From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med.cardiology,sci.med
Subject: Re: a tricky distinction: death & dying
Date: 2 Oct 2005 20:00:51 -0700
Message-ID: <1128308450.990733.188250@g47g2000cwa.googlegroups.com>

(PeteCresswell) wrote:

> One of those choices would be to provide palliative care for seven years
> - at, I'd guess, substantial cost to the provider.
> 
> Another choice would be to have me end my life as soon after the
> diagnosis as possible - at a greatly reduced cost to the provider.
> 
> 
> 
> I would expect any rational for-profit entity to zero in on the second
> choice immediately.
> 
> The question then emerges as how to encourage me, the suffering patient,
> to end my life ASAP.
> 
> Withholding painkillers - either overtly or by getting the government to
> tighten the screws on controlled substances - seems patently obvious.
> Not a cheery prospect for those who would like to live as much as
> possible of the only life they have.
> 
> 
> 
> My recollection is that physician-assisted suicide has been legal for
> some years now in one of the European countries.
>
> Netherlands?
>
> Maybe somebody who knows can comment on the availability of palliative
> care in that country today vs before legalization of physician-assisted
> suicide.
> --
> PeteCresswell



COMMENT:

Euthanasia isn't particularly an issue in people who have less than 6
months expected life, and are in palliative care or "hospice" programs.
Those programs aren't expensive, because people are rarely sent to the
hospital, and (almost) never to the ICU. (If they go to the hospital
for treatment too much in a hospice program, they'll be informed gently
that they're not getting the idea, and will be de-certified).

In hospice, instead of being hospitalized with complications, people
get taken care of at home or in a skilled nursing facility, and
whenever they reach the point of needing complex care and they complain
of ANYTHING, they get enough anxiolytics and/or narcotics to put them
in la-la land. It's rare for very ill patient to last more than a
couple of weeks in such programs, as you might guess. You can call it
euthanasia if you like. If you can get a stroke victim certified as
needing hospice care, it works pretty much the same. They don't survive
their first major complication or infection. Indeed, they don't survive
fecal impaction, since the treatment for abdominal pain and vomiting in
hospice is antiemetics, and a lot MORE morphine and Ativan.

If you have incurable cancer, even if it's a slow one which is expected
to take more than six months, you can usually get hospice-certified,
anyway. You just have to quit your chemo and give up on the idea of
going to the ICU every time you get an infection. If you're willing to
do that, you can have all good drugs you want, in unlimited quantity.
The only additional requirement is you don't live alone. If you last
more than 6 months, they'll happily re-certify you for another 6, and 6
more after that, for years (there is no technical limit to how long you
can stay in hospice-- it's sort of like college). The system does not
care how long, because (as noted) this really is cheap by comparison
with standard full-bore medical care.

So, for people with certifiably "fatal" illnesses in the US, the issue
of euthanasia is more or less a non-issue. It's already been decided.
You just get certified as home-hospice, and then you spend a week or
two (or even a month or two) taking enough morphine that you don't care
if you're malnurished or even well-hydrated. After a few weeks in bed
on massive drugs, that will be the end of you, and you won't suffer,
guaranteed.

The big legal issues in euthanasia in the US are for people who want to
kill themselves and *can't* get into a hospice program, because they
DON'T have untreatable cancer, or aren't elderly and very frail, and
nobody reasonably expects their medical conditions to kill them within
6 months.

So, make sure you don't confuse the groups (or the arguments), with
examples of cancer or AIDS patients in pain. That's not where the
euthanasia issues are at, today. At least in the US. As for other
countries, of course I cannot generalize.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med.cardiology,sci.med
Subject: Re: a tricky distinction: death & dying
Date: 2 Oct 2005 21:46:48 -0700
Message-ID: <1128314808.003461.290720@o13g2000cwo.googlegroups.com>

fresh~horses wrote:
>
> I assume you mean Americans whose health insurance will pay for this.
> No?


No. There are no totally uninsured Americans. Everybody, if unable to
pay and without resources, gets medicade. True, medicaid doesn't pay
for everything you can think of, but then neither does Health Canada.
Medicaid (and medicare) do pay for hospice. If you have a bad disease,
getting in as simple as the referring doc referring you (which he or
she has no reason not to do), and the doc in charge of the hospice
program and its funding managers accepting you (which again they have
no reason not to do).

If you lived in a mansion and simply refused to pay your medical bills
in the US, would they let you die in the street?  No, they'd take you
to the hospital. Which would eventually certify you indigent, put you
into medicaid, and then put a lien on your property. So the same thing
would happen, just with more legal complications. After you died, the
State would collect its piece for your care, before your relatives got
theirs.  So unfair!

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med.cardiology,sci.med
Subject: Re: a tricky distinction: death & dying
Date: 4 Oct 2005 15:44:06 -0700
Message-ID: <1128465846.851972.159530@o13g2000cwo.googlegroups.com>

fresh~horses wrote:
> Steve Harris wrote:
> > fresh~horses wrote:
> > >
> > > I assume you mean Americans whose health insurance will pay for this.
> > > No?
> >
> >
> > No. There are no totally uninsured Americans. Everybody, if unable to
> > pay and without resources, gets medicade. True, medicaid doesn't pay
> > for everything you can think of, but then neither does Health Canada.
> > Medicaid (and medicare) do pay for hospice. If you have a bad disease,
> > getting in as simple as the referring doc referring you (which he or
> > she has no reason not to do), and the doc in charge of the hospice
> > program and its funding managers accepting you (which again they have
> > no reason not to do).
>
> Space. Is this a physical allocation?

COMMENT:
Nope, in the US hospice is a program, not a place. It can be run from
your home, IF you live with a caregiver who can give you your meds, and
can make a phone call to the hospice nurse when you die, or are about
to. And if it's home hospice, you're expected to die at home. In some
places the nurse can even pronounce you dead. The coroner or medical
examiner already has your number as a terminal case, so that's just a
phone call. The next call is to the funeral home removal service. All
neat and efficient and I can't argue with it.  I've seen much worse
deaths in hospitals and ICUs.

IF you're already in an institution, they all have hospice programs. So
they just switch your label. No CPR. Further complaints, see Ativan and
morphine.  That's oversimplied, but has enough general truth to be
worth the time it takes me to type it.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med.cardiology,sci.med
Subject: Re: a tricky distinction: death & dying
Date: 4 Oct 2005 16:29:19 -0700
Message-ID: <1128468559.881751.30230@g43g2000cwa.googlegroups.com>

William Wagner wrote:
> > > Space. Is this a physical allocation?
> >
> > COMMENT:
> > Nope, in the US hospice is a program, not a place. It can be run from
> > your home, IF you live with a caregiver who can give you your meds, and
> > can make a phone call to the hospice nurse when you die, or are about
> > to. And if it's home hospice, you're expected to die at home. In some
> > places the nurse can even pronounce you dead. The coroner or medical
> > examiner already has your number as a terminal case, so that's just a
> > phone call. The next call is to the funeral home removal service. All
> > neat and efficient and I can't argue with it.  I've seen much worse
> > deaths in hospitals and ICUs.
> >
> > IF you're already in an institution, they all have hospice programs. So
> > they just switch your label. No CPR. Further complaints, see Ativan and
> > morphine.  That's oversimplied, but has enough general truth to be
> > worth the time it takes me to type it.
> >
> > SBH
>
>  Any suggestions as to best practice ?  My mom passed  and the most
> immediate effort was directed towards flushing her pain pills.  This
> with hospice.   Misplaced concerns too be nice. I like to go slow with
> the passing of love ones.  I'm OLD fashion I guess.  But notifying
> officials rips away any control of my love ones here in S Jersey.

COMMENT:
If you're with your family member when they die, you don't have to call
the hospice right away. If hospice IS there, they might act as
drug-nazis, but that varies from state to state. Some clean up, some
don't.

Likewise with removal. So long as you're not planning on some
outrageous time to keep a decedent, you can delay on calling the
funeral home, also. Or tell hospice to wait. In California, once you
get the sign-off from the coroner or medical examiner (it varies county
to county) you can do the body transport to the funeral home yourself,
if you like. All the law requires is that it be respectful. But back of
the van in a sheet is perfectly fine. Just keep that paperwork with you
on the highway :).  Those laws got passed here in the wake of the
funeral industry expose in The American Way of Death, so the
legislature put some of this back to do-it-yourself, as in the old
days. Many states, at least here in the West, are the same. About
Jersey, I don't know. You should find out.


> Confused.
>
> Sort of acknowledgement  that my  expertise is flawed and we will do the
> best we can.
>
> Bill