eMJA: The intention to hasten death of terminally ill patients

Letters

The intention to hasten death of terminally ill patients

Mathew Piercy, Gerald B Fogarty, Aubrey W Jansz and David M Gawler

MJA 2002 177 (3): 165-167

To the Editor: The study by Douglas et al1 reports that the purposeful hastening of death in terminal illness is both widely practised and an acceptable method of palliative care for over a third of Australian surgeons.

Yet the study is based on a questionnaire strongly favouring theoretical scenarios rather than actual practice. The framing of the questions maximises reporting bias towards "hastening death" by the use of absolute terms (eg, "Have you ever . . .?"; "[Are] there any circumstances . . .?"1). The study also fails to determine the stage in a terminal illness at which hastening of death had been, or might possibly be, acceptable to the surgeons, nor the reason for its implementation.

If the patient's symptoms are already adequately controlled and the dying process is not prolonged, we do not see why it is necessary to administer doses in excess of those required to control symptoms. Whose symptoms are we treating?

Peter MacCallum Cancer Institute, East Melbourne, VIC.

Mathew Piercy, MB BS, Critical Care Registrar; Gerald B Fogarty, BSc, MB BS(Hons) , Radiation Oncology Registrar.

John Faulkner Hospital, Coburg, VIC.

Aubrey W Jansz, MB BS, FRACS, Senior General Surgeon.

Northern Hospital, Epping, VIC.

David M Gawler, MB BS, FRACS, FRCS, Senior Vascular Surgeon.

Correspondence: Dr Mathew Piercy, Peter MacCallum Cancer Institute, East Melbourne, VIC 3002. mepiercyATidx.com.au

Douglas CD, Kerridge IH, Rainbird KJ, et al. The intention to hasten death: a survey of attitudes and practices of surgeons in Australia. Med J Aust 2001; 175: 511-515. <eMJA full text> <PubMed>

(Received 27 Nov 2001, accepted 7 Jan 2002)

Luis Vitetta, David Kenner and Avni Sali

To the Editor: We wish to comment on the article by Douglas et al about surgeons hastening death.1

Recently, Ray2 noted that, historically, surgeons have had to witness their patients' pain probably longer than any other medical specialty. Hence, it is not surprising to read Douglas and colleagues' report1 that more than a third of surgeons surveyed performed life-terminating events without explicit and persistent requests. The desire for death, as perceived by doctors and patients, has been correlated with ratings of pain, depression and poor family support.3,4

Surgeons, while intending "no harm", could be seen to be palliating themselves (relieving their own distress) as well as their patients' when performing life-terminating events. Helplessness, hopelessness and negative attitudes toward life-sustaining treatments are common and understandable in palliative care, and experienced by both doctors and patients.3,4

Surgeons are relatively new to palliative care and could have a significant contribution to make to the psychosocial support of cancer patients with terminal illness. Decisions by surgeons about hastening death may be modified by greater interaction with their patients' families and with other healthcare providers working with terminally ill patients.

A clinical-outcomes study of 102 consecutive deaths of terminally ill patients admitted to hospice care during 1997–1999 highlights the importance of family support in the outcomes immediately before death.5 The study period coincided with a time of heightened awareness of euthanasia in Australia.

Fifty-six per cent of the patients had received continuous family support and 44% sporadic support; these patients appeared to have less distress and better preterminal outcomes, despite 10% experiencing significant family conflict and distress. However, no spontaneous or other requests for euthanasia were recorded in patient files or notes by staff. This could reflect, in part, family support received in an environment conducive to positive interactions between patients, their families and health professionals. Involving such palliative care teams in surgeons' care for terminally ill patients may have a significant effect on both pre-terminal outcomes and hence requests for euthanasia.

Douglas CD, Kerridge IH, Rainbird KJ, et al. The intention to hasten death: a survey of attitudes and practices of surgeons in Australia. Med J Aust 2001; 175: 511-515. <eMJA full text> <PubMed>
Ray JB. Pharmacologic management of pain: the surgeon's responsibility. Surg Oncol Clin North Am 2000; 10: 71-87.
Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill. Am J Psychiatry. 1995; 152: 1185-1191. <PubMed>
Back AL, Wallace JI, et al. Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses. JAMA 1996; 275: 919-925. <PubMed>
Vitetta L, Kenner D, Kissane D, Sali A. Clinical outcomes in terminally ill patients admitted to hospice care: diagnostic and therapeutic interventions. J Palliat Care 2001; 17: 69-77. <PubMed>