisdom of this approach theorizing that if CPR was futile for a given patient (she studied situations in which it surely was) then it shouldn't be offered or even discussed. This argument had a profound impact on me because it filled me with revulsion. I couldn't believe that a physician would write such a thing. To me, patient autonomy was a given.

Then, I began my clinical rotations and actually started working in the hospital. On the medicine wards for the first time, I started to see the incredibly ill, cancer infested, old, demented, zero-quality-of-life patients that we were going through the motions with and performing full codes. Almost none of these patients survived and the few that did had devastating loss of function and disability that made their quality of life even worse. All we ended up doing was delaying the inevitable...and causing unnecessary suffering on the way.

It came to me during these times that coding such patients was indeed futile. Only then did I understand that Dr. Blackhall was right.

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Anonymous Anonymous said...

Doctor Ford,

If I understand you correctly, and if Dr. Blackhall is right, then a doctor shouldn't have to even offer such a patient CPR. Nor a respirator. And if a respirator ought to be withdrawn in Canada against the family's wishes, than surely it can be withheld against their wishes. Or... as happened to me with my father, not even discussed; don't ask - don't tell.

Please consider carefully the slippery slope. Just as in Halacha there seems to always be room for dispute, the same is true of medicine. Just how poor does "poor protoplasm" have to be to cross the threshold? Aren't the terms "cancer infested, old, demented, zero quality of life" value judgments? Who is the judge?

Hypothetical: An old, demented woman who isn't cancer-ridden and who has a reasonable quality of life, recognizing most of her loved ones most of the time and in no pain -- but who now presents for her first hospitalization with pneumonia, dysphagia and a zenker's thrown in for good measure. Her surrogate wants her to be full-code and demands intubation and reintubation. Tough call? Who makes the call? Who is to say what is a "severe" co-morbid condition as opposed to a mild one?

Doctors, like most people, tend to befriend and work with the like-minded. Don't they run the risk of being too aggressive in affixing the Poor Protoplasm label? What if, from the family's position, the doctors are being too quick to rush to judgement? If we don't preserve patient autonomy as sacred, won't it get too easy to brush the family off as "unrealistic?" I get the impression that what you saw on your clinical rotation was pretty cut-and-dry, but can you envision a situation where a doctor may get ahead of himself and "push" a patient in the direction he think she's going? Won't this only get worse as we boomers grow old and as Medicare DRGs dwindle in value?

Consider what happened to my father in Silver Spring, Maryland. He never cost the medical system a dime until his first hospitalization, yet he was deprived of the right to fight for his life on his terms and in accordance with his beliefs. Are those the kinds of paternalistic compromises that a doctor should be allowed to make? I hope not.

January 20, 2008 10:26 AM  

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