Medical ethics on limited options

Posted by The J Train

I really didn't offer up much of an introduction in my previous post.  I'm an internist (which, I tell those who ask, is like being a pediatrician, but for adults) fresh out of residency and starting up in private practice in eastern Kentucky.  I have been writing on the internet for a very small audience for some time, starting with my eponymous web site (now on "indefinite standby") and a blog called The Internal Monologue (now defunct), and more recently on my LiveJournal (now Friends Only).

Amanda Marcotte links to this story about some doctors in New Orleans who had to get their hospital evacuated, but who had terminally ill patients who were too sick to survive the trip.  Rather than leave them to die alone, they gave the patients big enough pushes of morphine to end their lives before everybody got out.  I don't know how reliable it is, but it's absolutely plausible (that is, I'd be shocked if this didn't happen somewhere in all this).

"Triage", as the word root implies, originally meant separating patients into three groups--those who would likely be OK without medical care, those who are beyond any help, and those who can benefit from medical care.  The idea is to concentrate resources where they can do the most good; it's no use spending valuable time working on someone with hours left to live no matter what when you can save decades of meaningful life for three or four other people in the same time.  In that case, the right thing to do is to provide comfort for the dying, and in a serious and urgent situation, that might include active euthanasia.

This is not hard to justify once you accept the fact that some patients are going to die in the short term, despite anything anyone can do.  A lot of people don't accept that; they believe that one should never give up hope, and that death should be fought until the last dying breath.  We doctors often encourage that attitude, because somewhere along the way, we decided that it was healthier for patients and families to plan on a miracle than to prepare themselves for the inevitable.  The hospice movement has helped us get a lot better about that in the last couple of decades, but it's still pretty common for doctors to tell patients and families not to give up hope when the prognosis is long since clear.

I can see the patients they're talking about--probably the ones already requiring large doses of morphine for comfort care, so they're not responsive or interactive.  Their families, previously by their sides as much as possible, are (reluctantly) long gone.  (The tone of the article, plus the fact that every hospital in America has several of these patients, leads me to think this is who they're talking about.)   If the hospital absolutely has to get cleared out, there are only three options:

--Evacuate the patients.  It may not even be an option.  If it is, they'll probably die en route.  If they do make it, it's just so that they can wait to die in a different building, probably still separated from family, and (just to be frank about it) using resources and manpower that are already scarce to delay the inevitable for a little bit.  The patients' last hours will be spent in a flurry of activity, and on the other end comfort will almost certainly take a back seat to raw necessity.

--Leave the patients.  They won't make it, but the lack of nursing care or meds will mean their last hours will be spent alone and miserable.  This is not an option, IMO.

--Push the morphine.

From a strictly utilitarian standpoint, there is only one good option, and a disaster like Katrina brings out the utilitarian in all of us.  That doesn't make it easy to do, or easy to accept.

Comments

[Thad]

a disaster like Katrina brings out the utilitarian in all of us.

Great encapsulation, and great post, J Train. Thanks.

[ghostcatbce]

While I realize there is a great deal of sense in what The JTrain said, I have been chasing this story through several different reputable Britsh newspapers, and it's just not there. The Daily Mail is considerd a tabloid, a cut above The National Enquirer, but not much of one. Someone is milking the genuine suffering that took place in New Orleans, for their own benefit.
Simply put, this story makes no sense. While I realize it is highly plausible that these actions did indeed take place, why would anyone rush to admit it? Under Louisiana law, they would be confessing to murder. They would also be increasing the pain and grief of already grieving relatives. No, with due respect, I cannot accept this story at face value. Until firmer evidence presents itself, I'm going to stick to my belief that someone is using the terrible events that took place in New Orleans to line their pockets.

[Orac]

I have to tell you. This story sounds more than a little fishy to me. It just doesn't pass the "smell test." I would want to see another independent source documenting it before I believe it.

For more doubts about this story, see:

http://thewelltimedperiod.blogspot.com/2005/09/doctors-killing-patients-in-no.html

[Orac]

Actually, this part sounded fishiest of all:

Mr McQueen, a utility manager for the town of Abita Springs, half an hour north of New Orleans, told relatives that patients had been 'put down', saying: "They injected them, but nurses stayed with them until they died."

Somehow I doubt that anyone would tell families this. Also, if it's true, where are the corroborations from families?

The more I think about it, the more this story sounds like an urban legend in the making. Maybe I'm wrong, but I've seen very convincing articles in British newspapers before that turned out not to be urban legends. I'm remaining skeptical for now.

[StealthBadger]

If it is an Urban Legend... then it is the beginning of a whisper that could re-open the conversation on being able to choose the manner of your death, as opposed to what the Radical Right proposes (which is part and parcel of their rather twisted stance on abortion): Mandatory Life.

Once again I really wonder why the many, many embryos killed in IVF somehow "don't count" in their tally.

[Flint]

"Once again I really wonder why the many, many embryos killed in IVF somehow "don't count" in their tally."

It is a logical conundrum ain't it? Abortion is murder, IVF is just fine and the "death" of the left over embryos is peachy... as long as you don't use them for stem cell harvesting to save a human life???? Say Wha?????

As to the euthanasia story it sounds bogus because who would confess really? this is especially true considering that they are in the land where the Scopes "monkey trial" done got it wrong and the Talibaptist rule.

Doctors do this stuff all the time but they sure as hell don't talk about it. Morphine has terminated more ALS patients than the disorder and I don't have a problem with that. Watching someone suffocate isn't pretty.

The other thing that the Talibaptist do that has always gotten to me is they would rather see a terminal cancer patient die in agony than give them heroin like they do in England, because every Talibaptist knows that drugs are evil. Better to writhe in agony than die with dignity or... ya gotta suffer if ya wanna sing da blues.

[Geeno]

While it may have happened, I can't imagine that anyone involved would say anything. What good could possibly come of it. If it did happen, noone is going to talk about it.

[Bob Koepp]

Flint - Since when do the Talibaptists control the provision of palliative care? I know that a lot of physicians are afraid to prescribe opiates for pain relief, because they don't want trouble with the DEA. But how many physicians who do prescribe opiates have found themselves in court as a result? Bullshit hyperbole like you're spewing is partly responsible for the failures of palliative care that you decry so loudly.

[Flint]

Bullshit Bob...

"I know that a lot of physicians are afraid to prescribe opiates for pain relief, because they don't want trouble with the DEA."

It is exactly the attitude that opiates are bad which has been foisted off on our society that has created the situation where physicians are afraid to even prescribe them to relieve the suffering of their patients.

Now where does that societal attitude come from Bob? Do you think the DEA just decided this arbitrarily?

Do you think that the issue of medical marijuana is being scientifically evaluated or does it reflect what some see as a "moral value" judgement?

In England with terminal cancer patients they do use the opiates in regulated doses and many of them continue to even go to work and keep their normal routines until the day before they die.

I think I'd prefer the English approach rather than seeing patients writhing in pain.

[Flint]

One more thing Bob...

My mother has been diagnosed with motor neuron disease and as fate would have it my closest friend's mother died from ALS.

I sat around one evening with him and his sister a VP of patient care for one of the larger hospital systems in the state and we discussed how their mother had died and the role of pain killers in hastening death.

Its one of the realities of caring for the terminally ill and its a situation that I well understand.

As for your assertion, "Bullshit hyperbole like you're spewing is partly responsible for the failures of palliative care that you decry so loudly", you can take this and stuff it where the sun don't shine asshole!

[Bob Koepp]

name calling will certainly persuade critical minds....

People who promote the idea that we live in a society where prescribing opiates for pain control puts doctors at significant risk from law enforcement are spewing bullshit which contributes to the ignorant fears of the doctors in question. I reapeat my entirely non-rhetorical question: How many physicians who do prescribe opiates have found themselves in court as a result? The numbers demonstrate very clearly that fear of prosecution in these circumstances is an irrational fear, fed by misinformation (i.e., bullshit)

[Flint]

More twaddle Bob?

"How many physicians who do prescribe opiates have found themselves in court as a result? The numbers demonstrate very clearly that fear of prosecution in these circumstances is an irrational fear, fed by misinformation (i.e., bullshit)"

That is absolute crap Bob, their "fear" is not from misinformation and it sure isn't irrational. It comes from docs who were handing out scripts for oxycotin and turning a handsome profit ala Rush Limbaugh and crowd.

To the best of my knowledge heroin has never been legal in this country, although opium and derivatives were in the late 1800's and early 1900's.

Further... you evaded a major point that tells the tale and that is medical marajuana. During the Clinton administration numerous states passed laws allowing it. The Justice department turned a blind eye on prosecution of the growers and distributors leaving punative action to the state authorities.

This changed during the Bush administration and they have actively arrested and prosecuted the growers of the medical marijuana and stated, when they did so that despite all of the assurances and documentation, that they were afraid that it would get out into nonmedicinal applications. Interestingly enough, Bush and the Neocons saw Federal rights trumping states rights, a highly "unconservative" point of view.

The difference between the two administrations attitudes, I assert, is the religious rights role as the "base of support" for the Bush administration.

Additionally, this administration has piled up a record of being "anti-science" in numerous instances such as; global warming, stem cell research, and the ever popular intelligent design. This was the reason for my "talibaptist" snark.

Now as to my name calling, well Bob I am a bit emotionally involved with this issue. I do think that you are very intellectually dishonest in your assertions and I really hate to be the one to break it to ya Bob... but you really are an asshole!

[Bob Koepp]

In case you didn't know, Flint, heroin and morphine are opiates. The efforts of the administration to prevent the use of marijuana as a pain medication are just as disgusting and stupid as you suggest. But that's irrelevant to the question of whether physicians are likely to be prosecuted for prescribing opiates for pain control. Many physicians think there is a significant risk, but the facts don't bear out their fears. People like you, who insinuate that there is a significant risk of prosecution, help to perpetrate an "urban myth" that contributes to the underprescribing of pain medications. I may well be an asshole, but it's you who's spewing bullshit.

[Flint]

Bob...

It’s you who are the unquestioned king of bullshit. As I pointed out in my last post:

"That is absolute crap Bob, their "fear" is not from misinformation and it sure isn't irrational. It comes from docs who were handing out scripts for oxycotin and turning a handsome profit ala Rush Limbaugh and crowd."

There have been numerous docs busted running pill mills and handing out these scripts for opiates. That is why the DEA is paying close attention to physicians who prescribe these drugs frequently. It has nothing to do with your "urban myth" theory which is nothing more than first rate crappola.

If you weren't aware of the numerous scandals regarding oxycotin and its use as a party drug thanks to a few unscrupulous docs I'd have to ask what frickin' rock you've been living under?

Further your attempts to dismiss my point about medical marijuana:

“The efforts of the administration to prevent the use of marijuana as a pain medication are just as disgusting and stupid as you suggest. But that's irrelevant to the question of whether physicians are likely to be prosecuted for prescribing opiates for pain control.”

It’s not irrelevant at all because it shows a definitive stance of the administration that is based on a “moral” value judgment and not on any scientific evaluation and that is very much the issue in discussion. Further the Federal Government classes it as a narcotic even though it is definitely not!

The University of Pennsylvania did extensive research on THC the active ingredient in marijuana as a prep for surgery in concentrated form. The value of it was that many patients are on so many drugs when they hit the table that the numerous interactions become an anesthesiologist’s nightmare. The Feds shut those experiments down quickly when the groups began publishing positive results.

And yes Bob, I am very much aware that heroin is an opiate, but to the best of my knowledge there has never been a “clinical state” for heroin in this country. They do use the less concentrated form morphine, laudanum, and a close relative paragoric, but I’ve never heard of heroin being used. That doesn’t mean that it hasn’t, I’m just unaware of it.

Interestingly enough Keith Olbermann did a segment on the story that spawned this post. He had on the Medical Director of Charity Hospital and they discussed this story. Olbermann dismissed this story for many of the same reasons that I did, which is who would talk about it in the first place.

The Director agreed with him and added that it seemed unlikely to him because there are numerous drugs that can be used for euthanasia with a patient, but he felt that morphine was a poor choice and he doubted if any physician would use it.

Now as my grandmother used to say, “if you argue with a fool long enough, after a while the people who are watching won’t know the difference between you.” With that, I’ll defer to the wisdom of the matriarch of my clan. Night Bob!

[gordo]

Flint--

Just so ya know, Bayer and other companies sold heroin over the counter until 1910. Bayer first started selling it as a cough medicine, touting it as a non-addictive alternative to morphine. Unsurprisingly, they saw huge increases in sales every year from 1898 to 1910.

[gordo]

PS

Great post, J Train. While the article itself is unreliable (it's hard to sort out what the doctor said vs. what the reporter read into it), you've really driven home the fact that being a doctor can often force a person to make gut-wrenching choices.

[Flint]

Thanks for the info Gordo... Smack OTC... who'd a thunk it?

"Just so ya know, Bayer and other companies sold heroin over the counter until 1910. Bayer first started selling it as a cough medicine, touting it as a non-addictive alternative to morphine."

I think the funniest part of your post is the Bayer claim. Wonder what they'll say about Cialis and that "four hour erection" warning in fifty years?

Cheers

[Leigh]

Any prolifer would assert that killing IVF embryos is wrong, which is why most would be "anti-IVF". I see nothing "twisted" with the logic that killing the most innocent of us is wrong. I am glad my mother agreed! Was it Mother Theresa that said "It is a poverty that a child must die so that you may live as you wish".

[Pass USA - Pass a Drug Test with ease]

Pass USA provides the latest drug passing products and information on the market. Our extensive products range from hair, saliva, blood, urine, and complete body detoxifications, along with knowledgeable customer service members that will help you along the way for a successful and painless natural procedure for passing your upcoming drug test with guaranteed results.