Monday, June 6, 2016

"As California's End of Life act goes into effect, some doctors question where to draw the line"

From Los Angeles Times:


"As a new law goes into effect in California allowing terminally ill patients to take medicines to kill themselves, physicians are contemplating whether they would ever write a prescription for death.

"For Dr. Neil Wenger, an internal medicine doctor and director of the UCLA Health Ethics Center, physician-assisted dying blurs what had once been a clear distinction for physicians.

"'We have always, up till now, been able to say we will never hasten a death,' Wenger said. 'Suddenly, that bright line is not so bright.'

"He added that the Hippocratic Oath doesn’t just say that doctors shouldn’t harm patients but specifically forbids providing poison to kill someone. 

"Wenger’s stance is common among doctors in California: He accepts that physician-aided death is now legal -- in fact, he’s in charge of implementing the new law at UCLA -- but remains unlikely to participate himself, saying it goes against his oath to save lives.

"Though both advocates and opponents of doctor-aided death call California’s legalization a big step -- either forward or backward – for medical care, experts predict that it would probably be a marginalized practice within the healthcare system, with few patients asking for lethal medications and few doctors furnishing them. 

"'For most of us this may be a once or twice in a lifetime, or in a career, situation,' said Dr. Jay Lee, head of the California Academy of Family Physicians.

"When the End of Life Option Act goes into effect Thursday, California will become the fifth state in the nation to allow patients with less than six months to live to request end-of-life drugs from their doctors. 

"The law is intended to help terminally ill patients avoid suffering. When he signed the bill into law in October, Gov. Jerry Brown wrote that he believed it would be a comfort to have this option if he were 'dying in prolonged and excruciating pain.'

"More than three-fourths of Californians were in favor of such a law, including 82% of Democrats and 67% of Republicans, according to a poll conducted last year by the Institute of Governmental Studies at UC Berkeley.

"But doctors tend to be more wary. Neither the American Medical Assn. nor the California Medical Assn. support such legislation.

"Physicians have no obligations under California’s law; they don’t have to prescribe such medications if asked or refer patients to colleagues who will. They don’t even have to discuss aid-in-dying if a patient approaches them about it.

"But leaders of physicians groups say they want doctors to be able to talk about the treatment so they can properly address patients’ concerns and questions.

"For the last several months, these organizations have been holding webinars and training sessions and providing educational materials about the law. The California Academy of Family Physicians launched a podcast in April about end-of-life care options.

"Lee said they want doctors to be better at talking about all treatment options around death, as well as physician-aided death specifically. 

"'Not everyone feels entirely comfortable yet, because it’s been, kind of, in the medical community, a taboo topic,' Lee said.

"Some doctors object to the idea that a patient’s pain could be so great that they would choose to die. It’s unlikely for pain to not be controlled with palliative care or other treatments, they say.

"Wenger said that sometimes a patient feels so much pain that they need to be sedated to a point of unresponsiveness. But he’s only seen one or two patients like that in his more than 20-year career, he said. 

"In Oregon, only 25% of those who died from lethal medication said they were worried about pain control, according to data from the state’s public health department

"More common reasons for choosing aid-in-dying were loss of autonomy (92%), being less able to engage in activities that made life enjoyable (90%) and burdening family or caregivers (41%)."

Read more:

"Some doctors object to the idea that a patient’s pain could be so great that they would choose to die. It’s unlikely for pain to not be controlled with palliative care or other treatments, they say."  So, because they don't like the idea, it doesn't happen. 

From the comments on The Journal Times site on a story entitled: "Heroin deaths continue locally in Racine County":
My concern about any so-called ‘...comprehensive solution to the opioid epidemic’is with the bureaucrats who lump seniors who deal with 24/7 pain together with drug addicts. That broad brush approach may be simple for bureaucrats to implement but it causes massive problems for patients and doctors. Doctors now fear the loss of their license if they prescribe even nominal opioid amounts to the elderly to control 24/7 pain when nothing else has proven to work. I am not talking about one-off pain med needs. I am talking about pain management for degenerative diseases where it has been proven that nothing else works. Many elderly tried PT, exercise, Chinese herbs, acupuncture, yoga and more. These are the people I am talking about. Bureucrats and legislators would be best served by talking first hand with elderly constituents who live with debilitating 24/7 chronic pain to try to understand this critical issue.
Today’s opioid epidemic means the elderly are discriminated against via broad-brushed laws that toss them into the same bucket with teen age heroin and meth addicts without consideration for underlying causes of 24/7 pain, e.g., degenerative osteo and rheumatoid arthritis, cancer, spinal degeneration. If you experience 24/7 pain, you are automatically labeled a drug abuser, an addict, no different from a meth head! It is now YOUR FAULT that you experience pain. YOU are a terrible person because you have pain. YOU are to be vilified, accused, judged, AND YOUR PAIN WILL NOW BE IGNORED!!!!! Those responsible for helping you, i.e., doctors, throw their hands up in the air and claim there is nothing they can do to help. In other words, maybe the elderly should just go into some corner somewhere and die. Please, don’t tell me I am over simplifying anything here. I’m just speaking facts.

Don't let the pendulum swing too far yet again but this time in the opposite direction. We let it swing too far on the use of opioids. Some patients and some doctors abused it. We now know through that experience that it not only did not work, it caused this epidemic, increased addictions and deaths. But, let’s also analyze the data to prove who died. Were the deaths among elderly who were under doctor care? Were the deaths among kids trying to get a high? Were they among known addicts? The news media carefully avoids any data to prove which age groups are most affected. Why is that when we know -- or should know -- data are critical to reaching intelligent decisions?

Here is a doctor’s comment about the critical need for data analysis from the 3.16.2016 edition of Med Page Today:

“Sadly, Opioid Addiction has become the medical news of the day. Unfortunately, much of the conversation has been based on a giant lie, half truths, and misinformation which makes trying to solve a real problem that much more difficult.

First we have to understand that the vast majority of overdoses are the result of use of heroin, methadone, and the illegal use of prescription opioids. The number of deaths from the legal use of prescription opioids under the care of a legitimate doctor - as opposed to the pill mills - is relatively uncommon.

Unfortunately, much of the news coverage lumps the legal use of prescription opioids in with non legal use and illegal opioids giving an entirely false impression of the problem. As a result, and given the changes in regulations, being in pain has effectively become criminalized and Doctors are now forced to act as parole officers.

The real problem is actually concentrated in the broader use of illegal drugs. In other words it is not medical problem but an illegal drug and crime problem.

This is a problem that will not be fixed until people start treating it for the problem it really is instead of lying about the facts.” End Med Page Today quote.*This comment on the article “FDA science advisors talk strategy on Opioids” was written by “ZB” at this link. Comments are on the right side of the article:

Let’s learn from MAJOR errors of our past that were based on ignorance and no small amount of marketing by pharmaceutical firms. Let’s be smart this time, let’s be selective, let’s be definitive, let’s use data and be intelligent about any laws that deal with pain management for the elderly. Also, let’s focus on the underlying causes of addiction and put programs in place to address the causes.

Pain management does not warrant broad brush solutions or ignorant assumptions. The link below cites the personal encounter with chronic pain by Philip Pizzo, postgraduate medical student, that dramatically changed his limited view of chronic pain. As he puts it: “Previously, I had sometimes wondered whether the chronic pain that patients reported was as incapacitating as they claimed. I now know that it can become debilitating. It can take over one's life, sap one's energy, and negate or neutralize joy and well-being.” Read his New England Journal of Medicine article here:

The elderly in chronic pain are not intent on getting high. They need and seek effective pain management that allows them to live their lives in comfort, to remain productive members of society, and to enjoy their family and friends. No bureaucrat or legislator should allow any bill to lump the elderly together with addicts or kids seeking a high in search of a ‘...comprehensive solution to the opioid epidemic.’

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