Thursday, 15 May 2014

Crossing paths with Death Incorporated

This quirky but highly sane article first appeared in The Sydney Morning Herald:

An intensive care unit doctor reveals his thoughts on the euthanasia debate.

Dr Graeme Duke
I am no expert on Death. He never stops to chat, even though he visits my intensive care unit regularly. I’ve lost count of the times we’ve crossed paths - I guess it must be two or three thousand by now? I suppose we’ve never got along. After all, 75 per cent of my patients with life-threatening disease - his prime clientele - survive. Maybe he doesn’t like me?

Much of my time is spent listening to patients with a life-threatening illness and their families. I have since found that much of what I was taught about Death was wrong. Even more of my time is then spent dispelling the myths disseminated by his marketing department. 

His latest advertising gimmick is that euthanasia is popular. This strikes me as odd. According to popular opinion there is overwhelming community support for euthanasia. And yet when I listen to dying patients and families I discover this is simply not true. What they fear is loneliness, pain and indifference. What they prefer is quality to quantity, symptom-relief to suffering, time spent close to loved ones not machines, shared decision-making, and above all a doctor who will listen. This is not euthanasia. This is simply good medicine. 

I admit I have been asked to hasten death. But in my experience this is surprisingly rare. 

So I decided to quiz at least 20 other specialists who care for the dying in a dozen major hospitals and palliative care services. I discovered I was not unique. The topic of, let alone a request for, euthanasia rarely surfaces during end-of-life discussions.

So why do we cling to the myth? I suspect Death employs a very shrewd public relations manager.

His favourite ruse is that dying is painful. I freely admit too many suffer in their dying. One is too many. Yet we live in an unparalleled age of extraordinary means to relieve suffering and control unpleasant symptoms. 

Sometimes suffering is prolonged. I confess this is not because I try all possible treatments and they fail. More often it is because treatment is found difficult and is left untried. 

Contrary to popular opinion, doctors do not purposely prolong life when death is unavoidable. If there is opportunity to restore health or independence, treatment is offered. If it will no longer help, we do not and should not offer it, even if you demand it. 

I admit, however, that I am still sometimes slow to recognise Death.

Death claims he is a natural part of life. He may be universal and occasionally merciful, but I have never found his claims to be of comfort to a dying patient or their loved ones. It is good to celebrate a wonderful life, but not the event that extinguishes it. It may be a relief to see the end of pain, but not the price this requires.

What I have discovered - to my astonishment - is that far more are comforted by hearing that death is heart-breaking and wretched, irrespective of the age or the circumstance.

Of all the myths about Death, the saddest and most malignant is that you have no say. This, too, is false advertising.

If you have a serious or long-term illness, talk to your family and friends and your doctor. Tell them what is important to you. Independence? Family? Relationships? Staying at home? Being active? Reaching a milestone? If you are unsure, say so.

Treatment requires your consent, so get the facts. Ask about treatment options, risks, prognosis and symptom relief. Will I recover? Return home? Regain independence? Be wary of misinformation, even from my own profession. If you are unsatisfied, ask for a second opinion. Take along someone you trust. If you are scared, admit it - you are not alone. 

Appoint someone trustworthy as your medical power of attorney. If you have a serious permanent illness, ask about advance care planning. If you wish to decline treatment(s) consider a Refusal of Medical Treatment certificate. 

Symptom relief is a compulsory component of healthcare. Contemplation of euthanasia is dubious, frequently dissolving in the presence of effective healthcare. 

Many patients and families have been kind enough to return and express gratitude. Even on the odd occasion to declare they have euthanised their membership of Dying with Dignity. None, to my knowledge, have signed up. 

Dr Graeme Duke is a senior specialist in the Intensive Care Department at Box Hill Hospital, Melbourne.


  1. This article is peppered with red herrings and non-sequitors. It also doesn't follow its own advice.

    If death is always to be avoided, then ceasing dialysis or removing a respirator should also be prohibited by law.

    Also, everyone wants a choice at the end, so saying that "very few people actually want it" adds nothing to the debate.

  2. Who said that death is always to be avoided? Not me and not the author. That's a flagrant misrepresentation. The fact that few genuinely want it seems to be questioning the validity of the polls.
    BTW, I'm not publishing your other post as it was abusive.

    1. It was implied in the article, Paul. Time and again, Dr. Duke claimed that death should never be relied upon as the answer to suffering.

      Everyone wants a choice. The polls are valid. That's why the police are so reluctant to arrest and prosecutors so reluctant to prosecute.

      Remember the case of Freeda Hayes, where an acquittal was returned in under 10 minutes?

    2. Sorry, it was not implied. Suggest you read it again.

    3. "I admit I have been asked to hasten death. But in my experience this is surprisingly rare."

      Grame seems to imply that since requests for hastening death, including the double effect, are rare, we do not need to utilise such methods at the end of life.

    4. No he's not. He is simply stating a fact.

    5. But requests to remove respirators or cease dialysis are also requests to die. I don't think it's a fact.

      After all, who knowingly asks for a respirator to be unplugged unless they wish for death?

    6. Clear distinction here: Asking for a respirator to be removed, dialysis to cease or any number of other interventions is to allow the illness or disability to take its natural course. That is accepted as a genuine exercise in autonomy because, should the person die as a result, they will have died from their illness or injury - not the action of a third party where the intent was to kill.

    7. Irrelevant. Those actions also hasten death.

    8. Sorry, who ever you are - your missing the point.

    9. Let me explain it this way.

      If I sold both of my kidneys on the black market, I could access assisted suicide in Australia any time I wanted, without any waiting period. All I'd have to do is stop dialysis.

    10. If your intention in this ludicrous scenario was to sell your kidneys to create a medical disability so that you could refuse medical treatment, then perhaps it would be suicide. But to call it 'assisted' is a logical fallacy.

    11. How so? The only way my suicide could be carried out would be if my wish to refuse dialysis was respected.

    12. Another thing that makes it assisted suicide: I would need help to remove both kidneys. It's not something I can do alone.

  3. An interesting point. Kidney dysfunction would not normally be seen as a life-ending condition. However, people do have the right to refuse medical treatment. Whether it is an act of suicide - deliberately intending to end one's life - or simply refusing treatment so as to let nature take its course - cannot really be generalized here.

    1. Unless you could prove that my intent was suicide, I'd be able to die from kidney failure.

      With the state's full backing, no less.

    2. You really are chasing little furry animals down burrows with this line of argument. The state has no interest at all here. Dying from natural causes (ie: underlying disease) is natural. So long as the care is sufficient, not negligent and does not intend to kill, the state has no real interest at all.