Prolonging life: strategies and ethical considerations

Prolonging Life

Human life is a 'gift of god' and it is therefore not within the rights of man to put an end to life including his own life. Improving the quality of care and 'Prolonging life' should be the main goal of medical treatment. Palliative care should have more focus on better management of pain and disease symptoms. Legalizing euthanasia is not a good solution and could result in severe abuse that could undermine the sanctity of medical practice. We risk ending up in a medical and moral crisis if our hospitals slide along the slippery slope that is euthanasia.

End of life care has become a highly debated social issue not only in the U.S. But also throughout the world. With mercy killing or euthanasia now developing into a legal option, atleast in some countries new issues pertaining to the ethics and morality of palliative care have arisen. Proponents of euthanasia justify their case citing several reasons including the futility of continuing care in a non-responsive and terminally ill patient, the high cost of doing so, and the better utilization of critical care facilities where it is most needed and last but not least, to put an end to the misery of the patient. However, such a viewpoint fails to understand how it can negatively impact palliative care. The results from the Netherlands, one of the first countries to legalize euthanasia do not present a healthy picture. The arguments based on autonomy and compassion are also found wanting in many aspects. The aging population and the strain it places on medical resources is certainly an important healthcare issue that needs to be looked into by healthcare policy makers. However, economics as a justification for not 'prolonging life' fails under all ethical and moral counts. A brief overview of the ethical, moral and medical perspectives would provide better insight into this highly debated health care issue.

Palliative Care

Supporting the personhood of the patient during the critical period of illness when he/she needs most care is one of the important aspects of palliative care. While providing interventions to normalize the distressing symptoms, the nurse should also make sure that the disruptions are at a minimum. Other than clinical support, offering emotional support to the patient would help in reducing social isolation in the patients. As the World Health Organization states palliative care is, "The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of Psychological, Social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families." [G. Fanciullo, 2005]. Thus end of life care involves provision of complete care that is aimed at alleviating the symptoms and the pain, taking maximum efforts to meet the psychological needs of the patient and to ensure that terminal illness does not lead to the loss of personhood of the patient.

The Christian moral ethos emphasize the 'sanctity of life' and this doctrine forms the basis of palliative care. The underlying principle being that human life is a 'gift of god' and it is therefore not within the rights of a man to put an end to life including his own life. Similar belief is shared among other major religions of the world. Religion values life intrinsically for what it is. In giving its opinion on euthanasia, the Vatican defined euthanasia as, 'an action or an omission which of itself or by intention causes death'. [Simon Woods, 2007,PG 122] However, pro-euthanasia group stresses more on the quality and not the sanctity of life. But clinical evidence also suggests that, "The Hospice experience generally is that quality of life which seems completely inadequate to the healthy onlooker is in fact almost always valued highly and clung to tenaciously" [Twycross RG]. The perspective of a suffering patient and that of a healthy onlooker maybe vastly different in terms of gauging the quality of life.

Pro-euthanasia groups talk about the quality of life as an important criterion in prolonging life and continuing treatment. However, this argument is really weak and as we discussed above the quality of life maybe perceived differently by the patient and the healthy onlooker. Besides the following comment by a nurse on euthanasia is clearly direct and to the point. "There is no quality of life when the patient is dead.." [Euthanasia.com] This is a clear expression of the anguish and clearly illustrates that palliative care should focus on assuaging the pain and improving the symptoms of the patient during his final days and not be debating the quality of life as a basis for continuing medical intervention. Such an approach to providing end of life care is really dangerous and could easily become a destructive practice of medicine. The former surgeon general of the United States Dr. C. Everett Koop, M.D., says,".. we must be wary of those who are too willing to end the lives of the elderly and the ill. If we ever decide that a poor quality of life justifies ending that life, we have taken a step down a slippery slope that places all of us in danger. There is a difference between allowing nature to take its course and actively assisting death" [Life issues Institute].

The medical argument based on the futility of treatment as a justification for euthanasia (active or passive forms) is totally wronged. Every physician has taken the Hippocratic oath, "I will give no deadly medicine to any one if asked, nor suggest any such counsel." [Chao, 2002] Thus euthanasia clearly undermines the fundamental oath of the physician and distorts the role of the physician from a lifesaver to a life ender. It also creates an unnecessary fear in the patient. It is essential to understand that both active and passive forms of euthanasia are against the ethics of a physician. The passive form of euthanasia involves withdrawal of life support interventions while the active method involves administering a lethal injection. While in the first instance 'something was not done' or the inactivity that contributed to death, in the latter case 'something was done' to bring an end to the patient's life. [Pregnant Pause]

Even in cases where the patient voluntarily requires euthanasia it should be understood that "the request to die may simply be a cry for help." The fact is that even temporary unbearable pain or disease may sometimes prompt us to give up life. Interpreting a patient's request not to prolong his/her life is therefore not a straight forward task. As Dr. James Gilbert, University of Exeter, says from his vast experience of working with terminally ill patients, there is "no persistent rational demand" for euthanasia. [Seale C, 1995] Advanced directives by patients may well be prompted by fear of intense pain and the possibility of them being totally incapacitated. The American medical association has expressed its concern about the growing debate on euthanasia. In a recent statement the AMA stated, "There is, in short, compelling evidence of the need to ensure that all patients have access to quality palliative care, but not of any need for physician-assisted suicide ...." [Life Issues Institute] Thus improving palliative care and pain relief should be the focus of clinical practice and not about ending life. As Dr. Gomez, Virginia University says, "The delivery of (adequate pain relief) is 'grossly inadequate' today, and efforts to make such care universally available have not yet succeeded. We now have lots of documented evidence that an aggressive drug regimen can effectively protect dying patients from pain. Doctors won't have any trouble prescribing medication if they are careful and document their actions" [Life Issues Institute].

Let alone external life support devices, even hydration and nutrition is now subject to dispute. Studies have resulted in opposing viewpoints triggering conflicting opinions about providing hydration and nutrition for terminally ill patients who can no longer continue eating normally. It is well-known that dehydration can cause confusion, delusion and neuromuscular irritability. Parenteral hydration helps remove these symptoms and it is 'the minimum standard of care." If such minimum care could be withdrawn then there is every possibility that other interventions and therapies might be routinely dismissed for other patients. Though clear evidence maybe lacking for the comforting effects of hydration, there are no negative effects in providing hydration and nutrition. In fact, studies have reported that removing hydration could result in prerenal failure. Researchers have also opined that expression of symptoms may not be uniform for all patients. While some patients may not feel any symptoms from dehydration, others may experience opioid toxicity and restlessness. Thus providing hydration and nutrition for terminally ill patients who do not have any appetite or could not eat by mouth should be considered a very basic necessity. [ Robin L. Fainsinger, 2001]