Terminal Illness - Pulling the Plug or Forcing the Fight: Where is that line?

[iNow]

So, I feel this might make for an interesting discussion if it manages to find traction and attract participants. We are all familiar (whether through our own experience, the experience of those close to us, or through shared stories) with the difficult decisions which must often be made when a loved one becomes very ill.

 

We must weigh many uncertain variables, and we must do so while our logical minds are clouded by strong emotions and deep attachments. How do we decide what to do? Do we pull the plug and let them go? Do we keep them alive at all costs, even if it means the machines and technology are the only thing keeping them here? Can we live with ourselves if we decide to let the patient pass? What will their quality of life be like if we keep fighting for a few more days/weeks/months? Which part of that "gray area" in between is acceptable, and which part is not?

 

There are no good answers, of that I feel rather confident, but what's your opinion? Where is that line, how is it defined, and how do we recognize it when we ourselves are faced with finding it?

[Mr Skeptic]

I too am terminally ill. I have a disease called aging, and as of yet there is no known cure. I've only got about 60 more years to live.

 

Um, I think it is largely a question of quality of life. The smart ones among us have a living will and have talked to our family members telling them what we want done with us if/when we are alive but unable to make our own decisions. I consider my mind to be my self, and if my mind were to die there would be no point in keeping my body alive.

 

And I'm not talking only about a coma. If I were to become a drooling old person with diapers who can't do anything anymore, I don't think there would be much point in keeping me alive. However this is more complicated as there is a continuous decline rather than a sharp dividing line.

[iNow]

Thanks for your response, and you really hit on the heart of what I'm trying to explore here. At what point does "decline" become "declined too far?"

 

If you've been declining for 100 days, do you pull the plug on the 101^st, or must you wait until the 102^nd? Is 100 too few days of decline to be thinking about such things, or should it be closer to 300 or 400 days of decline, or maybe 50 days of remaining steady at a consistently/significantly declined level?

 

Do we keep them alive if they have a stuffy nose, but put them down if they have a cough? It's all just opinion, but where would you (the general reader... not just Mr.S) try to base your decision?

[Dudde]

It's a general consensus in my immediate family that were any of us to become drooling, completely dependent on both technology and others to live, that we don't want that.

 

I'm pretty sure it would take a while to be okay with the decision, but the general idea is that if we're not really living, then we don't really want to be. I think the line for me stops when I'm not doing my own life. Someone else to feed or change, something else to help me breathe - these are not qualities I consider myself alive for, and I don't want my non-living to be monetarily encumbering for anybody anywhere.

 

Of course if my living benefits someone in some significant way, research or something weird - hell I don't know what's going on anyway, just give me some chocolate and lead on!

[iNow]

So, let's assume you don't like the person. Maybe they are a real jerk, and they always rubbed everyone the wrong way. Do you terminate their life earlier than you would... say... someone you cared deeply about and whose company you thoroughly enjoyed? Would it really be a good thing to temporarily extend the life of the person you love, or are you just being selfish and causing them more suffering than they need to experience?

[jimmydasaint]

This thread is far too interesting to discard. As a reasonably ethical person, I would expect to be able to access all reasonable attempts at treatment for any person regardless of how much of a jerk that person was in the past. Once all efforts have been exhausted to save the person, then the person should be given food and water and allowed to respire without the aid of a machine. If the respiration fails then this avoids the use of an artificial machine to preserve life for longer. I think that behaviour would be considered humane and common sense.

[John Cuthber]

The simplistic answer is that it's easy; you ask the person if they wish to continue to live.

If they are in a position to answer that then it's easy, you respect their wishes. (no matter what the cost; remember that it might be you next time)

 

The problem arises when someone else has to make the decision because the person concerned is no longer able to do so.

I don't know the answer (in fact I don't think there is "an answer" ) but it makes things a lot easier if you talk to those who might be left in the position of having to make that choice while you still can and explain that , as far as you are currently able to judge, you wouldn't (for example) wish to continue if the spice girls disbanded or if you had no realistic prospect of being able to inform the world of your opinion.

[jimmydasaint]

The simplistic answer is that it's easy; you ask the person if they wish to continue to live.

If they are in a position to answer that then it's easy, you respect their wishes. (no matter what the cost; remember that it might be you next time)

 

The problem arises when someone else has to make the decision because the person concerned is no longer able to do so.

I don't know the answer (in fact I don't think there is "an answer" ) but it makes things a lot easier if you talk to those who might be left in the position of having to make that choice while you still can and explain that , as far as you are currently able to judge, you wouldn't (for example) wish to continue if the spice girls disbanded or if you had no realistic prospect of being able to inform the world of your opinion.

 

Fair enough as an opinion JC. However, are you in favour of assisted death, if the person wishes to end their lot? I think a few people may disagree with you on that score. Moreover, it has become clear that cost decisions in the British National Health system ( a free-to-use system which used to be the envy of the world) are considered with more value than the health of patients. For example, if you asked for a rare drug that could alleviate symptoms, the National Health System may choose not to deliver, unless you publicise your cause in the media. So much for morality and ethics...

[John Cuthber]

"However, are you in favour of assisted death, if the person wishes to end their lot? "

Yes.

Also you need to realise that healthcare is an infinite sink for cash. It doesn't matter how much you spend, people will still suffer and die.

The question of how much you spend is political, so morality and ethics go out of the window.

This problem is generally swept under the carpet unless, as you put it "you publicise your cause in the media"

[jimmydasaint]

The recent case of Ray Gosling, the British broadcaster pushes this Thread back into the limelight:

 

Mr Gosling, 70, confessed on a television programme broadcast on Monday evening that he had used a pillow to smother the man, who had Aids, as he lay in a hospital bed.

 

He claims the couple had previously made a pact that he would help end his lover’s life if his pain became unbearable, and that he had no regrets about what he had done.

 

http://www.telegraph.co.uk/news/uknews/crime/7257905/BBC-presenter-Ray-Gosling-facing-further-questioning-over-mercy-killing.html

 

This makes it more complicated. Who is to decide if the person is undergoing unbearable pain? What if the ill person changes their mind? What is the view of people who follow a religion?

[jackson33]

jimmy; Personally, I'm happy to see the thread brought back up, wish more would contribute.

 

Even if Mr. Gosling had a written contract or where applicable in the US a marriage license and that contract, no person can enter into or commit an otherwise illegal act. Killing a person, illegal under British common law. I'm assuming he has not been charged or out on some kind of bail, but he will eventually be charged and convicted (after public confession) of a crime. The actual crime (charges) or the punishment is a different story (extenuating circumstance) and could be found guilty of something without serving time. The funny thing is, if charge for premeditated murder (1st Degree and won't happen), he could be found innocent and acquitted.

 

Assisted suicide, in the US is being addressed by a few States, but in any even this will have to be come actions of a medical professional One problem for denial of HC, causing death in the US, is charges can be filed against an insurance Company, Hospital or Physicians but not normally against a Government.

[jimmydasaint]

jimmy; Personally, I'm happy to see the thread brought back up, wish more would contribute.

 

Even if Mr. Gosling had a written contract or where applicable in the US a marriage license and that contract, no person can enter into or commit an otherwise illegal act. Killing a person, illegal under British common law. I'm assuming he has not been charged or out on some kind of bail, but he will eventually be charged and convicted (after public confession) of a crime. The actual crime (charges) or the punishment is a different story (extenuating circumstance) and could be found guilty of something without serving time. The funny thing is, if charge for premeditated murder (1st Degree and won't happen), he could be found innocent and acquitted.

 

Assisted suicide, in the US is being addressed by a few States, but in any even this will have to be come actions of a medical professional One problem for denial of HC, causing death in the US, is charges can be filed against an insurance Company, Hospital or Physicians but not normally against a Government.

 

jackson, I agree with you. I think it is likely that, after extensive police questioning, Mr Gosling is likely to be released. Further, if he is charged of murder, he is likely to be acquitted due to the extenuating circumstances. However, if too many of these cases result in the release of the defendant, there is the problem of suicide cults where a charismatic leader can assist hundreds of healthy people in suicide. Assuming that the leader survives due to early police intervention, he/she can then claim that the mass suicide was decided by a pact which he/she fulfilled.

 

Moreover, what if a person had a kidney condition which requires dialysis. The person with the condition is sick of the regular dialysis and protests at the disturbance caused to the daily routine. If they are assisted in suicide, do their opinions count as extenuating circumstances?

[jackson33]

However, if too many of these cases result in the release of the defendant, there is the problem of suicide cults where a charismatic leader can assist hundreds of healthy people in suicide. Assuming that the leader survives due to early police intervention, he/she can then claim that the mass suicide was decided by a pact which he/she fulfilled. [/Quote]

 

jimmy; That's why I think he will be charged with something, in the US, likely 'manslaughter', but here, premeditated is a negative. I'll try to keep up with this, since certainly fits into my line of interest.

 

Moreover, what if a person had a kidney condition which requires dialysis. The person with the condition is sick of the regular dialysis and protests at the disturbance caused to the daily routine. If they are assisted in suicide, do their opinions count as extenuating circumstances? [/Quote]

 

Technically anything can fit into 'extenuating circumstances' (COMPASSION/character/history/age/relationship and much more) and in most cases is addressed during the sentencing trial, or the criminal trial when both are determined at the same time (US States differ). I'm not sure of British procedure.

 

Remember, no one can enter into an illegal agreement. That means the person on dialysis can't legally ask/request assistance, making the assistance an illegal act, any agreement voided whether written or verbal. Under normal circumstance, again according to jurisdiction, withholding intent (going to commit suicide) from the authorities, is also a crime, called 'accessory to' or 'conspiracy to', whatever.

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Merged post follows:

Consecutive posts merged

Feb.22, 2010...

 

BBC presenter Ray Gosling disclosed today that he has told police the name of the lover he confessed to killing.

 

Gosling, 70, was arrested on suspicion of murder last week after revealing in a TV programmer that he smothered a former partner as he lay in a hospital bed dying of Aids....

 

"I said to the doctor 'Leave me just for a bit' and he went away. I picked up the pillow and smothered him until he was dead.

 

"The doctor came back and I said 'He's gone'. Nothing more was ever said."....

 

Following repeated questioning by detectives over 30 hours in custody he was released on bail until April, but only after naming the man he killed.

Gosling told the Nottingham Evening Post today: "If I'd not told them who it was, I'd still be locked up now."...

 

 

But he added: "I don't regret saying what I did on the television. The BBC didn't use me. They let me decide what I wanted to say. They told me the risks of doing it."

 

Aiding or abetting another person's death is illegal in England and Wales under the 1961 Suicide Act, and is punishable by up to 14 years in jail.

If Gosling was convicted of murder, he would face a mandatory life sentence. [/Quote]

 

http://www.independent.co.uk/news/uk/crime/ray-gosling-named-mercy-killing-lover-to-police-1907207.html

 

This is pretty much all that will be known until April, when probably he will be charged with "Aiding or abetting" (opinion) and will receive some time in prison. What remains interesting is the Doctor involved, obviously knew what was going to happen, certainly after the act, is also guilty. When ever two persons are involved and an illegal act occurs, conspiracy comes in, demanding the highest degree of a charge and for both parties. That would be 'murder' for Gosling, 'aiding and abetting' for the Doctor, if still alive. "Young Chap" tells me this could be a very old 'Cold Case'.

[John Cuthber]

Mr Gosling may very well turn up in court and say "I made that story up to illustrate the moral issues".

He might get done for wasting police time but, as far as I can see, there is no legal case against him. It would be different if there were any corroboration like the young man's cause of death.

[Pangloss]

How can there be no case against someone who confesses to a crime?

 

How does it make sense that the reason that the perpetrator states for committing the crime would be relevant to the determination of his or her guilt?

 

Seems odd to me. You commit a crime, anything you say is surely suspect, but if you open your mouth and utter the words "I did it because they told me they wanted to die" and you walk away from police custody. It's like some kind of bizarre magic spell.

[Dudde]

How can there be no case against someone who confesses to a crime?

 

~~~~

 

"I did it because they told me they wanted to die" and you walk away from police custody. It's like some kind of bizarre magic spell.

 

I think if you can prove that you had more to gain from them living than them dying (i.e. as a couple, I'd prefer my girlfriend alive so I'd have someone to sleep next to, as opposed to her dying and me inheriting $100k) then it should at least merit a reduced sentence.

 

However, the point brought up earlier also raises an interesting point with regard to the cultist suicide - most of the time they're brainwashed anyway, so getting them to sign a piece of paper should be a cakewalk in those circumstances, even getting it notarized or some such thing.

 

personally, I'm not in favor of assisted death, but if all that's keeping you alive is machines, I'm definitely in favor of taking the machines away

[iNow]

The issue of assisted suicide was explored in a very mature, compassionate way this week on the Frontline program.

 

I appreciate everyone's interest in the thread thus far. If your interest persists, you might appreciate the ~50 minute special available below.

 

 

 

http://www.pbs.org/wgbh/pages/frontline/suicidetourist/

Five months after being diagnosed with ALS, Craig Ewert arrived in Switzerland for his scheduled suicide. A story about struggling

to live ... and deciding when to die.

 

 

Watch Online --> http://www.pbs.org/wgbh/pages/frontline/suicidetourist/view/

 

 

 

"I am dying. … There is no sense in trying to deny that fact," 59-year-old Craig Ewert says of his rapid deterioration just months after being diagnosed with ALS, a motor neuron disorder often referred to as Lou Gehrig's disease.

 

"I'm not tired of living," explains Ewert, a retired computer science professor. "I'm tired of the disease, but I'm not tired of living. And I still enjoy it enough that I'd like to continue. But the thing is that I really can't."

 

<...>

 

"At this point, I've got two choices," Ewert reasons. "If I go through with it, I die, as I must at some point. If I don't go through with it, my choice is essentially to suffer and to inflict suffering on my family and then die -- possibly in a way that is considerably more stressful and painful than this way. So I've got death, and I've got suffering and death. You know, this makes a whole lot of sense to me."

[jackson33]

The following article, made me think of this older thread and why I had agreed an important issue for folks to discuss. There is a probability every person has or will go through much the same in their lifetime, with a child, parent, spouse or will need to assist others going through much the same thing. Sad as this life experience is, with natural life expectancies reaching into the normal deterioration of the human body and mind, it's only going to become more commonplace.

 

If you read the article, read through some of the responses, which are just as telling of the looming problems as folks enter into artificial life to an inevitable death. Note, this case and most in my opinion never involve being hooked to machines for life itself, rather a natural deterioration of the body, once inflicted. Those cases I would think, would be simple decisions and far less common than the following...

 

 

 

Terence Bryan Foley, 67 years old, my husband of 20 years, father of our two teenagers, a Chinese historian who earned a doctorate in his 60s, a man who played more than 15 musical instruments and spoke six languages, a San Francisco cable-car conductor and sports photographer, and an expert on dairy cattle and swine nutrition, film noir and Dixieland jazz, was confused. He knew his name, but not the year. He wanted a Coke.

 

Should Terence begin to hemorrhage, the doctor asked, what should he do?

This was our third end-of-life warning in seven years. We had fought off the others, so perhaps we could dodge this one, too. Terence's oncologist and I both believed that a new medicine he had just begun taking, Pfizer's Sutent, would buy him more life.

 

Keep him alive if you can, I said.

 

Terence died six days later, on Friday, Dec. 14. [/Quote]

 

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/lessons-of-a-618616-dollar-death.aspx

 

This family apparently had good insurance, no doubt a group policy and with a cooperating employer, but there are and will be millions of not so lucky people, who will suffer more severe economic consequences on themselves or to the society they live in, with or without insurance or the stress involved when any third party is dictating those very personal decisions. Many folks, I suspect will go it alone in the US or anyplace, as long as their are medical facilities available to by pass those third parties, especially if it's their child, spouse or parent.

 

I'm not pretending to know any answers, even know exactly what I would do if forced to make those final decisions, for myself or anyone else. The practical element to judge, cost opposed to emotional feelings, is obvious. Even over the past 10 years (this case) it seems 617K$ was reasonable, and over that period I would think 100k/year such cases would be in order, probably more and with an aging American population and rising cost think those figures would easily double. 200k/year (2M over 10 years) and the cost per a 1.2M$ (10 years) or 240B$ to extend and undeterminable period of life, even then usually of low quality...

 

iNow; I really did write the above after seeing the referenced article in this mornings 'Money Central' front page, I hadn't seen your last post. Although this is counter (not intended) to the 'Assisted Suicide' mentality, the overwhelming desire to live by most IMO, is important. I'd be very reluctant to favor 'assisted' death for health problems like ALS (Lou Gehrig's Disease), some cancers, for many heart problems, complex dementia, any psychiatric problem, where future medical progress could actually reverse the progressive nature of some problems, especially 5 months into the diagnosis.

[iNow]

I'd be very reluctant to favor 'assisted' death for health problems like ALS (Lou Gehrig's Disease), some cancers, for many heart problems, complex dementia, any psychiatric problem, where future medical progress could actually reverse the progressive nature of some problems, especially 5 months into the diagnosis.

 

Why is that a decision you feel you should have the authority to make, as opposed to... let's say... the individual personally afflicted by those ailments?

 

I'm fine if you feel that way about your own personal care. I am not fine, however, if you feel that your preference should be mandated on others.

[iNow]

Is there anyone here who thinks you should ALWAYS keep the patient alive? All measures possible are warranted?

[jackson33]

iNow;

Since you brought an old thread back, that does interest me;

 

Why is that a decision you feel you should have the authority to make, as opposed to... let's say... the individual personally afflicted by those ailments? [/Quote]

 

Favor and having authority have different meanings. However, hypothetically if I had a family member slip into a coma, with a current diagnosis of the problems mention, and the doctor felt this would be a good time to do what that member had requested (pull the plug), I would probably try to prevent. This is based on personal experience, while in serious pain, having already having willed, no atrificial life support, then recovering and now three years later, question my own decisions, which I still have in my living will....

 

Is there anyone here who thinks you should ALWAYS keep the patient alive? All measures possible are warranted? [/Quote]

 

If the patient has no means to answer that question, their is no authorized person to make that decision or the family law of the State, doesn't directly address the same cause, then IMO the Doctor has the obligation to maintain life, until a court rules on the evidence.

 

What's that argument against Capital Punishment..."If one innocent person is put to death...", well if one person could have recovered, is that any different. As I said, I don't have the answers, it's a complicated issue based on a thousand variables, but what I don't want to see, is where this decision becomes a 'one size fits all' style scenario...

[D H]

Is there anyone here who thinks you should ALWAYS keep the patient alive? All measures possible are warranted?

All measures? Of course not. We ration health care right now. Suppose a heart becomes available for transplant, and three people come up as matches: a seventy year old life long smoker, a twenty year old with lots of congenital defects, and an otherwise healthy thirty year old. One guess as to who gets the heart.

 

Unless someone comes up with a way of curing the condition that ails Mr. Skeptic (post #2), we can't always keep the patient alive. Despite all that modern medicine has to offer, that ailment is eventually going to strike all of us because every single one of us is terminally ill.

[iNow]

If the patient has no means to answer that question, their is no authorized person to make that decision or the family law of the State, doesn't directly address the same cause, then IMO the Doctor has the obligation to maintain life, until a court rules on the evidence.

 

I think this comment really drives to the heart of the issue. Just what is it to "maintain life?" Does that mean there are machines keeping the heart pumping, or is it perhaps something more practical... where quality of life is involved?

 

I am essentially trying to pull out the difference of worth... I am asking readers to comment on the issue of worth. Is a life sustained by machines alone worth maintaining, or should the line perhaps be placed somewhere prior to that point? Is it really "life" if survival is little more than mechanical pumping?

 

I'm not yet sure where I land on this. How about you, reader?

[padren]

I think this comment really drives to the heart of the issue. Just what is it to "maintain life?" Does that mean there are machines keeping the heart pumping, or is it perhaps something more practical... where quality of life is involved?

 

I am essentially trying to pull out the difference of worth... I am asking readers to comment on the issue of worth. Is a life sustained by machines alone worth maintaining, or should the line perhaps be placed somewhere prior to that point? Is it really "life" if survival is little more than mechanical pumping?

 

I'm not yet sure where I land on this. How about you, reader?

 

Well, ideally the person on the machine has made a decision in the form of a living will, but in lieu of that you have to err on the side of caution which I personally would find to be the "less irreversible" one. So, you make the sort of effort on behalf of the patient that would be equivalent to them saying "try to keep me alive as much as possible." Doesn't mean you'd bogart the organ transport list from higher priority recipients, just give them the same care of someone who specifically indicated they wanted to "force the fight."

 

 

The issue does get clouded when you have family members with ideas of what their loved one would want (often conflicting) and at the same time a potential crushing financial burden. I would suspect very few people would want to be kept alive as a vegetable knowing it was bankrupting three generations of their family. The only thing that is crystal clear is there is no good reason not to have a living will. I really have no idea how to think about where this topic "goes" but my feeling is it should start with trying to save those as if they asked, when they never had an opportunity to voice any directives.

 

 

The interesting issue (in my mind) is really "Can someone in their right mind, want to commit suicide?" and while culturally the thought was unthinkable at one time, it's become more and more pertinent to end of life care. I think most of our current coping mechanisms are rather self serving - if you can get and take the pills, we can accept you "ended your pain" but if someone else got them for you, they better not know what you were intending, and god forbid they push a morphine button at your request. Push a different button that stops a machine - that's acceptable, even if it causes more suffering and takes longer. It seems like culturally the comfort of the living is the highest priority.

[john5746]

Well, ideally the person on the machine has made a decision in the form of a living will, but in lieu of that you have to err on the side of caution which I personally would find to be the "less irreversible" one. So, you make the sort of effort on behalf of the patient that would be equivalent to them saying "try to keep me alive as much as possible." Doesn't mean you'd bogart the organ transport list from higher priority recipients, just give them the same care of someone who specifically indicated they wanted to "force the fight."

 

I guess I really can't disagree with this point, but how much should we fight - even when the patient wants it? As mentioned before, resources are not unlimited and this includes medical staff. Does that busy nurse make a few less rounds to certain patients or hurry a little more with them?

 

I wonder sometimes if we hide behind our wall of wishful thinking to avoid making the hard decisions - just assume everyone can be milked until the last breath with no ill effects on the other patients. That being said, maybe it is best to leave it up to the decisions of the staff, to let the invisible hand of time constraints determine the outcome.