Issue date: November 11, 1998

Care of the dying: Doctors say there are compassionate alternatives to euthanasia Care of the dying: Doctors say there are compassionate alternatives to euthanasia (November 11, 1998)


Death may be inevitable, but pain and suffering that often accompanies the last stages of a terminal illness are not necessarily so, according to a number of physicians who are working toward improving the care of the dying.

When the problem of pain and suffering is properly addressed, the demand for doctor-assisted suicide lessens, according to Dr. Katherine Foley, a neurologist at Memorial Sloan-Kettering Cancer Center in New York and director of the Project on Death in America.

But in recent years, the focus of public discussions about death has been on the politically charged issue of physician-aided dying and euthanasia. Dr. Foley's interest lies, instead, in generating solutions to the problem of pain -- solutions that can be supplied by family, friends and health-care professionals who care for the dying.

Discussion of the care of the dying must be broadened to address what Americans value, what kind of society we are, and how we alleviate the pain and suffering of the terminally ill, Dr. Foley said in a presentation, "Transforming the Culture of Death in America," given at Stanford University last month.

Affirming life

Control of pain and of the psychological, social and spiritual problems of the dying through palliative care is paramount, said Dr. Foley, who also serves as chief of the Pain Service at Sloan-Kettering. The goal of palliative care is achievement of the best possible quality of life for patients and their families.

Palliative care affirms life, and regards dying as a normal process. It doesn't hasten or postpone death; it provides relief from pain and other distressing symptoms; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; and offers a support system to help the family cope during the patient's illness and their own bereavement.

Programs of palliative care stress that illness should not be regarded as an isolated aberration in physiology, but be considered in terms of the suffering it causes and the impact that it has on the patient's family. The unit of care is the family, rather than the patient alone.

In addressing the need to improve the care of the dying, the medical community must increase its understanding of the dying experience for patients and their families and identify barriers to appropriate end-of-life care, Dr. Foley said.

"In my clinical practice, I have been asked by suffering patients to aid them in death because of severe pain," said Dr. Foley. "I have had the opportunity to see these requests for aid in death fade with adequate pain control, psychological support, provision of family support, and with the promise that their symptoms would be controlled throughout the dying process," she said.

Physician and author Dr. Leon Kass attacks doctor-assisted suicide as an alternative to palliative care. "Physicians should focus on easing and enhancing the lives of those who are dying, rather than serving as a 'hired syringe' when medical treatment fails to restore health and wholeness," he said.

Dr. Kass, a physician at the University of Chicago and the author of "Toward a More Natural Science: Biology and Human Affairs," said appropriate amounts of analgesia, such as morphine, can be given to patients to relieve their pain. This is proper, he said, even when the amount of the drug given hastens death, as long as the intention is to treat the pain and not to end life.

More work to be done

While physicians like Dr. Foley and Dr. Kass are helping to lead a national discussion on palliative care for the dying, some members of the medical community apparently have a long way to go before terminally ill patients can be assured of such care. Severe, unrelenting pain interferes with the patients' quality of life, including their activities of daily living, their sleep, and their social interactions, said Dr. Foley.

Seventy to 90 percent of patients in the advanced stages of cancer have significant pain that requires the use of opium-based drugs, she said.

Eighty percent of elderly patients have chronic pain; and 66 percent have pain in the last month of life. Caregivers in a survey of deaths of 1,227 elderly people reported that 33 percent were in pain during the 24 hours before death, according to Dr. Foley.

Psychiatric problems occur in more than 60 percent of patients with advanced cancer, with adjustment disorders, depression, anxiety and delirium being the most prominent and well-described, Dr. Foley said. However, she said, studies show that psychiatric symptoms can be resolved with adequate pain relief.

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