Denny Klass’ Thoughts on Palliative Sedation

Editor Note:  Collington is lucky to have as a resident and resource Denny Kass, a renowned expert on issues relating to death and mourning.  A recent Washington Post article on how doctors can and do take steps that have the effect of easing the path to peaceful painlessness within the constraints of current law caused us to ask Denny to reflect on the rapidly changing landscape for us at Collington.  The key  quote from the post is : “Under palliative sedation, a doctor gives a terminally ill patient enough sedatives to induce unconsciousness. The goal is to reduce or eliminate suffering, but in many cases the patient dies without regaining consciousness.”  The opinions expressed are personal to Denny.

Will someone help us die when we are ready? The question has been, in different forms, part of the ongoing conversation at Collington for a long time. Last year the majority of Collington residents signed a petition to the Maryland legislature supporting an Oregon-style assisted dying law. A bus load of residents lobbied for the law in Annapolis. In February this year four residents attended a two-day conference on assisted dying at the National Science Foundation.

In this brief posting I will think about a few issues and possibilities in assisted dying in a way that I hope can help our community focus the discussion.

Physician assisted dying (PAD) modeled on Oregon’s law is now legal in several states. I believe the recent appointments to the Supreme Court will make it harder for PAD advocates, and because its opponents link PAD with abortion, the Court may restrict PAD as part of reversing Roe v. Wade.

Not having Oregon-style PAD actually has little effect at Collington. Those laws do not really fit our situation. The laws permit physicians to give lethal drugs, after many safeguards, to people who have a disease, usually cancer, that will kill them within six months. The same prognosis qualifies a person for Medicare to cover hospice. Howeer, that’s not the way most of us will die.

As we look around us, we can easily see that advanced aging is a series of debilitating physical and cognitive changes that slowly eventuate in death. Many of us have included Do-Not-Resuscitate (DNR) orders on our MOLST forms in the hope that if death comes quickly, emergency responders will not reverse it. But that will not happen for most of us.

An article in the Washington Post last week explored palliative sedation, a long-standing way physicians in both acute care and hospice have been legally assisting dying for a long time. The practice rests on a distinction between active euthanasia — giving medications to cause death, and passive euthanasia — giving medications (usually morphine) to relieve pain that may as a side effect hasten death. Thus passive euthanasia is treated the same as withholding or stopping active treatment.  The article notes that the opponents of PAD accept this distinction. Palliative sedation will probably escape legal changes in assisted dying that I think are coming in the next few Supreme Court sessions.

The Swiss have a different kind of PAD law in which all competent individuals retain their autonomy to determine their own manner of death. Individuals can decide when death is preferable to living. The film You Before Me was about a young quadriplegic traveling to Switzerland to die. In early May, we read news articles about  104-year-old Australian scientist David Goodall who took what he called the Swiss option. I think, however, the ultra-conservative Supreme Court majority would oppose a Swiss type law in the United States.

In the present legal climate, we can ask whether palliative sedation could be extended to the trajectory of dying most of us are on. Old age is a terminal condition. Even though it is composed of many diseases and syndromes old age always ends in death. The question remains: Will someone help us die when we are ready? Each of us could decide for themselves when our failing capacities makes death a better option than living, and after we have made that decision, could we ask to be put into a drug-induced coma that will hasten death.

For many in our community individual autonomy is the prime value. The opponents of PAD do not hold individual autonomy as a prime value. They think whether we live or die is God’s decision. Our Collington community is open to many religious beliefs. If some of our members wish to wait for God to decide their time has come, we should provide whatever support they need to be comfortable while they wait. Could Collington provide as much support for those who decide death is better than living as we provide to those who choose to wait for God?

2 responses to “Denny Klass’ Thoughts on Palliative Sedation

  1. Thanks for the thoughtful article. Many of our friends who live outside of Collington are also beginning to explore these issues, sometimes with their aged parents. I have shared this entry with them. I am confident we will continue this discussion.

  2. This is a very helpful perspective, Denny. As Collington’s health care providers change to provide what has been called “modern geriatric medicine,” it will be important to raise anew the question you pose at the end of your article. Thank you for raising it.

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