COMMENTARY

Good News About Dying in America

Disclosures

January 04, 2016

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Changing a culture is one of the most difficult of human tasks. The American cultural norm, for many decades, even centuries, has been to sustain human life and to prevent death for as long as possible. The cultural change we need now is to allow death to occur when its time has come and to do so with dignity and without undue pain and suffering for the patient to the greatest extent possible.

I am actually beginning to be a little optimistic about dying. Not my own dying—I am no more looking forward to that than most of you are. Nothing is pretty about dying, unless one accepts that it is a normal process and even our responsibility, sooner or later.

To accomplish medical and cultural change, one needs to work at the levels of moral beliefs and ethical standards with professional and individual leadership. Subsequent changes in state and federal laws and regulations may be needed. Economic drivers can move it along. But first, you have to get their attention.

When we published, "It's Over, Debbie"[1] in JAMA in 1988, the hullabaloo was massive. But this factual tale of a caring physician using intravenous morphine to end the horrid pain-wracked life of a young woman with terminal ovarian cancer shook a largely complacent culture. Next was Dr Timothy Quill and his disclosure[2] in the New England Journal of Medicine in 1991 that he prescribed barbiturates at the request of a leukemia patient to allow her to end her life. Then, beginning in 1990, Dr Jack Kevorkian and his suicide machine assisted in the deaths of more than 100 patients[3]; the right message writ large but by a deeply flawed messenger.

The hospice movement, centuries old, burgeoned in the United States in the 1990s and became a multibillion-dollar business. Palliative care, born out the hospice movement, is now widespread and may be provided at any time or place and not only in terminal care. Leaders from the ethics community such as Dr Linda Emanuel, director of the Institute for Public Health and Medicine (IPHAM) Buehler Center on Aging, Health, and Society at Northwestern University Feinberg School of Medicine in Chicago, and Dr Arthur Caplan, professor of bioethics and director of the Division of Medical Ethics at the New York University Langone Medical Center, have provided sage guidance along the way.

On the American legal front, Oregon pioneered physician-assisted suicide by popular vote in 1997. With all of the built-in safeguards, only some 1200 people in nearly 20 years have asked for the medications to kill themselves, and nearly half of those have not even used them.

The state of Washington followed Oregon in 2008, also by ballot initiative; then Montana, by court order; and in 2013, Vermont, by legislative action. Now, the big one: California Governor Jerry Brown, once on the Jesuit road to the Catholic priesthood, recently signed into law the End of Life Option Act. It will go into effect in 2016 in our largest state. Many more states will follow as we approach a tipping point.

On the US federal front, Medicare tried years ago to institute payment for physicians to provide end-of-life counseling for seriously ill patients. But Sarah Palin's 2009 demagogic "Death Panels" harangue derailed that effort. At long last, the Centers for Medicare & Medicaid Services has approved payment for voluntary end-of-life counseling as part of its 2016 Medicare physician payment schedule. When you pay physicians to do something, they will do it.

Finally, for the next driver in this phase of our metrics-crazed medical system, hospitals interested in their patient safety statistics might do well to note that much of what is chalked up as deaths related to medical error is actually occurring with the frail elderly, often in critical care units (CCUs). Many of these patients probably should not be in the CCU anyway. Maybe not even in hospitals. Most Americans say that they prefer to die at home, in the company of loved ones, not hooked up to tubes and contraptions, on meaningless and futile life support. Help your safety statistics; let the dying die at home.

That's my opinion. I am Dr George Lundberg, and this is At Large at Medscape.

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