The Conversation

Leo Oltzik was a lanky man with a piercing gaze, a draftsman who, among many
of his projects, worked on plans for the Second Avenue subway. In 57 years
of marriage, he and his wife, Eleanor, had a son and a daughter and hardly
ever argued.

They slept in the same bed, even after a railing had to be installed on one
side to keep Mr. Oltzik from jumping out. But around Thanksgiving, Mr.
Oltzik became too agitated for his wife and son to continue caring for him
at home. "He was fighting death," Mrs. Oltzik said.

After three days of efforts to calm Mr. Oltzik in the hospice failed, Dr.
Halbridge told the family that he was going to try an IV drip. Mr. Oltzik
was connected to an intravenous bag of Ativan, a brand name of lorazepam,
and he was given Roxanol, a liquid morphine, for pain and shortness of
breath. He lay in a large room where the December sun washed over flowered
curtain ruffs, plush carpeting and lavender chairs. He looked as if he was
sleeping, except to his wife.

"That's not him," she said, pulling out a photograph from better times.

On the sixth day, the staff invited Mrs. Oltzik and their son into a cozy
meeting room, equipped with an overstuffed couch and chairs. They were
joined by Dr. Halbridge; Barbara Walsh, a nurse managing the hospice team;
and Lynne Kiesel, a medical social worker, who called the Oltziks' daughter,
Barbara Ladin, in Florida, and put her on a speakerphone.

"We have these meetings to talk about how you're doing, how he's doing, and
to give you a chance to ask us questions," Ms. Walsh began, then turned to
Dr. Halbridge, who signaled his profession with the stethoscope wrapped over
his dark blazer like a shawl.

"Our biggest challenge was to try to get him not to be so agitated," Dr.
Halbridge began.

The staff had tried to calm him with various medications by mouth, without
success. "So we put him on an IV medication, which is dripping in at a
continuous rate," he said.

The doctor pressed ahead, in a cheerful, upbeat voice, tinged with regret,
saying that the staff had to decide what was better for Mr. Oltzik in the
long run and wanted the family's opinion. His blood pressure was falling,
"which implies that his body is slowing down, but he's comfortable, and
that's what we're looking for," Dr. Halbridge continued. (Low blood pressure
can be a side effect of Ativan and Roxanol, according to the drug
manufacturers, as well as a consequence of the dying process.)

Ms. Walsh added consolingly, "He really looks like he's sleeping."

She said, apologetically, that the hospice had tried to find a balance
between controlling Mr. Oltzik's agitation and making him too sleepy.

"We did go to this IV as kind of a last measure, because we know that people
do get sleepy and may not be as responsive, and we know how hard that is for
the family to see," she said.

Mr. Oltzik's daughter zeroed in on the question that had been hanging over
the discussion: "This is the end?"

"Yes, pretty much," Dr. Halbridge said, "because what we're
seeing is a man
who had a rather significant blood pressure on admission, and over the past
day now, and today again, his blood pressure is even lower. So we're talking
about a poor prognosis and a shorter time."

Mr. Oltzik's son detected an almost imperceptible change in his mother.
"Stay calm," he urged her.

Moments later, the social worker gently entered the discussion, saying,
"You've given him excellent care at home."

"I worked very hard," Mrs. Oltzik said.

Although throughout the half-hour meeting the staff had never explicitly
asked to continue sedating Mr. Oltzik, his daughter now gave them tacit
permission: "We understand that the inevitable is here, but we wish him to
go in peace and to find solace in that," Ms. Ladin said.

When the conference was over, Mrs. Oltzik still seemed to be ruminating. As
many relatives do, she had hesitated over whether her husband should be
given nutrition and water through tubes, now that he could not feed himself.
The thought of someone dehydrating or starving is one of the most difficult
emotional burdens for families, and was the crux of the famous fight over
Terri Schiavo, a vegetative Florida woman whose husband wanted to let her
die, but whose parents did not.

Palliative care doctors generally agree that sedated patients do not feel
pain from dehydration or starvation, and that food and water may only
prolong agony by feeding the fatal disease.

Mrs. Oltzik had done some research, and decided that nutrition and water
would only burden her husband's system. "The idea is now not to make him
work harder, but to be as peaceful and calm as he can," she said. "Common
sense dictates that that would be the way to go."

Much of the conversation had proceeded not in black and white like a legal
document, but in shades of gray. By the end, they all seemed to understand
one another, though ultimately Mrs. Oltzik would express some sadness at
being unable to interact with her husband.

The Family's Dilemma

From Karen Foster's perspective, watching her husband, Frank, die while
sedated was the least in a series of cruel blows. Mr. Foster, who arrived at
the Franklin hospice about the same time as Mr. Oltzik, had stoically hidden
his liver cancer from his family for years. As recently as October, he was
still driving, Mrs. Foster said; then he suddenly went downhill.

The night before Thanksgiving, her husband was acting bizarrely, and soon he
was admitted to the hospice, Mrs. Foster said. Dr. Halbridge put him on
morphine for pain and Ativan to calm his shortness of breath and anxiety. It
was terminal sedation, Dr. Halbridge said, but Mr. Foster's liver was
failing so rapidly that no medication could have hastened his death.

Mrs. Foster sat stiffly at his bedside in a cloche hat and long coat, as if
she expected him to go any second. She said she was relieved that her
husband was no longer suffering. The sight of him sedated, his mouth open in
a premonition of death that some doctors call "the O sign," was less
shocking than the disease he kept secret, she said.

But families sometimes push back. Marguerite Calixte, a day care worker,
asked Dr. Halbridge to wake her husband out of deep sedation -- begun the
day before because he had trouble breathing -- so she could say goodbye.

Her husband, Alix, who was 53, had trained as a nurse and had told her that
if he was going to die of his colon cancer, he wanted to die at home, with
his wife and their two teenage children.

On a Thursday night, Dr. Halbridge began decreasing the morphine drip, and
by the next morning, Mr. Calixte's eyes fluttered open. "I've been talking
to him," his wife said on Saturday, in Haitian cadences. "I say, 'If you
want to go home, squeeze my hand tight.' He keep doing it over and over."

Ms. Walsh, the team manager, patiently gave Mrs. Calixte a lesson in how to
take care of her husband, but doubted that he would be able to go home on
Monday, and she was right.

He died that Saturday night, when his wife went home to have dinner with
their children.

Mrs. Calixte believed the morphine was to blame. "He died quicker," she
said. "I don't know when it was going to be, but it wasn't going to be now.
The thing is, he was going to suffer. I know that. But he wasn't going to
die so quick."

Dr. Halbridge said there was "no way of knowing which would have taken him
sooner," the medication or the disease. He said the conflict between his
desire to make Mr. Calixte comfortable and Mrs. Calixte's wishes made the
case "a tough one, I admit."

Teaching a Difficult Subject

The American Academy of Hospice and Palliative Medicine has endorsed
"palliative sedation to unconsciousness" and in 2008, the American Medical
Association issued a policy statement supporting palliative sedation, except
when it is used primarily for emotional distress. Even the United States
Supreme Court, while rejecting a constitutional right to physician-assisted
suicide, has opened the door to palliative sedation.

There is general agreement that "a patient who is suffering from a terminal
illness and who is experiencing great pain has no legal barriers to
obtaining medication, from qualified physicians, to alleviate that
suffering, even to the point of causing unconsciousness and hastening
death," Justice Sandra Day O'Connor wrote in a 1997 case, Washington v.
Glucksberg.

One provision of the House health care bill, which passed in November,
recognizes that palliative care may include treatment "furnished for the
purpose of alleviating pain or discomfort, even if such use may increase the
risk of death." The bill -- but not the Senate version, passed on Thursday
-- also allows doctors to be reimbursed for discussions with patients about
what treatments they would want or decline. This gave rise to charges by
some Republicans that "death panels" would be convened to decide who
deserves life-saving treatment.

Amid the furor, the bill was revised to make clear that patients would not
be forced to forgo treatment.

Terminal sedation remains touchy enough that last month, Dr. Lyla Correoso,
Bronx medical director of the Visiting Nurse Service of New York, and Dr.
Shaiova spoke with doctors, nurses, administrators and social workers at
Metropolitan Hospital about how to explain the process to families and
colleagues, so no one would feel guilty or betrayed.

The title of the lecture, projected on a giant PowerPoint screen, conveyed
the crux of the dilemma: "The Double Effect: Is it the Drug or the
Disease?"

"Some people speculate that people are really covering up the fact that this
is really perhaps a type of euthanasia or maybe something else that's really
afoot," Dr. Correoso said. "You have to have good overall intent, and most
physicians, that's what we're here for -- we're here to do something good."

She advocated setting "goalposts" in advance, by asking patients to
stipulate "the farthest line I'm not going to cross" -- including sedation.


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