Compassion and Control at End of Life: An Appeal From Dr. Donald Low

John Mandrola

Disclosures

September 26, 2013

Dr Donald Low was a prominent Canadian physician. When Toronto faced a deadly SARS outbreak a decade ago, Dr Low was a voice of calm and reason. His research in cell signaling and infectious disease led some to think he was Canada's best chance for a Nobel Prize in Medicine. He did a lot of good in the service of others, right until the days before he died.

His courageous 7-minute video recorded 8 days before he died from a brain-stem tumor helps shed important light on dying with dignity. Here is one of the smartest and most accomplished doctor-scientists in the world speaking about what matters most to him—control. He is worried, not about dying, but about losing control. He bemoans the illegality of physician-assisted suicide in Canada. He makes note that those who oppose death with dignity would change their mind if they lived in his body.

At the risk of turning this blog into something sad, I can't help but be stirred. A few thoughts popped into my head.

Sudden Cardiac Death

Sudden cardiac death came to mind first. Compared with a brain-stem tumor, ventricular fibrillation looks good. I realize that sounds crazy; an electrophysiologist should consider sudden death a mortal enemy. And it is true: I certainly don't want humans dropping dead prematurely, but, when you progress past the folly of immortality, considering mode of death is important. Things like going to take a nap and not waking up or going out for a ride and falling off the bike dead are tragic in one way but beautiful in another. You love life; you don't want it to end, but . . .

I recall a beloved patient of mine. He was kind and humble man—a true gentleman. About a month after his ICD saw him through a VT storm, he developed a sore throat. The biopsy showed head and neck cancer. Despite my best efforts to encourage early palliative care, he suffered greatly from the disease and its treatment for months before he died. Such tragedy paints ventricular arrhythmia in a different way, doesn't it?

Anger

The second emotion I felt was anger. It brought back memories of Dr Paul Hugh's outrageous post in the Wall Street Journal this May. It's one thing for fringe politicians to promote the notion of death panels; it's far more inflammatory when influential physicians do so. To oppose giving a fellow human control of their destiny in the face of suffering lacks compassion. The Oath of Maimonides calls us to see the suffering in others and look after "the life and death of thy creatures."

The most important message of Dr Low's video concerns the issue of control. The good doctor worries most about losing control. Did you hear what he said about palliative care? He said it could lessen but not alleviate his suffering. Why would he say that? It's because he knows palliative-care doctors are constrained by what they can do in this medical-legal climate. Of course, terminal breathlessness can be alleviated. But in doing so, would some unenlightened colleague think it was the opioids that killed him, not his brain cancer?

Disease Kills

This is a teaching point: you're not getting opioids in high doses if you're not suffering from a terminal disease. When used to treat severe disease, opioids and the doctors who prescribe them aren't killing people—they are relieving suffering. Disease is what kills people. We must remember the fact that where physician-assisted suicide is legal, it's rarely used. Most patients don't utilize it because they find comfort in knowing they have control at the end of life.

Finally, as always, it's heart-healthy to end on an up note. Dr. Low's courage and commitment to serving fellow humankind inspires me. There's a lot about being a doctor that is prideful. Calling folks like Dr. Low colleagues ranks highest.

Love doctors.

JMM

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