We Don’t Give the Dying What They Need

What separates doctors who advocate physician-assisted suicide from those who don’t is how we deal with the final stage in the life of a terminally ill patient. How this time is filled makes all the difference in the world for patients and doctors alike.

Jack Kevorkian’s prescription--one that closes rather than enriches this end-of-life period--has skewed public debate. His sentencing to prison for murdering a patient is an opportunity for all of us, physicians and patients, to take a fresh look at end-of-life care and rethink our responsibilities to one another.

When medical cures fail, physicians can feel helpless at the very moment that patients need us more than ever. Most terminally ill patients don’t want a final injection; they want the opportunity to fill the time they have left with meaningful experiences. Physician-assisted suicide too often cuts short a person’s innate need to wrap up loose ends, to say good-bye to family and friends and to die peacefully.

While himself a prisoner in World War II at Auschwitz, Viktor E. Frankl, a physician, watched medically healthy concentration camp victims suddenly die. He concluded suffering did not destroy lives but suffering without meaning did. Frankl later wrote, “Striving to find a meaning in one’s life is the primary motivational force in man,” and that this drive is expressed in a “tension between what one has already achieved and what one still ought to accomplish, or the gap between what one is and what one should become.”

How can physicians help patients fill this gap as their lives come to a close?

Relief from physical suffering is not enough. An Institution of Medicine study showed that 40% of all patients experience moderate to severe pain in the final weeks of life, pain that in most cases can be prevented. In fact, numerous initiatives are underway in medical schools and residency programs to train physicians to treat pain appropriately. But what then?

Physicians need to listen to their patients. In a recent George Gallup survey, respondents overwhelmingly said they want more attention given to the spiritual dimensions of dying, to be listened to and to have someone with whom to share their fears and concerns. In numerous surveys, 65%-70% of the people polled say they want their physicians to address spiritual issues with them--but only about 10% of the physicians actually do.

Physicians need to view dying as a natural part of life, not a disease. There is no reason why 10%-50% of various patient populations should receive care that violates their personal preferences--often in costly emergency rooms or intensive care centers. Ninety percent of those surveyed say they would prefer to be cared for at home if terminally ill. Yet in 1992, 57% of all deaths took place in hospitals and another 37% in nursing homes.

These surveys reveal an end-of-life paradox: While terminally ill patients want their spiritual needs addressed, our health care systems do not yet make room for this care.

In this final stage of life, our responsibilities as physicians must stress the spiritual along with the physical needs of our patients. By treating the whole person, not just the disease, and by paying attention to the patient’s full range of suffering--physical, emotional and spiritual--we can provide patients with the means to achieve a self-satisfying death. Dying is a natural part of life and ought to be meaningful and enriching, not dreaded and feared. Our entire society, not just physicians, must learn to honor and respect a patient’s right to close his or her life gradually and peacefully.

As long as physicians ignore their patients’ personal wishes, as long as physicians view terminally ill patients as medical failures and as long as fear of pain drains the patient’s energies, physician-assisted suicide will retain a certain grotesque appeal.

Our enduring goal is to nurture, not truncate, life. Perhaps one day spiritually assisted deaths will be just as common as physically assisted births are today. Only then will Kevorkianism fade away once and for all.