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Book Review: "No Good Deed: A Story of Medicine, Murder Accusation, and the Debate over How We Die"
Posted on June 8, 2011
Dr. Lewis Cohen is a psychiatrist who's worked with dying patients whose problems include renal failure and who've decided to forgo further life-prolonging therapies, including dialysis. The "good deed" of his title is the administration of optimal, aggressive palliative care to these and other dying patients, even at the risk of hastening death.
Cohen's book takes as its point of departure the case of two nurses accused by a coworker of conspiring to murder a patient. He documents the ordeals to which they (and several similarly-accused care-givers) are exposed, and elaborates on the personal trauma for all involved. He explores the circumstances which give rise to these unfortunate situations, as well as several of the broader end-of-life care issues—international attitudes on end-of-life care including everything from truth-telling to aggressive palliative care, Oregon-style Death with Dignity policies, and active euthanasia. The book is non-technical, very accessible, and provides real insight into the national controversy over aggressive palliative care for the dying.
Current American health care policy is a work-in-progress, borne of a heated, decades-long ideological, legal and policy war, between advocates of patient autonomy and aggressive palliative care for the dying on one hand, and those who espouse a "sanctity of life" ethic which requires mandatory life-prolonging treatment irrespective of prognosis or patient's wishes. One of the more recent and dramatic battles in this war involved the case of Terri Schaivo, which ultimately played out first in the US Congress and then in the US Supreme Court. Current law and health care policy suggest the victory has gone to the advocates of autonomy and of aggressive palliative care in the specific battles over the right to refuse any treatment (even life-prolonging treatments already in progress, and artificial nutrition and hydration), hospice, advance directives, and even end-of-life palliation so aggressive it may hasten death. However on the frontlines of palliative care delivery, Cohen explains things may not be so clear.
American Medical Association (AMA) policy states "[P]hysicians have an obligation to relieve pain and suffering……of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death [italics added]." Similarly the American Nurses Association (ANA) stipulates "[T]he nurse may provide interventions to relieve symptoms in the dying client even when the interventions entail substantial risks of hastening death [italics added]."
How, then, can health care givers adhering to these policies be at risk? Two reasons: The first involves the way the line is currently drawn between optimal aggressive palliative care and homicide. The second involves the ongoing ideological battle.
While American law, as well as AMA and ANA policies, accept the administration of palliative treatments even at the risk of hastening death, they are squarely opposed to intentionally hastening death, even for compassionate reasons. (Current exceptions are Oregon, Washington and Montana.) As a result, the difference between a homicidal act and the administration of optimal palliative care to which the dying patient has a right may lie in neither the deed nor the outcome, but in the intention of the agent. Thus the doctor or nurse who administers a death-hastening treatment may either simply be doing his/her job as called for by AMA and ANA policies, or may be committing homicide. Given the prospect of having their own fates turn on this distinction, doubtless some caregivers are inclined to stay their hand in providing aggressive palliative care—even when a dying patient is suffering and it would be entirely appropriate.
The second reason caregivers are at risk is because of the ideological divide I alluded to above. Ideologies can dictate what we see, and actions seen as exemplary through the lens of compassionate palliative caregivers can easily strike a proponent of the "sanctity of life" as homicide pure and simple. In the case that Cohen focuses on, an aide calls the police to report a murder after she has been instructed by a nurse not to replace an oxygen mask she has just removed, and then witnesses the nurse telling the patient "it is all right if you go now" before administering morphine, shortly after which the patient expires.
While such cases are not common, they are not unknown, and Cohen provides some statistics on this and interviews several of those involved in other cases. He offers several suggestions to improve the situation, including better education of all involved in palliative care settings and relevant legal authorities, the provision of channels within hospitals through which concerns can be voiced, as well as state medical advisory panels for law enforcement officials (including homicide detectives) who may be unfamiliar with the nuances of current palliative care standards.
Although Cohen's sympathies are ultimately with those who believe in aggressive palliative care, the book is not a "hatchet job" with respect to "sanctity of life" advocates. Cohen does his best to convey sympathetically the point of view of those whose belief in the sanctity of life is heartfelt, including the nurse's aide who felt she had witnessed "a monstrous act". A nit I would pick is perhaps too much space is devoted to the personal stories of the two nurses and their accuser, to which Cohen returns repeatedly. But grounding his account in these personal stories certainly serves his goal of bringing home the personal risks palliative care specialists may subject themselves to in their pursuit of providing optimal end-of-life care.
Posted on June 8, 2011 in The Arts
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