Surely we who might someday be in those nursing home beds must be horrified at the apparent inattention to pain. Of 4,000 patients who reported daily pain, only 16 percent received acetaminophen, and almost no one got regular doses of opioids. What should be done?
Gradually, care for the dying has been improving. Public interest in hospice and other alternatives to high-tech hospital death has been on the rise. Barriers to effective pain treatment were beginning to come down. Then last month Congress got into the act with a proposal to require the Drug Enforcement Administration to revoke the license of any physician who intentionally causes a patient to die.
If it becomes law, the Lethal Drug Abuse Prevention Act of 1998 will put a damper on progress now being made in providing pain relief to dying patients. If the politicians who crafted this legislation truly want to prevent physician-assisted suicide, they're taking the wrong approach. Fear of unrelieved pain ranks among the main reasons people give for requesting help ending their lives. Intimidating doctors into being stingy with painkillers is not the solution. Granted, the proposed bill allows physicians free rein in prescribing drugs to alleviate pain, but the amount of morphine, for example, required to relieve the severe pain of bone cancer may also repress respiration to a point that may be lethal. Physicians in fear of losing their licenses are likely to err on the side of caution and under-prescribe. And the message that this bill sends to patients and their families is that pain control is dangerous, that expecting to be comfortable near the end is unrealistic and maybe even immoral—that it's better for the dying to tough it out.
Last year the Supreme Court ruled that physician-assisted suicide was a matter for the states to decide. Since then, legislatures around the country have taken up that issue. Regardless where one stands on the question of whether physicians should be permitted to help dying patients voluntarily end their lives, a consensus is growing that your doctor should be able to ease your passage. What worries people most is the prospect of dying in misery. With good family support, good nursing care and adequate pain control, dying in misery is not necessary.
Adequate pain control has been an option since 1989, when Texas became the first of several states to pass an Intractable Pain Act. Not that passing a law necessarily solves problems, but it can pave the way to a solution. Despite recent advances, the reluctance of physicians generally to relieve dying patients' pain is widely documented. Doctors need to be informed about what the law says and to be confident that they will not be punished for practicing state of the art end-of-life care. State medical boards are bringing their members' knowledge of this issue up to date.
Our health care system still has trouble treating patients once treatment comes down to comfort, rather than cure. The art and science of palliative care finally are being introduced into medical and nursing school curricula and continuing education programs.
Public awareness of the need for end-of-life planning is growing. Choosing the right course when the choice is between prolonging life and maintaining life's quality happens one patient, one family member, one doctor at a time. The ham-fisted proposal before Congress would stymie this hard-won progress.
When dying patients say the pain is unbearable, doctors must be free to provide comfort. These very personal decisions should remain in the hands of those who have the biggest stake in their outcome - patients and their families, and the doctors and nurses entrusted with their care.
This article first appeared in The Washington Post, Friday, August, 21, 1998, and is reprinted here with permission of the author. Ronald A. Carson, racarson@utmb.edu, is director of theInstitute for the Medical Humanities, the University of Texas Medical Branch at Galveston.
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