End-of-Life Choice, Palliative Care and Counseling

Pain Management

Poor Pain Control for Cancer Patients

By Pauline W. Chen, MD
The New York Times
September 20, 2012

Recounting her father’s struggle with cancer was difficult for the young woman, even several years after his death. He’d endured first surgery and then chemotherapy and radiation, she told me, and the cancer had gone into remission. He was thrilled, but the aggressive treatment left him with chronic, debilitating pain. Once active, he struggled to get around in his own home.

“It wasn’t the cancer that got him,” the daughter said. “It was the pain.”

Her father had turned to all of his doctors, with little relief. His surgeon had looked at his operative wounds, pronounced them well healed, then stated that they were in no way responsible for his disability. Both his cancer doctor and his radiation doctor congratulated him on being in remission but then declined to prescribe pain medications since they were no longer treating him and couldn’t provide ongoing follow-up and dosing guidance. His primary care doctor listened intently to his descriptions of his limitations, but then prescribed only small amounts of pain meds that offered fleeting relief at best.

“I’ll never forget what my father had to go through,” she said, weeping. “I wouldn’t wish this on anyone.”

I wish I could have reassured her that her father’s case was unusual. Sadly, according to a new study in The Journal of Clinical Oncology, a significant percentage of cancer patients continue to suffer from pain as her father did. More

Themes Identified for Improving End-of-Life Care in ER

Medical Xpress
September 5, 2012

Major and minor themes have been identified by emergency nurses who often provide end-of-life care in the emergency department setting, according to a study published in the September issue of the Journal of Emergency Nursing.

Renea L. Beckstrand, Ph.D., R.N., of the Brigham Young University College of Nursing in Provo, Utah, and colleagues surveyed 1,000 emergency nurses for suggestions regarding how to improve EOL care in the emergency department setting. Overall, 230 nurses provided 295 suggestions for improving care. The researchers identified five major themes and four minor themes. The major themes, which were mentioned by 20 or more respondents, included allowing emergency department nurses to have more time to care for dying patients; allowing family to be present during resuscitation; and providing more comfortable patient rooms, privacy, and family grief rooms.

Minor themes, mentioned by 16 or fewer nurses, included increased ancillary service involvement; pain management and minimizing suffering; family education; and honoring patients’ desires and wishes. “Large numbers of patients die in emergency departments in the United States every year. Caring for those who are dying in emergency departments is difficult because these highly technical departments were primarily created to save lives,” the authors write. “Implementing changes based on emergency nurse recommendations may dramatically improve EOL care for dying patients and their family members.”

Briton Who Fought for Assisted Suicide Is Dead

By John F. Burns
The New York Times
August 22, 2012

A 58-year-old British man suffering from so-called locked-in syndrome died Wednesday, six days after a panel of High Court judges rejected his request for help in ending his life. His death is certain to galvanize the already contentious debate about assisted suicide in Britain.

The man, Tony Nicklinson, a former rugby player and sky diver who suffered a stroke in 2005, died at his home in Melksham, 80 miles west of London, at 10 a.m., according to a statement issued by the law firm that represented him.

Mr. Nicklinson’s family used his Twitter account to say that he died of natural causes. At a news conference, Saimo Chahai, the family lawyer, said Mr. Nicklinson had been refusing food since the court ruling and had declined rapidly over the weekend after contracting pneumonia. “The fight seemed to go out of him,” she said.

After having a stroke while on a business trip to Athens, Mr. Nicklinson, a civil engineer, developed locked-in syndrome, an incurable condition in which a patient loses all motor functions but remains awake and aware, with all cognitive abilities. He had spent the last seven years paralyzed from the neck down and unable to speak, feed himself or even clean his own teeth, communicating through a system that allowed him to write messages on a computer screen by blinking his eyes.

He had argued in court that he would be physically unable to administer a lethal drug to himself, and that his only path to release from his “living nightmare” would be permission from the court to have somebody else — in his suggestion, a doctor — administer the necessary dose without fear of prosecution.

Under British law, anybody, including a doctor, who knowingly helps a terminally ill person to die faces possible criminal prosecution and a lengthy jail term if convicted.

In an essay he wrote before the court case, Mr. Nicklinson said, “It cannot be acceptable in 21st-century Britain that I am denied the right to take my own life just because I am physically handicapped.” He added, “It is astonishing that in 1969 we could put a man on the moon, yet in 2012 we still cannot devise adequate rules for government-assisted dying.”

In its ruling last Thursday, a three-judge panel of the High Court said that Mr. Nicklinson’s case was “deeply moving.” But, writing for the panel, Lord Justice Sir Roger Toulson said a decision in Mr. Nicklinson’s favor would constitute “a major change in the law.”

“It is not for the court to decide whether the law about assisted dying should be changed and, if so, what safeguards should be put in place,” the ruling said.

The government of Prime Minister David Cameron, as well as the British Medical Association, representing 140,000 doctors and medical students, applauded the ruling.

In their Twitter message, Mr. Nicklinson’s wife and two adult daughters said: “You may already know, my Dad died peacefully this morning from natural causes. He was 58. Before he died, he asked us to tweet, ‘Goodbye world the time has come, I had some fun.’ ”

Mr. Nicklinson’s anguished appeals to be allowed to seek assistance in ending his life culminated with a heart-wrenching scene, captured in a video posted on the BBC Web site, after the court decision last week.

It showed him sitting at home in a striped sports shirt, sobbing heavily and groaning as he listened to a television report of the court ruling. His wife, Jane, standing at his shoulder, can be seen leaning over to wipe his mouth.

In Europe, only Belgium, Luxembourg and the Netherlands allow euthanasia. Switzerland allows assisted suicide and is the only country that helps foreigners die, at a clinic near Zurich.

The British law against assisted suicide was mitigated in 2010 with a statement by the Crown Prosecution Service, responsible for criminal cases, that set out the detailed circumstances that would be taken into account in reaching a decision on whether to press charges.

Keir Starmer, director of the prosecution service, said at the time that it was for Parliament, not prosecutors, to change the law that made assisted suicide a crime. But strongly held views on the issue, which cross party lines in the House of Commons and involve uncompromising opposition from right-to-life groups, including the Roman Catholic Church, have kept governments from tackling the issue for decades.

Calif. man, 88, won’t be charged with assisting in suicide of ailing wife

By NBC News staff and wire
NBC News
August 23, 2012

An 88-year-old man who was arrested shortly after the death of his ailing wife on suspicion of aiding in her suicide will not be charged with any crime.

San Diego prosecutors determined that the case against Alan Purdy couldn’t be proven beyond a reasonable doubt, said Tanya Sierra, a spokeswoman for the district attorney, on Wednesday night.

Margaret Purdy, 84, was found dead in her home with a plastic bag over her head in March, her death ruled a suicide by the county medical examiner. Family said she had becoming increasingly depressed as she battled a series of ailments and injuries in her final years while her husband doted on her.

“She had mentioned for some time that she was under a great deal of pain and that this was a very hard life,”  the couple’s son-in-law, John Muster, said in a telephone interview from Berkeley at the time of the arrest.

The once vibrant woman left a suicide note on her desk after being bedridden in her final years from severe pancreatitis, as well as an autoimmune disease, a crumbling spine and three fractured vertebrae that never healed, The Los Angeles Times reported.

Alan Purdy’s sister-in-law, Margot Smith, told The Associated Press Wednesday that it would have been awful if prosecutors had decided to pursue a case.

“I’m absolutely delighted to hear it. He’s 88 years old and hard of hearing and he loved his wife dearly,” Smith said.

Smith added that Alan Purdy was so hard of hearing that he had trouble making out what authorities were saying to him at the time of his arrest.

“I’m delighted to hear this,” Purdy’s daughter, Catherine Purdy, a Berkeley psychologist, told The Times. “I feel like justice has finally happened.”

The Purdys were close friends for many years and proved a perfect match when they married later in life, relatives said. It was the second marriage for both Purdys, each of whom had outlived their previous spouses, said The Times. Margaret Purdy kept a close eye on her husband, who lost much of his hearing with age. He, in turn, watched after her as she coped with her ailments.

A previous suicide attempt
In Margaret Purdy’s last year of life, her pain became so severe that she was unable to get out of bed without Alan’s help, and she stopped doing activities that she enjoyed, like painting, The Times reported in May. Three months before her death, when Alan was out of the house, Margaret had attempted to take her life by poisoning herself with carbon monoxide in their garage; Alan came home and pulled her out of the car before she could finish, The Times said.

Alan Purdy, a pilot with a doctorate in biomedical engineering, worked for years at the federal Occupational Safety and Health Administration, and Muster said both were “fully functioning mentally.”

When paramedics arrived at their home on March 20, Purdy told them his wife had taken 30 sleeping pills crushed in applesauce, then suffocated herself, The Times reported. He told them — and later deputies — that he didn’t help her, but he also said he didn’t try to stop her.

From the bedroom that he and Margaret shared for nearly 15 years, Purdy admitted to The Times, ”Yes, I sat beside her as she died. I didn’t want her to feel abandoned. I wanted her to know that I loved her.”

There is no specific federal law regarding either euthanasia or assisted suicide. All 50 states and the District of Columbia prohibit euthanasia — which is when a doctor actively kills a patient — under general homicide laws.

California is one of three dozen states that have specific laws prohibiting assisted suicides. Seven ban assisted suicide under common law.


Husband won’t be charged in wife’s suicide

By Tony Perry
Los Angeles Times
August 23, 2012

Criminal charges will not be filed against an 88-year-old San Marcos man who sat beside his ailing wife as she committed suicide, the San Diego County district attorney’s office announced Wednesday.

After a thorough review, the office decided that it could not meet “the ethical and legal burden” of proving a charge of “assisted suicide” against Alan Purdy, according to a spokesman for Dist. Atty. Bonnie Dumanis.

“We do not discuss the reasons when we don’t file criminal charges,” spokesman Steve Walker said, “other than [to say that] we only file when we believe we can prove the case beyond a reasonable doubt.”

On March 20, Purdy’s wife, Margaret, 84, committed suicide after years of unrelenting pain from a variety of ailments. The couple were married for 15 years.

Purdy, a semiretired engineer, did not try to stop his wife as she swallowed apple sauce mixed with sleeping pills and put a plastic bag over her head.

“Yes, I sat beside her as she died,” Purdy told The Times weeks after the death. “I didn’t want her to feel abandoned. I wanted her to know that I loved her.”

Purdy’s children and his wife’s children from a previous marriage were opposed to criminal charges being filed.

“I’m delighted to hear this,” said Purdy’s daughter Catherine Purdy, a Berkeley psychologist, when informed of the district attorney’s decision. “I feel like justice has finally happened.”

Her father, Catherine Purdy said, “is very lonesome and unhappy. He lost his wife, and then to have to wait for this decision — it’s been very hard on him.”

A rarely enforced California law from the 19th century says that anyone who “deliberately aids, or advises, or encourages another to commit suicide” is guilty of a felony. Unlike several other states, California does not have a law that permits physician-assisted suicide.

Once a vibrant woman who enjoyed traveling and painting, Margaret Purdy was bedridden in her final years from severe pancreatitis, an autoimmune disease, from a crumbling spine, and from three fractured vertebrae that never healed properly. She left a suicide note on her desk.

Alan Purdy was arrested even before the medical examiner removed his wife’s body from the couple’s home. But at an arraignment in March, the district attorney said that the case was under review.

“This is a great relief, of course,” Purdy said of the district attorney’s decision ultimately to not file charges. He said he grieves daily for his wife but said that he’s “definitely happy [the district attorney's office] made this right decision.”