The Paladin in Palliative Care: Miscast as the Black Knight

I’m trying to figure out how specialists in palliative care get mischaracterized as “killers”. I’ve thought of them as the paladins of end-of-life care although, according to a recent article in the April 23, 2012 issue of American Medical News (AMN), patients, families, and even some physicians continue to misunderstand them as the black knights of medicine [1]. They are subject to all kinds of name-calling including murderer, euthanasia, and killing. This is 30 years after hospice was made the standard of care for terminally ill persons. In fact, the data that drove the article were from a recent survey of well over 600 palliative care physicians, published in the March issue of Journal of Palliative Medicine [2].

This puzzled me even more when I received my copy of the April, 2012 issue of Psychiatric Annals, which was almost entirely devoted to the topic, “Psychosocial Interventions in Palliative Care.” A representative articles as summarized by Editor, Jan Fawcett, MD, was about distinguishing demoralization from clinical depression, and he praised the guest editor, Dr. Lorenzo Norris, MD, Medical Director of Psychiatric Behavioral Services for The George Washington University Hospital, for including both psychotherapy and psychopharmacology topics [3]

The focus in AMN was the prescribing of large doses of opiates and sedatives, sometimes to the point of hastening death, though not with that intention. The definitions of “euthanasia” can be found at this web link, Euthanasia Definitions and the operative word is “intention”. If that’s not present, then acts such as withholding futile medical treatments and administering high doses of medications for pain relief are not euthanasia.

So how did we get to the point where misperceptions about palliative care are “hard-wired”? Why are we afraid that physicians will not provide the most compassionate care for fear of being reviled as murderers? How does it happen that physicians doing their best to relieve suffering at the end of life are formally investigated by state medical boards, prosecutors, and institutions?

I tend to agree with some of those doctors who were interviewed for the AMN piece that the answer lies in the glacial pace of a cultural change in medicine and how patients and families view the role of physicians surrounding the issues of death and dying. The simple answer seemed to be that as laws and ethical practices evolved over decades about how and why doctors should learn to just be with dying patients–somebody forgot to tell “the public”.

That answer sounds too simple to be plausible to me. And yet, if doctors themselves are still accusing palliative care physicians of murder when they try to relieve pain and dyspnea, and they are not even aware of what else is being done to heal existential distress and depression–why couldn’t it be that we simply haven’t talked with “the public” enough?

Apparently physicians haven’t adequately spread the word amongst themselves, especially if I can view diametrically opposed perceptions about palliative care in medical and psychiatric publications which probably went to print within a couple of weeks of each other.

Maybe this has something to do with our fear of death.

Death is the wish of some, the relief of many, and the end of all–Lucius Annaeus Seneca (4 BC-65) Roman philosopher and playwright.

1. O’Reilly, K. B. (2012). Pain control carries a risk of being called a killer. American Medical News, American Medical Association. 55.
Accusations of euthanasia are common as patients, families and even other health professionals struggle to adjust to the new realities of end-of-life care.

2. Goldstein, N. E., L. M. Cohen, et al. (2012). “Prevalence of formal accusations of murder and euthanasia against physicians.” Journal of palliative medicine 15(3): 334-339.
BACKGROUND: Little is known about how often physicians are formally accused of hastening patient deaths while practicing palliative care. METHODS: We conducted an Internet-based survey on a random 50% sample of physician-members of a national hospice and palliative medicine society. RESULTS: The final sample consisted of 663 physicians (response rate 53%). Over half of the respondents had had at least one experience in the last 5 years in which a patient’s family, another physician, or another health care professional had characterized palliative treatments as being euthanasia, murder, or killing. One in four stated that at least one friend or family member, or a patient had similarly characterized their treatments. Respondents rated palliative sedation and stopping artificial hydration/nutrition as treatments most likely to be misconstrued as euthanasia. Overall, 25 physicians (4%) had been formally investigated for hastening a patient’s death when that had not been their intention-13 while using opiates for symptom relief and six for using medications while discontinuing mechanical ventilation. In eight (32%) cases, another member of the health care team had initiated the charges. At the time of the survey, none had been found guilty, but they reported experiencing substantial anger and worry. CONCLUSIONS: Commonly used palliative care practices continue to be misconstrued as euthanasia or murder, despite this not being the intention of the treating physician. Further efforts are needed to explain to the health care community and the public that treatments often used to relieve patient suffering at the end of life are ethical and legal.

3. Fawcett, J., MD (2012). “Helping People Live at the End of Life.” Psychiatric Annals 42(4): 116.
Death is something we all must face, both for our loved ones and ultimately for ourselves.

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Comments

  1. Linked to you in my Downhill Slope Post “Are You Ready To Die?” Grateful for your blog.

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    • Hi Kathy, I’m off to hospital rounds so time only for a quick reply. You are so very welcome and I appreciate your comment!

      Best,

      Jim Amos, MD

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