To ask why we apply end of life compassion logic to dogs but not humans

[NorthernRosie]

It struck me again today (whilst reading Tim Dowling's Guardian column!) that many people seem happy enough to believe that it's kinder to put down animals at the end of their lives to end suffering but when it comes to our own species the majority argue against people's right to make that decision.

After all an animal can't actually make the decision but a competent human adult can.

Why is this?

This is to do with how disproportionately religious groups wield power. It you believe in a creator then it follows that (human) life is not ours to take.

The British Humanist Association are lobbying to bring legislation in line with public opinion.

I don't believe in the Invisible Sky Fairy; I've no partner or kids and all my close family have died.
So, although I've friends who would miss me for a while, any choice I make about continuing to live or not would be based solely on my enjoyment of life compared to level of pain or disability suffered.
I consider it my right to choose.

I plan on going to Switzerland if ever I have a painful terminal disease, or if my doctor informs me that my favourite brain cells are dying before the rest of me.
Fortunately I am comfortably off and can pay for all this Swiss palaver; I suppose the poor just suffer to the bitter end, as always.

BlueSmarties the term used has changed slightly to 'DNACPR': Do not attempt cardiopulmonary resuscitation. The reason for this is that DNR (do not resuscitate) was deemed to give the impression that resuscitation, which is a violent and traumatic procedure, was something that was bound to succeed.

The legal status is that medical staff have the right to decide whether they will attempt resuscitation, unless there is a legal directive stating otherwise (such as an Advance Directive). Even if there is an Advance Directive, the team caring for the patient can't act on it (or rather, not act) unless they have actually seen it. So, in the event of cardiac arrest, if someone shouted 'Stop! Tony didn't want to be resuscitated and he has an advance directive!' then staff would be obliged to continue resuscitation attempts until such time as they see the advance directive. Which is why it's so important to sort that stuff out as soon as possible.

Medics will spend a lot of time discussing the prognosis for a patient, what avenues of treatment could be given and why they believe there should be a 'ceiling of intervention'. It gets very complicated. So in ICU we could have a patient that is 'for' BiPAP, not for Filtration, not for intubation and not for CPR. We could have another patient who is for everything except intubation and ventilation....the list goes on.

Ultimately, it is a medical decision and the responsibility lies with the Consultant the patient is assigned to.

These decisions are never taken lightly, though, and it's not unusual for a Consulant to ask for a review with one or two other Consultants to help them decide where the 'ceiling of intervention' is.

Lougle
Thank you, that's very informative.

So how do medics decide on where the 'ceiling of intervention' should be? Is there an official algorithm of sorts which can be applied? Are cost / resources / hours of life gained factored in?

I'm curious partly as a different relative was offered a very expensive resource heavy procedure when their prognosis was very very poor (told they had a minuscule chance of survival, though zero chance of survival without the procedure), which made me wonder how much discretion individual teams of doctors are given in these situations?

It's never cost. Ever. Some of the treatments given incost thousands of pounds....it isn't a consideration. It's about prognosis. If you know that x condition has a terminal trajectory and that once

Oops...

If you know that once someone with x condition is intubated and ventilated, it will be virtually impossible to wean them back off the ventilator, you are prolonging physical life but not function, for example.

It's really very complicated and there are so many variables....how well the person was prior to illness, whether the root cause is reversible or progressive, whether there are other compounding issues (e.g. other medical conditions that are worsened by the treatment for the primary condition), whether the patient is responding to treatments, etc.

Lougle
Thanks.

Couldn't what you've described above basically amount to assisting a person to die by withholding treatment (where deemed appropriate)?

To what extent are the consultants required to justify their decision to give or withhold life extending treatments? Is there a lot of lengthy paperwork to illustrate how and why various factors have been considered? Or are they not really accountable?

No. Medical intervention puts a stop (or pause) in the process of death. Take, for example, respiratory failure. If a person doesn't get enough oxygen from their usual process of breathing in room air and breathing out carbon dioxide, their oxygen saturation (the level of oxygen in their blood) will decrease, leading to hypoxia. Organs don't cope well without oxygen and eventually, the brain is starved of oxygen and the person dies. To interfere with that process, we can give oxygen via nasal cannula (little tubes that sit in the entrance of the nose) or a face mask, or CPAP (Continuous Positive Airway Pressure) or BiPAP (Biphasic Positive Airway Pressure) or High-flow oxygen therapy or Intubation and Ventilation. Room air is 21% O2. We can increase oxygen to 28%, 35%, 40%, 60%, 80%, 100% or anything in between. Obviously, someone requiring 100% oxygen (5×room air) to get adequate blood oxygen is very ill. If their condition is reversible, it's reasonable to continue, but if it deteriorates further, there is nowhere else to go -you can't give more than 100% oxygen and there is a limit to the pressures you can use to deliver it.

Assisting someone to die is an active process. Withholding treatment is passive. Often somebody would be 'for active treatment' at the same time as having a DNACPR firm completed. That means that all possible treatment will be given while the patient is alive, but if the patient suffers cardiac arrest, there will be no attempt to resuscitate and death will result.

Doctors fill in a triplicate form which outlines their decision and reasons for it. They never use DNACPR lightly.

The thing with this is, how easy would it be to convince an elderly person that they are being a burden? There are people out there who would do this to speed up receiving some inheritance. This is just an example. I worry that it could be abused

Any process can be abused, but I still don't believe that argument is a good enough reason to deny citizens the right to control their own life and management of their death.

What safeguards have other countries got in place I wonder?

In my experience, relatives are usually desperate for the person not to die and will go to significant lengths not to allow it to happen - even if it prolongs suffering - is that any different than insisting that they shuffle off their mortal coil?

Very few safeguards are in place to prevent relatives from insisting upon intervention. If the doctor refuses and puts the syringe driver in place and that person dies within 24 hours, then the relatives will be angry and possibly complain about that doctor. Shipman has a hell of a lot to answer for. Doctors are over cautious now and it takes someome with confidence and a lot of experience to stand up and say "enough". GPs now are pretty cowed from what I see. I don't know what goes on in hospital, but they have more backup from the consultants and their colleagues I would imagine.

I'm talking about people such as the elderly who do not necessarily have a lifelong condition.

Don't get me wrong, I am all for it but I do wonder how it would be "policed"

People need to put in place an advanced directive stating their needs and wishes. Put it in place before you become old/frail/sick etc. State your wishes without any family input.

I have had no discussions with any of my family, nor do I intend to do so. They will be informed of my wishes but it is entirely my decision.

Family and friends tend to be far too emotional. "You can't die. I couldn't go on without you in my life." I've made the mistake on a couple of occasions of taking a close friend along with me to hospital appointments. Never, ever again. Friend ends up in hysterics. I do get really fucked off that I'm not 'allowed' to discuss my inevitable death as it's too upsetting for others.

I have incurable cancer. That is my reality. I've come to terms with this. I just wish others would try and do the same.

Do you have an advanced directive zombie? You need to keep your doctors informed of your wishes. I'm so sorry you're in this awful position.

Zombie I am sure that when the time comes for those decisions, the doctors will be able to go with your wishes.

Zombie.

Lougle
Interesting that the whole thing hinges around the active / passive perspective, thanks for clarifying. The active / passive argument seems overly concerned with semantics to me, and not focused enough on the net result.

Still, I'm glad to hear that triplicate forms are required, or at least, I'm reassurd that there is accountability!

Lougle hmm.... I wonder if I should read what I was written up for in ICU!? I'm not sure if I'd like it or not!

I think the bottom line is that doctors would always prefer to save a life if possible. Sometimes they have to decide that a treatment/treatments are not in the patient's best interests. As medical advances are made, it gets harder and harder to accept that there is nothing more that can be done.

In years gone by, simple chest infections would routinely kill. Acute kidney injuries would kill. Cardiac conditions would kill. Cancer would be diagnosed in the very late stages and routinely kill.