Choosing a better death

Could dying be better?

By now most people acknowledge that there are “good” deaths: peaceful, with minimal pain, at home surrounded by loved ones – and “bad”: pain-filled and prolonged, often for months or years and more often than not in a hospital or other institutional setting. The movement toward “good” death – legalized medical aid in dying – has been growing for decades in the U.S., but has been gaining momentum and attention in recent months.

Liner.2Robert Liner MD, a retired obstetrician/gynecologist, gave an informative update on the movement at a recent University of California San Francisco grand rounds. Liner is one of four patient plaintiffs in a California lawsuit which would make that state the sixth to legalize physician aid in dying, and a longtime supporter of leading end-of-life organization Compassion & Choices. The suit is also joined by three physician plaintiffs.

Liner, whose cancer is in remission, said he would personally prefer to avoid death altogether. “But along with birth, dying is a universal experience. It’s what we all do.” And equally universal, he noted, is the wish to make that experience a little more compassionate, a little closer to what most of us would choose.

Liner outlined the current status of California SB-128, the End of Life Options Act, now working its way through the senate. While granting terminally ill, mentally competent adults the right to ask their physicians for life-ending medication, the bill would also establish safeguards such as requiring assessments by multiple physicians and repeat requests for the medication made at least 15 days apart. A similar law in Oregon has proven valuable in many aspects over the 18 years in which it has now been in place, Liner said. Death W Dignity newspaper

He cited a study published in the New England Journal of Medicine at the end of the Oregon law’s first decade which found that since passage of the law Oregon has seen improved training for physicians in end-of-life care, an increase in individuals’ completing advance directives, improved pain management and rates of referral to hospice and an increase in number of people dying at home.

Putting the better-death movement in historical context, Liner referenced a significant case several decades ago that sometimes goes unnoticed. In 1991, he explained, New York physician Timothy Quill published an article in the New England Journal of Medicine describing how he had prescribed barbiturates to a dying patient when her leukemia reached a point at which she no longer wanted to live. A grand jury subsequently declined to prosecute. Quill later became one of the plaintiffs in a case that wound up reaching the U.S. Supreme Court. And in 1997 the Court let stand a New York law prohibiting what was then called physician-assisted suicide, ruling that there is no federal constitutional right to die – effectively turning the issue back to the states.

Five states – Oregon, Washington, Vermont, Montana and New Mexico now allow physician aid in dying, Liner explained. California’s efforts to become the sixth include a campaign launched last year by Compassion & Choices and the lawsuit filed early this year.

Scales of justiceLiner distributed copies of the April edition of San Francisco Medicine, the journal of the San Francisco Medical Society, in which he and two of the other physicians involved in the lawsuit explain their support for legalized aid in dying. “Collectively, we represent almost a century of medical practice, teaching and research…(and) probably most relevant is our extensive experience caring for dying patients,” write lawsuit plaintiffs Liner, Donald Abrams, MD and Marcus Conant, MD in San Francisco Medicine.

The lawsuit is backed by national disability rights advocacy group Disability Rights Legal Center, Liner explained, and cites a number of reasons why aid in dying should now be legalized. While some arguments – such as privacy and liberty interests – are complex, one seems fairly straightforward: California penal code section #401, which makes it a crime to aid or encourage someone to commit suicide (a very different situation from a dying person’s wish to shorten his suffering), was written more than a century ago. Before dying shifted from being commonly a home event overseen by the familiar family physician to hospitals or other institutions where the large majority of Americans now spend their final days and weeks. Before medical technology made it possible to prolong life, often far past any “life” many would choose.

Liner, and millions of other Americans, believe choice in dying should rest with those who are dying themselves.

 

 

Wise Words from Doctor Turned Patient

Bob-baldric

Not every doctor gets an extended view of what his or her patients experience. But one who did – and has shared both the experience and its message(s) is a recently recovered friend and end-of-life issues colleague of this writer, Robert Liner, MD. Liner spent 20 years as an Ob/Gyn with clinical and teaching positions, principally at Mt. Zion Hospital in San Francisco, followed by 20 years in private practice of prenatal diagnosis and gynecologic ultrasound. Among his exhausting list of interests and endeavors are piano lessons, playwriting, poetry, working to publish an illustrated lullaby — and serving on the Leadership Council of Compassion & Choices of N.CA. (And occasional adventures into designing menswear, such as a reincarnation of the ancient ‘Baldric‘, modeled above, which Liner feels makes a lot more sense than the necktie.)

Not long ago, though, all of these – plus a simultaneous major house move and recent new marriage to longtime lady friend – were severely complicated by a bout with life-threatening illness.

“A year ago, on my sixty-ninth birthday,” Liner wrote in an article that recently ran in San Francisco Medicine, “I checked into Kaiser Hospital for work-up of a chronic cough, back pain, severe anemia and a low-grade fever. Believing that patients often overreact to symptoms and seek medical attention prematurely, I had let things go a bit far. I’d been easily fatigued and a bit short of breath, but when a couple of days prior to my hospital admission my wife saw me leaving food on my plate at a favorite restaurant, she insisted on taking me to the ER. I told her this would be an abuse of ER resources but, once there… watching two units of blood being transfused into me, I brilliantly arrived at (the same) conclusion: I was seriously ill.”

Liner covers the days of his hospitalization with openness and humor: “Generally, when getting medical care, I avoid mentioning that I’m a physician. Even experienced providers sometimes have steadier hands when not aware they’re administering to a physician. Or, for that matter, to a malpractice attorney.” (You can read the entire, illuminating piece in the current issue of San Francisco Medicine. It is a significant message to physicians, and an informative and reassuring message to anyone facing hospitalization.)

Liner emerged from more than six months of chemotherapy, radiation therapy and “a lot of drugs” with his B-cell lymphoma in complete remission and a low percentage chance of recurrence. But in addition to the firsthand lessons for physicians and patients about illness, he offers a powerful lesson for all of us about dying – since all of us, patient and doctor alike, do eventually die. Liner and his wife faced that possibility throughout a 36-hour period in which it seemed likely that his disease would, in fact, be terminal; they faced it with “a profound sadness.” But he explains:

“There was nothing irrational about that sadness. Patients who are genuinely terminally ill and who seek physician aid in controlling the time and circumstances of their deaths should not be thought of as irrational or pathologically depressed. If, unexpectedly, my lymphoma recurs, the prognosis would be ‘dismal.’ If that happens, I believe it should be within the scope of ethical, legal medical practice for my doctor to provide me with a lethal prescription – a key to the exit.

“Physician aid in dying is something distinct from suicide. The disease would be killing me. No compelling state interest here. No slippery slope. Only a decision to be made by me as a patient, along with my family and my doctor. As a physician and as a patient, I see this as a fundamental liberty interest and as sound, compassionate practice of the art of medicine. Of, course, where my death is concerned, I’d rather skip the whole thing.”

Wouldn’t we all.

 

 

Doctors, neckwear & the male brain

Bob-baldric
Dr. Liner in his Baldric

This space is happy to offer up-to-the-minute insights, today’s concerning connections between neckties, germs, the male brain and other organs.

First, reporter Rebecca Smith writes in today’s Wall Street Journal that neckties may be helping spread flu germs, and many people inside and outside the health care industry think they should go.

“The list of things to avoid during flu season includes crowded buses, hospitals and handshakes. Consider adding this: your doctor’s necktie.

Neckties are rarely, if ever, cleaned. When a patient is seated on the examining table, doctors’ ties often dangle perilously close to sneeze level. In recent years, a debate has emerged in the medical community over whether they harbor dangerous germs.

Several hospitals have proposed banning them outright. Some veteran doctors suspect the anti-necktie campaign has more to do with younger physicians’ desire to dress casually than it does with modern medicine. At least one tie maker is pushing a compromise solution: neckwear with an antimicrobial coating.

BUT HOW ABOUT JUST SWITCHING TO THE BALDRIC?

My friend Robert Liner MD, a distinguished physician/piano player/tango dancer/fellow board member of Compassion & Choices of N.CA and general Renaissance man, made this switch some time ago. In rather characteristic Liner fashion, he then established a company which produces Baldrics in order that others may enjoy them.

Earlier Baldrics were worn by most respectable Scots so they would have something handy from which to hang their swords. But for the 21st century, as Liner writes on his company web site:

We are re-inventing the Baldric for present day men and women on the go. I originally conceived the idea of the Baldric as a new fashion statement for men. Instead of a constricting necktie, a man could dress up with a Baldric. Instead of carrying a sword, the modern man could employ his Baldric to carry his sword equivalent: a cell phone, I-Phone, Blackberry or other p.d.a.. Additionally, in place of a bulky wallet, he could keep credit cards, folding money and small personal items easily accessible in a secret pocket in his Baldric. The Baldric is a hybrid: it’s a necktie alternative that performs like a sleek, modified, minimalist messenger bag.

Contacted today about the germ issue, Liner reports he had indeed heard of such. “Of course, it’s seemed to me,” he muses further, “that the more significant problem with neckties from the point of view of health and world peace is the possibility that neckties reduce blood supply to the male brain. This may account for a good deal of what looks like irrational behavior on the part of my sub-species. This can especially be a problem during adolescence and at other times (ie. most of the time) when demand is placed upon the male circulatory system to divert blood to an organ that is not the brain but sometimes functions in place of the brain. Under these circumstances, the male blood stream can hardly afford to have any restriction placed upon the “choke point” by a necktie so that what little blood is left available to go north to the “main brain” is impeded, resulting  in chaos on a global scale.”

Considering the problems of H1N1 and other viruses, and the potential for advancing world peace as Dr. Liner suggests might happen with fewer neckties, this space hereby blatantly endorses the Baldric.