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April 7, 2005
Erring on the side of life
In the wake of the Terri Schiavo case and Bush’s use of it for his infamous political motives, the role of palliative care for terminally ill patients is under intense scrutiny in America, writes Dr Mahjabeen Islam
Palliative care, a relatively new speciality in medicine, deals with the looking after of the terminally ill or those who have chronic diseases in which cure is not possible.
It originated from the Hospice movement founded by Dame Cicely Saunders in 1967 in England. A hospice is a place where terminally ill patients are treated and the emphasis is on pain and symptom management. Palliative care programmes are within acute care hospitals. A hospice patient is typically predicted to live only six months, but palliative care patients may live several years. The focus is more on improving their quality of life.
Thanks to Hollywood, America’s culture is rigidly based on immortality. So pervasive is it that physicians feel uncomfortable in discussing treatment options in the face of serious diagnoses. The New York Times reports that there was a time when families wanted treatment stopped but hospitals insisted on it. And now advances in medicine and the media’s coverage of a few patients who awoke from coma after years has families wanting to keep the patient connected to life support. Thus awaiting the same miracle to happen to them.
The advent of advanced directives in the United States goes toward greatly helping the patient who has thought about the future. In these situations discontinuing life support and curative treatment become, essentially, a brainless proposition.
It is in these situations where there is no such directive that physicians, dealing with the terminally ill, are faced with families that are not only overwhelmed with grief, but who also have unresolved issues and conflicts that makes it very difficult to arrive at a cogent plan of action.
Hospitals across the United States now have Palliative Care Units (PCU), where physicians and staff specialize in the care of the seriously ill. The choice to have these units has nothing altruistic about it. Studies have shown that the cost incurred on a patient in the last few days of hospitalization when they are in the PCU is one-quarter of what it is when they are in a non-palliative care unit. And with the government’s eye on utilization, hospitals find it in their best financial interest to have PCUs.
To see Terri Schiavo, who is in a vegetative state in a Florida hospice, is distressing for the family.
Deciding the course of action in a terminally ill patient depends greatly on the religious and cultural orientation of the patient and his/her family. In case of life threatening treatment issues, Muslim American patients are easy to deal with as they believe in the concept of prayer and medicine.
At the opposing end of the spectrum are Evangelical Christians, who simply refuse treatment. When it comes to serious diagnoses or discontinuation of life support, Muslims allow it more easily.
A great deal also depends on the manner in which the discussion is conducted by the physician; if unrealistic hope is held out, the family waits for a miracle and if the situation is explained candidly the family allows death with dignity.
Evangelical Christians in this regard can go either way; belief in the eternal life can have them let go, or a passionate belief in miracles can keep the ventilator connected.
If a living will and durable power of attorney for health care is not made out in life and at the time of serious decision making the patient is not competent, then the legal system of the United States gives that decision to the spouse.
Schiavo had a troubled marriage and had been suffering from an eating disorder that caused her potassium to fall and her heart to stop briefly. Speculation laid murder charges on her husband. A few years after the start of her vegetative state, he has a mistress from whom he has two children. Being Catholic, he wants his wife’s cremation without an autopsy rather than having her buried which makes one wonder all the more.
As parental love is unconditional and apolitical, perhaps there ought to be a legislative amendment that in terminally ill cases with no advanced directives, the health care power of attorney should belong to a parent and not the spouse.
This is not to say that the Schindlers’, Terri Schiavo’s parents, frantic desire to reinsert the feeding tube and prolong her life is necessarily the correct one. There are times when it is not life that is being prolonged but suffering.
The vast majority of patients that do execute an advance directive choose discontinuation of life support and artificial feeding in a situation where a meaningful recovery has been ruled out.
Very importantly, if the religious affiliation of these individuals who execute such a directive is taken, a full spectrum will be seen ranging from atheists to Evangelical Christians.
“In a serious diagnosis we should always err on the side of life” said President Bush, himself an Evangelical Christian. The sanctity of life is not the only tenet in Christianity even though Evangelicals delude themselves into believing that it is. It is sad that President Bush and his brother Jeb Bush, governor of Florida, have used the Schiavo case for political mileage.
A legal snub from the Florida courts and the Florida Supreme Court is well-deserved mainly because of President Bush’s blatant dichotomy about the definition of life and who is expendable and whose life ought to be preserved.
A drug addicted teenager should not be given the choice of an abortion even though she grew up in the cycle of poverty with no hope of ever getting out whilst her government spends trillions on the defence budget.
The thousands of servicemen that have been sacrificed and more than 100,000 Iraqi civilians that have died due to America’s unprovoked aggression in Iraq do not come under the umbrella of having a sanctified life. In the Bush mindset only the unborn baby and vegetative patients have precious lives.
As though the world was not falling apart as it were, we now have the Evangelical leader of the free world telling us what kind of life is expendable and what kind is not. And while we learn those definitions, let us also learn the meaning of selective, dichotomous and hypocritical.
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