Doctors' Secret Language for Assisted Suicide | Hacker News Reader

Doctors' Secret Language for Assisted Suicide

theatlantic.com

197 pointsnitin_flanker63 comments

I accidentally euthanised my father because I misunderstood the conversation I was having with a nurse. He had a stroke and was in intensive care, we were told he probably wouldn't live - and if he did - he'd require care for the rest of his life. He had fallen into a coma when the nurse kept asking me if I thought he was in pain and needed more morphine. She kept giving him more, returning to ask the same question and doing it over and over. I can't remember how many times. He began Cheyne–Stokes breathing, and eventually died.

I remember feeling strange about the situation, and years later I connected the dots between the amount of morphine given, the breathing (symptomatic of morphine overdose), and his subsequent death. Understanding that I was responsible was something that took a long time to cope with.

My mother faced terminal cancer a few years ago, and I found myself in exactly the same situation. Thankfully I understood what was happening. The decision to take her off fluids and to "help her along," was made by a team of medical staff with myself deeply involved in the discussion (which looking back, was a desperate attempt for me to negotiate any way I could for her life). At least Mum understood she was going to die, and I'm glad my eyes were open to what was happening.

I feel that the economics of hospital beds have a lot to do with this. Beds in the oncology ward are in demand, as of those in intensive care. I've seen all of my families previous generation die of cancer in either in the same way - in hospital, in oncology or intensive care, always assisted death.

It makes me think that if I ever go down that road I don't want to be anywhere near the medical industrial complex.

Reading this, and other comments, makes me realize there is a secret assisted-dying dance in play in the medical system. If you say the magic words "I think he is in pain" repeatedly, then the medical staff can legally administer a coincidentally lethal amount of morphine.

If assisted-dying was legal, regulated, and a well accepted practice there would be none of this "Do you think he is in pain? wink" nonsense and they could directly ask whether or not you would like to have him humanely euthanized.

Then no one else would ever have to begin a comment with "I accidentally euthanized my father" ever again. That is just too tragic. Even if it was honestly the best course of action, I'd want to at least be cognizant of my decision, not to just piece it together years later. :(

I was worried I see a lot of comments like this. Your concerns are legit, but it's far worse for people to watch their loved ones suffer.

The discussion I have with families is usually very up-front about the fact that our comfort-care medications can hasten death. But in the ICU that I practice in, that's almost always a good thing. Sometimes use continues infusions to avoid the correlation between a dose given and subsequent respiratory arrest. But I have no doubts about the ethical nature of this. Just wish we could be more open about it, as the article suggests.

Perhaps you misunderstand me; it sounds like you think I'm against assisted-dying.

I am, however, against ACCIDENTALLY euthanizing loved ones due to a miscommunication.

I agree, I think the situation with possible miscommunication is now, to me, one of the better arguments for legalization of assisted-dying. What a tragic story; but I'm glad I read it, I will surely now be cognizant of it should I find myself in a similar situation.

My grandfather had Alzheimer's and after several years of accelerating decline, he fell and broke his hip and over the course of another year slowly deteriorated into him being wheelchair-bound and basically catatonic, until he developed a wound which would not heal.

It finally got bad enough that he was moved to hospice. The doctors and nurses at his hospital did not make any sort of suggestions about "helping him along" and it was my wife (whose mother works for a probate/guardianship attorney and has observed the process many times) who suggested that they use the code words to "help him along". My parents and grandmother, ever in denial, would not consider it.

So instead he lay there being given palliative care but no food or drink, only water sponged on his lips to keep them moist, for 2 weeks before he finally died of either starvation or dehydration. It was awful- his urine turned a dark purple and it was like he melted from the inside.

I wish the doctors had been a little more forward about it. There was absolutely no purpose in making him endure that. I can only hope his mind was by then too far gone to suffer, but it sure looked like suffering to me. My wife and I have discussed it and both know that's we would prefer a little help. Sometimes it really is the most humane thing to do.

This is ghoulish. I'm sorry you had to go through that, and it honestly makes me terrified of having to deal with it when my parents pass someday - my father has already had a stroke, and told me he does not want to go through it again, that he would rather be taken off life support and be allowed to pass peacefully. I can't even imagine having to watch someone I cared for starve to death in front of me.

One might argue that giving "no food or drink" is simply a crueler version of assisted suicide.

With a lot of these stories, I get the impression that the goal is to reduce the medical professionals' suffering, which may or may not coincide with minimizing the patient's suffering.

you didn't accidentally euthanize your father. The nurse purposefully did, and she was covering her butt by involving you. You were an unaware observer (Sorry). She knew what was the humane thing to do, and she knew you were not up to it, and so she assumed responsibility.

Death of parent is difficult. Sorry that you had do go through such a difficult time.

There's another word for that - murder.

I am totally in favor of euthanasia under the right circumstances. A nurse tricking someone who is certainly is shock into nodding their heads and saying "ok" is not under any conditions the right circumstances.

> A nurse tricking someone who is certainly is shock into nodding their heads and saying "ok" is not under any conditions the right circumstances.

I saw you got a downvote, which is a shame, since I think that you made a good point: the importance of assisted suicide as a right should not allow its use to cover any instance of intentional death. However, I think that point might have been based on a misreading of LCDninja's post (https://news.ycombinator.com/item?id=11706159). As near as I can tell, there was no trickery going on, just an honest, if tragic, instance of two people trying honestly to interpret a conversation, but coming to different interpretations about its meaning because the one who understood that there was subtext present could not legally make it explicit.

As others have said, the nurse knew it was the right thing to do and was just involving you to avoid any liability. You aren't a trained medical professional and didn't know what was going on. Trust that the medical staff made the right decision. It sounds like they probably did.

Honestly, I don't think the overriding factor is economics. I think the overriding factor is that medical professionals know what a dying person looks like, have some understanding of what continuous, inescapable pain might feel like, and want to do the most humane thing possible.

Having been in a room with a terminal cancer patient fighting through her body shutting down, it wasn't a question of "How fast can we clear this bed." It was more the sense of "This is what every second of the rest of her life is going to be. Should that life be hours or minutes long?"

If I was legitimately in that much pain, my greatest fear is that my loved ones would choose to keep me alive (and in pain) just so I could "live" a bit longer.

> I accidentally euthanised my father

Oh my god! That is horrible, and you are absolutely not to blame in any way. From the way you tell it, the instigator was the nurse. At the bed-side of your dad in a coma, you are in no shape to rationally process what is going on and grasp the full meaning of the questions; and in fact it took you years to "connect the dots". The nurse knows exactly what morphine can do and what are the limits on dosing; she had the dots all connected.

You must rid yourself of the every last trace of blame; to be caught in the flow of events does not imply being the root cause. Start by taking back the sentence I accidentally euthanised my father. It isn't true; you didn't do that, accidentally or otherwise.

Have a great day!

The doctor said to my relative, "Here is the morphine injection device. If you press this button once, you will get a small dose of strong morphine. If you are in severe pain you can press it twice. Never press it more than three times, as you would die for sure at five or six presses." He had terminal cancer, severe pains and he died peacefully thanks to the hint.

Is this like a syringe or a machine? I thought those machines would limit the output

Must be something the staff can adjust. I had a morphine button once, and they told me it was impossible to overdose on it. Wasn't worth it over a knee operation!

I'd imagine it's something like this; https://en.wikipedia.org/wiki/Syringe_driver

It probably varies, but I would guess that there is a lot of leeway, particularly in machines for hospitals, and they can likely be configured to only reject dosage levels grossly above the maximum feasible for any weight without jeopardizing the plausible deniability the doctors want.

It was a machine. I think the other posters may have already described configuring it for plausiable deniability. It was no secret that this was a possibility, my relative told me and several others about a week before he finally used the opportunity. The end was good - as much as you can call dying of cancer good. It was indescribably hard to see him die, but it was even harder to see him suffer in agony being slowly eaten from inside by this terrible disease. I cried then and I cry now but more time would only have meant more suffering. I can't even call it a suicide. It had nothing to do with suicide, he didn't want to die. He wanted to stop the pain and there was no other way. Ending his life was the final pain relief.

But suicide is sometimes that - no other way to stop the pain.

> Is this like a syringe or a machine? I thought those machines would limit the output

Isn't it amazing that in trying to make sure nothing bad happens we make it impossible for good things to happen?

Well, don't take that too far; if there weren't a limiter, the probability for accidental malpractice would be very high indeed (especially since the requester button is often in the hands of a medically-untrained patient).

But it's good to know the limiter can be disabled when that is deemed necessary.

Not having been in this situation, and (potentially relevant) being in the UK, are the family/patient really allowed to administer drugs like this?

It seems to me that administering potent drugs such as morphine would be controlled by medical staff who have the knowledge around safe doses.

If you're on hospice, you're typically at home, with a caregiver coming by once or twice a day to see how you're doing, clean up, etc., and to check on the automatic IV drip machines. These machines come with a remote that lets the patient request additional pain meds, and they're supposed to have limits on how often the button can be pressed in a certain time period. But if you're on hospice, with stage IV pancreatic cancer or other no probability of survival and extremely painful illness, those limits are sometimes not set.

Source: A friend's mom was a hospice nurse who ended up going into hospice herself.

When my grandmother was in hospice care at home, there were bottles of liquid morphine in her refrigerator. Her family was free to administer it as needed, for pain.

This is the same deniability strategy used by Prohibition-era 'grape drinks': "After dissolving the brick in a gallon of water, do not place the liquid in a jug away in the cupboard for twenty days, because then it would turn into wine." [1]

[1] http://drinks.seriouseats.com/2013/05/wine-and-prohibition-w...

Normally, the morphine injection systems have a hard limit preventing you from overdosing; if you press it before the timer has elapsed, it'll beep at you (and record the press so doctors can get a sense of whether you want more painkiller than you're getting and how long the doses seem to be working for you), but it won't administer.

I never stopped to think about it before you shared this story, but in hindsight it's not surprising to me that feature can be overridden. I bet the manufacturer has even put in just enough safety interlocks to make it hard to do accidentally, but not enough to prevent it outright. You know, because sometimes doctors may need to tweak it on a per-patient basis...

Another factor is a 600lb patient is going to need a regular does that would kill a 120lb patent. So, from a manufactures perspective it's not obvious what a 'lethal' does is.

I feel badly for people that cannot obtain the medicines to do this without "establishment" help. Having seen relatives go through a long period of decay, it really is horrible. Not only suffering for the person, but the destruction of memories for the rest of the family.

If it was someone very close to me, I'd personally acquire the medicines needed. It's not that hard to find a supplier of powerful opiates, even if you have to buy diamorphine on the street. Opiate overdose appears to be a very nice way to go.

The first assisted-suicide advocate I ever met left an impression I will never forget.

He had the most romantic life story. He was an Indian from Gujarat who had moved to America in the 1960s to become a hippy. Then one day he found a flier for an Indian dance troupe that was coming through town. In the back row of the group photo he saw a face that he instantly recognised as the love of his life.

He followed her back to India, where he courted and they fell in love. Her parents refused permission to marry, so he got a haircut and a job in the civil service, and the parents accepted. They married and soon had two small, beautiful children.

Then she got breast cancer.

"At the end, she was in so much pain. It lasted so long. I would have done anything, anything to make that easier for her. But I could only watch while the cancer slowly tortured her to death." He was still broken from the experience. It had been 30 years. Life-sized portraits of her were hung throughout the house. The mythic quality of their love was undiminished, not only for him but for anybody who entered that house.

What their love needed was a quiet, peaceful, comfortable death. That would have been good and right and true. It's worth fighting for.

> the cancer slowly tortured her to death

With the help of the Indian government, which makes it extremely difficult for people to get access to opioids, even if they're terminally ill patients.

http://www.newyorker.com/tech/elements/an-epidemic-of-pain-i...

Wow that's evil. The war on opiates is unethical. The fear of people enjoying a vice overrules compassion, which is just sick.

Absolutely worth highlighting, yes.

Having gone through the death of a grandparent following a stroke, the magic words we had to use were "I think he's in pain." He was well and truly gone by then, but his body was still battling on despite that. Any questions regarding whether we could give him something to let him down easy were met with legally-mandated "no, we can't give him anything... unless you think he's in pain."

It took us a few rounds of this before we cottoned on and completed the dance: "Yes, I think he's in pain."

Confirmation from the article:

"It is legal for people to take or give large doses of narcotics to relieve pain, even if a known side effect is that it may hasten death."

-- Stanford medical ethicist David Magnus

My heart just aches for the poor woman who had to inject her husband.. I can't even begin to imagine having to do this with my partner.

For every person talking about it openly now, I'm sure there are literally hundreds more dealing with this in secret, and that's a terrible shame. I really hope euthanasia laws progress globally to allow these poor people some peace.

Funny, i thought the exact opposite. "How lucky!" She was so fortunate to be there at the end and have the ability to take action.

Watching a loved one die, slowly, while you stand by helplessly observing their pain... that is much worse.

She obviously did not feel this way. She had no support from the medical establishment she was surrounded by. I imagine it was isolating, and made a painful moment worse.

Lucky in the sense that she could help her husband, but unlucky in that she had no support, mentally or medically, for her actions. I can't imagine how lonely she must have felt in a time when she so desperately needed others around her.

I think there are quite a few people who enter into lifelong marriage commitments without realizing that when you say "sickness and health..." Yes, that's what you're signing up for. There may come a time when you're the only person your partner trusts to make those calls.

I've seen a terminal cancer patient breathe her last after the nurse (with doctor authorization) overrode the safeties on the infusion system to give her an overdose of painkillers. She wasn't ever getting out of that room alive, and everybody knew it. She died with her family and loved ones at her side.

I think what a lot of people (in America) may not understand about the national euthanasia discussion is that in the absence of firm policy, we don't have no euthanasia; we have ad-hoc, case-by-case, absolutely-functionally-necessary euthanasia. The notion that doctors can always do no harm is a polite fantasy that blinds people to the messy realities near the boundary of human life and death.

Similarly to the abortion question, end-of-life euthanasia is something people find medically necessary sometimes, and in the absence of a society-wide consensus that allows for it, doctors, nurses, and patients are left doing the best they can and bearing the moral responsibilities alone. Unlike the abortion question, absolutely everyone is going to be in a place where they are either caring for someone who is dying or dying themselves.

Also on assisted suicide and interesting: "By the time you read this, I’ll be dead - Between 1999 and 2001, I helped eight people die, including the poet Al Purdy. Now, as I prepare to take my own life, I’m ready to tell my story" by John Hofsess

http://torontolife.com/city/life/john-hofsess-assisted-suici...

I also recommend the Documentary "Choosing to die" with Terry Pratchett http://www.dailymotion.com/video/xnu340_terry-pratchett-choo...

Very powerful and thought provoking

The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers. Harold Shipman got away with being the most prolific serial killer of all time because he was knocking off old people.

This is the argument that needs to be made, because euthanasia is and will go on anyway.

Good point, shermozle. And the problem with it being allowed and acceptable is that older people "don't want to be a burden", and younger people with inheritances in the balance might make a decision based more on greed than on wanting to help.

It's a difficult and emotive subject, and you can easily argue both sides convincingly.

> The problem with this being a secret, behind-the-scenes thing is that there's plenty of scope of serial killers.

How large is the serial killer market? How about a Tinder-like app[1] that matches serial killers to hospice patients on a morphine-only contract. The 'killers' get to pay a fee[2], and part of it goes to the clients' estate.

1. This is a rather macabre thought experiment. My apologies if you are/have a loved one going through hospice care and this offends you.

2. How many laws would this disruptive arrangement break? Sadly the law is behind the curve

I had a similar 'secret language' experience, though not at all related to AS. I have a diabetic pet, and the vet was explaining how to use insulin. Naturally, one of our concerns was cost. He kept mentioning how he'd seen many people use insulin for months after it's expiration-date. He was clear that you should "always follow the instructions", but that occasionally he'd seen people use old insulin, and, as long as they were consistently checking their glucose, it worked fine for them.

We finally figured out his message: The insulin expiration date might or might not be valid. Testing is better than going by the bottle's expiration date, within reason of course. He couldn't tell us to ignore the date, but he could tell us about when he'd seen it work past the date.

Oregon was the first state to approve physician assisted suicide.. but last year, after a stroke left a relative in a coma with no possibility of recovery, my family got to learn that the state recently passed a law making it illegal to disable a pacemaker.. So even though we requested that they unplug her, they were not able to turn off the one thing that was still keeping her going for a day or so longer..

"Just over 3 percent of U.S. doctors said they have written a prescription for life-ending medication, according to an anonymous survey published in The New England Journal of Medicine in 1998. Almost 5 percent of doctors reported giving a patient a lethal injection."

That seemed really high, given that most physicians aren't in relevant specialties. Clicking through to the article, it actually says: "The sample was drawn from 10 specialties, selected on the basis of previous surveys as those in which physicians are likely to receive requests from patients for assistance in hastening death." Further, it was clear that there were self-selection biases in the responses.

Another process that "assists" dying is withdrawal of fluids while someone is heavily sedated. The ensuing death is "natural", but inevitable.

Allowing someone to die of dehydration (a process that takes many hours and involves gradual shut down of organ function) might be marginally more kind than letting someone die more slowly, but is only fractionally so.

Fortunately most doctors have more empathy and ethics.

The difficulty comes with conditions that aren't immanently terminal. Campaigner Debbie Purdy took eighteen months to starve herself to death after she reached the point where she did not want to continue with her progressive MS. That's just insane and barbaric, but fewer doctors will step in at that point.

We need better laws, as a matter of civil rights. If I have the right to life, I should have the right to relinquish it.

> If I have the right to life, I should have the right to relinquish it.

That statement needs better justification than sounding good. For assisted suicide, It is necessary but not sufficient that the person wishes suicide. Just because someone wants to die doesn't mean that we should let them die. And even if someone wants to die, it doesn't imply that that person have a right to demand someone else to kill them - you do not even have the right to demand that someone else kills you by looking the other way when you kill yourself. The criteria for when someone should be allowed to help someone else to die is complex and requires a lot of safeguards.

> Just because someone wants to die doesn't mean that we should let them die.

I think it does mean we should let them. In most places it isn't illegal to commit or attempt suicide.

By having a process to end your life we've a much better chance of having professionals encounter people at an earlier time. For people who want to end their life because of other addressable needs, we've a better chance of helping them through it.

Forcing someone to live indefinitely when they desire to die is cruel and draconian and ultimately fruitless. People will find ways to end their life, and often in ways that traumatise or damage others.

> it doesn't imply that that person have a right to demand someone else to kill them

Straw man. Nobody is suggesting people have the right to demand any particular person kill them. Assisting with dying is optional for patient and assistor in jurisdictions that allow it.

> The criteria for when someone should be allowed to help someone else to die is complex and requires a lot of safeguards.

The criteria supporting any human right is complex and requires legal safeguards. Your point seems artificially argumentative.

> By having a process to end your life we've a much better chance of having professionals encounter people at an earlier time.

Indeed, it is not like it is going to work like the suicide booth in Futurama, probably you will need to see some therapist and you will have the opportunity to explore different resolution to your problems. The "call for help" suicide for example will most likely been caught with no risk of death.

Isn't that what happened with abortion ? Because parent argument is very similar to those against abortion.

"You probably don't want an abortion, talk to this psychologist and wait a minimum of X days before you can do this" =? "You probably don't want to end your life, talk to this psychologist and wait a minimum of X days before you can do this"

In the case of abortion you weigh the mother's wishes vs the child's potential existence, in the case of suicide you weigh the individual vs their friends and family. I suppose whether or not they're similar depends on how you weigh these factors.

I suppose the only saving grace of this "natural" death by thirst, which is not an uncommon occurrence, is that it is done while the person is heavily sedated. Otherwise it would be incredibly painful, I imagine.

> Allowing someone to die of dehydration (a process that takes many hours...

Many hours is an understatement - or at least I'd suggest measuring in hours is going to give people who don't know the wrong impression.

I've just done "hospice at home" with a friends mum. Nevermind hours, Janet managed over 12 days nil by mouth and without fluids. 3 years ago (though as an inpatient) my grandfather managed just over 4 weeks unconscious and without fluids - just after we were told he wouldn't make it through the weekend..

Whilst (outdoor) survival guides suggest 3 days without water is your max, when the person is sedated and on pain relief the human body can go on substantially longer.

It's insane that we think this is reasonable. It's little different from simply suffocating the person, except much longer and more agonizing.

That's how my grandfather went, at the end of years of steadily worsening Alzheimer's. We kept suggesting to my parents that they suggest to the staff that he was "in pain", but they wouldn't. It took him over 2 weeks to die. It was a terrible thing to watch, and seemed completely pointless- you've already decided that he's going to die, why prolong it? Somehow doing something to "help him along" is killing him, but withholding food and water is not. :(

>Somehow doing something to "help him along" is killing him, but withholding food and water is not. :(

I am also confused by this. If a person is unable to feed themselves, and you are responsible for caring for them, it is murder to not give them food and water. Imagine if doctors did this on purpose to a patient who was not terminal.

I don't see the difference between starving someone to death and giving them a morphine overdose except that one is very nasty and one is not.

The heartbreaking stories in this article, as well as several from the comments, all seem to be the symptoms of an overly litigious climate in our healthcare system. Health workers are afraid to speak plainly. It's gross.

I don't think that's the case. I think the primary factor is the laws which govern how medical professionals can act - and I think that has more support from the article, and by people's comments.

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