The most pointed questions came from a chaplain, Rabbi Isaac H. Mann. Was it
possible, he asked, that a person under deep sedation could still be feeling
pain, and how would the staff know?

"Yes," Dr. Shaiova replied. But they often expressed pain through agitation
or grimacing, she said, adding, "Err on the side of treating them" with
pain-controlling drugs.

The chaplain pressed for more clarity, even after the meeting had broken up.
Was she trying to say, he asked Dr. Correoso, that if morphine killed a
patient, "you wouldn't mind?"

"Then you've already broken the principle of double effect," Dr. Correoso
replied.

"The doctor knows that this can kill the patient," Rabbi Mann insisted.

"The doctor doesn't know," Dr. Correoso said. Then she repeated a refrain
often heard in the world of palliative medicine: "It's not easy to kill a
patient. People think it's easy, but it's really not. That's why Dr.
Kevorkian had to use all that" combination of drugs.

The Gray Zone

On the day Dr. Shaiova and Dr. Correoso lectured on terminal sedation, they
were also consulting with a patient at Metropolitan Hospital who was dying
of lung cancer. The patient, Gloria Scott, 50, had learned of her cancer in
June.

End-of-life treatment often has a kind of studied ambiguity to it, and such
was the case with Ms. Scott.

After she was moved to the hospice wing of Margaret Tietz Nursing and
Rehabilitation Center in Jamaica, Queens, she received fentanyl, a synthetic
opioid pain reliever, through an IV line that gave her the drug
continuously, and allowed her or a nurse or doctor to push a pump for more
when she had "breakthrough" pain. Under her right ear, she wore a
scopolamine patch, used to reduce secretions. Scopolamine has sedative and
mood-altering properties, and was once combined with morphine to induce
"twilight sleep" for women giving birth. Ms. Scott also had standing orders
for Ativan, the sedative, and Haldol, for delirium, two more drugs in the
palliative sedation arsenal.

At first, though in pain, she was lively. She sat on the bed in the lotus
position, which eased her pain, and in her Betty Boop voice, punctuated by
an infectious giggle, she talked about her favorite Motown music and her
plans to get a business degree.

She fiercely resisted signing a "do not resuscitate" order, although she
would later change her mind. "I don't know when is my last day," she said.
"I might outlive one of you all."

She asked her doctor at the hospice agency, Erik Carrasco, to keep the
fentanyl, which she had begun taking at the hospital, turned down low.
Otherwise, she said, "you sit here and you nod. I don't want to be like
that."

Two weeks later, the change in Ms. Scott was marked. She was still alive but
dessicated and barely responded to visitors. Her companion, Milton Cruz, was
troubled by her "semi-dreamland" state, as he put it, but was shy about
asking questions.

In her last days, she lost the desire to eat or drink, though nurses
continued offering food and water, Dr. Carrasco said. The textbook survival
time for patients who stop eating and drinking is two weeks, Dr. Carrasco
said, but he said he had seen people last longer -- elderly people who had
survived the Holocaust and "people who are waiting for someone, like a
son."

She died after 22 days. Dr. Shaiova said she did not consider Ms. Scott's
sedation to be palliative or terminal sedation, because that was not her
doctor's intention. Her body had sedated itself as a defense against the
disease, Dr. Shaiova said, and she had been on fentanyl long enough to
develop some tolerance, making it unlikely to have hastened her death.

"When you're sick, you're sick, and everything else is somewhere in the gray
zone, and that's the problem," Dr. Shaiova said.

Dr. Carrasco said that while the medication might have contributed to her
drowsiness, he believed she had died a natural death. "What I've been seeing
sometimes is you release the pain," he said, "and even though you are using
very small amounts of morphine or narcotic, they relax and pass away."

The Semantics

Even when everybody agrees that terminal sedation is a humane response to
unyielding suffering, many doctors seem to feel a prick of conscience.

"There should be ambivalence," said Dr. Joseph J. Fins, chief of medical
ethics at Weill Cornell Medical College. "If it became too easy and you
weren't ambivalent, then I would really start worrying about it. But the
fact that you're worrying about it doesn't mean you've done something
wrong."

In a 1996 paper in the Journal of Palliative Care that is still debated
within that community, Dr. J. Andrew Billings, a Harvard professor and
palliative care doctor at Massachusetts General Hospital, and Dr. Susan D.
Block, a psychiatrist, took on the moral ambiguity surrounding terminal
sedation. They argued that the main distinction between terminal sedation
and euthanasia was time.

Terminal sedation would lead inexorably to death, but "not too quickly,"
they said. They derided the rule of double effect in this context as a
rationalization, a subtle cover-up, of what they called "slow euthanasia."

Even a simple morphine drip, they said, could put patients into a stupor at
the right dose or when combined with other drugs or when concentrated by the
inefficiency of a damaged liver or kidneys.

"If the morphine drip becomes a code word for slow euthanasia," they wrote,
"laypersons may be increasingly wary of the other uses of opioids."

Both Dr. Billings, who is still at Harvard, and Dr. Block declined requests
to be interviewed.

The authors did not endorse euthanasia, but their arguments have been used
by others looking to make the case for public acceptance of euthanasia, to
the dismay of some doctors who defend terminal sedation.

People who adopt this argument say, "We know what you're really doing, it's
crypto-euthanasia," Dr. Fins said. "Polemics really have no place at the
bedside."

Dr. Fins said he sometimes told families that terminal sedation was
altruistic, because they might be giving up an extra day or two "of
communication with the person you love in the service of that love."

As for the argument that double effect is overly scholarly, Dr. Fins said:
"I can't imagine a world at the end of life without double effect. We'd be
highly impoverished without it, and patients would suffer needlessly without
it. We do need our philosophical contrivances in order to be pragmatic
physicians and caregivers."

Ambivalent, Then Accepting

Mr. Oltzik died two days after the meeting between Dr. Halbridge and his
family, and Dr. Halbridge was frank in describing his treatment.

Asked if he would call it palliative sedation, Dr. Halbridge said, "This
would be called terminal sedation, almost." He said he hesitated only
because the word "terminal" sounded negative and might make the family feel
bad, when "it's really comfort care." The terms
"palliative" and "terminal"
were interchangeable, he said.

Speaking with considerable passion, he said he saw himself as the doctor who
would not "forsake" patients by telling them he could do nothing for them.
If there was no cure, he could at least offer comfort. "We are not gods who
can cure everything, and I think at some point in time you have to accept
that," he said, "and to me, it's the mark of an honest doctor who
understands when that time has come."

The decision to administer terminal sedation was based on a review of the
patient's history that convinced him that Mr. Oltzik was "terminally
agitated," he said. "It means that he is entering the dying process and for
whatever reason -- whether it's physical, spiritual -- something is
interrupting the peaceful passing, and to me, because it's so uncomfortable
for the family and for the patient, that's the time to medicate the patient
and make them comfortable, because no matter what you do, he's not going to
go back to the old Leo that he was."

He then told a self-deprecating joke about a doctor who gets to the gates of
heaven and demands to jump to the head of the line, only to be turned back
by St. Peter. But St. Peter opens the gates to someone else carrying a
doctor's bag. "That's God," St. Peter explains. "He just thinks he's a
doctor."

Young residents often challenge him, saying things like, "If I'm 105 years
old, I want to be fed, no matter what," Dr. Halbridge said. His response is,
"O.K., but did you ask your patient what he wants?"

Some patients are getting "multimillion-dollar workups" in the intensive
care unit, he said, but make their wishes known by pulling out tubes. "I
think a light bulb should go off in somebody's head after the third time he
pulls it out. Am I going to change the outcome of this, and if I'm not, why
am I doing it?"

At one point, however, Mrs. Oltzik changed her mind.

"She was having second thoughts on that, and then she was saying, 'I wonder
if we should cut back on his medication,' " Dr. Halbridge said.

She hoped for a last chance to communicate with her husband, but Dr.
Halbridge said he warned her that Mr. Oltzik was more likely to wake up
agitated and suffering. Dr. Halbridge did not want to feel like he was
experimenting. "I have a little bit of a problem with using the patient as
kind of a guinea pig and saying, 'Well, the medication worked nicely, now
we'll take it away and see if they bounce back the other way,' " he said.

Did he wake Mr. Oltzik? There was no need, Dr. Halbridge said: "He passed
away within a couple of minutes."

A couple of weeks later, Mrs. Oltzik still felt a bit uneasy. "They had him
so heavily sedated that he was in a stupor," she said. "I didn't
say goodbye
to him, which hurts me."

But she did not fault the hospice team's judgment. She could not think of
any other way to handle her husband's agitation. As to whether his death had
been speeded up, even a tiny bit, she said philosophically, "There was no
way of knowing."

Jeff Snyder, SysOp - Armageddon BBS  Visit us at endtimeprophecy.org port 23
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