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April 9, 1999/23 Nisan 5759, Vol. 51, No. 28
Kevorkian verdict highlights need for compassionate end-of-life care
KENNETH LEVINE
Special to Jewish News
The guilty verdict issued by the Michigan jury on March 26, convicting Dr. Jack Kevorkian of second degree murder of a terminally ill man, is welcome and long overdue. It clarifies Michigan's policy against assisted suicide and highlights the need for legitimate, compassionate care of the terminally ill and dying.
Kevorkian has narrowed dangerously the discussion of end-of-life issues in the United States. He has identified the right problem but has drawn the wrong conclusions.
Kevorkian deserves credit for calling attention dramatically to the problem of unmet and unaddressed suffering among many of the terminally ill in this country, a situation which the public and medical profession has ignored.
There has been a critical deficiency of medical education as well as a lack of commitment on the part of established medicine to do whatever is necessary to alleviate the distress of the dying. The requisite medical knowledge exists but has not been applied until recently.
As a doctor who has been involved in hospice and compassionate care of the dying for seven years, I can state without equivocation that all the physical sources of suffering associated with dying can be controlled.
The next question, as initially raised by a respected Michigan hospice physician, should be, "What is an alternative for the people in pain?" One answer is hospice. Hospice care is palliative (comfort)-oriented, not cure-oriented. It helps patients diagnosed as terminally ill with pain and symptom management.
By definition, hospice care goes beyond the physical symptoms and addresses significant social, emotional and spiritual issues. Each patient is cared for by an interdisciplinary team that typically consists of physicians, hospice nurses, nursing assistants, chaplains, medical social workers, bereavement coordinators and hospice certified volunteers. These professionals provide competent medical care as well as emotional and psychological support to deal with death and dying.
The fact is that in the midst of dying, many people are able to experience not merely comfort but an increased sense of well-being, which often includes a deep sense of connectedness to others and the world.
My strongest objection to Kevorkian's vision for the dying concerns not suffering, but missed opportunity. "The transition from life can be every bit as profound, intimate and precious as the miracle of birth," wrote Ira Byock, a leader in hospice care.
The Michigan verdict sets the standard for the rest of the nation. But even Michigan public policy needs to grow beyond courtrooms and legislation. The medical community and the general public need to be involved.
No one is exempt from death. Therefore, we all should be concerned with the quality of end-of-life care.
To solve the underlying problem, there are some issues that need to be addressed.
. The general public and the medical community must recognize that death is inevitable and that there comes a point in time in treating most diseases when recovery is no longer an option.
Then it is time to cease seeking to cure and instead seek to provide comfort and support. For some patients, this is a turning point that may be difficult to face. It is a fundamental philosophical shift for most.
Hospice is expert at helping patients with this transition. As society accepts this philosophy, it will be easier to provide hospice care.
Currently, only a small percentage of the people eligible for hospice are receiving it. As we make the philosophical shift, hospice care will become more prevalent and readily available.
. The public and the medical community must know more about the quality of care being delivered to the terminally ill and dying.
All patients deserve quality end-of-life care but not all hospices are equal. Many differ on whom they will admit into their service, unjustly restricting patient access to hospice care.
The public and the medical community must hold all hospices accountable for the quality of services provided so all hospices will comply to the highest standards of care for patients and their families. Those who cannot comply should not be in the hospice business. Patients and their families deserve only the very finest in competent, sophisticated, holistic care at this time of life.
. If a patient is not in hospice, it is difficult to access pain control and palliative care programs.
Hospitals have a moral and ethical responsibility to demonstrate a capacity and willingness to refer regularly to hospice or to develop quality, comprehensive palliative care service. It should be as easy to obtain a consultation from an expert in pain management as it is for a patient with heart disease to call a cardiologist.
Hospitals already have written standards of care in place affecting medical procedures and diagnoses; they must develop the same for pain management and end-of-life care.
. Physicians and other health care providers have a moral and ethical responsibility to learn about state-of-the-art pain and symptom management. They also should learn more about hospice's interdisciplinary approach and plan of care that includes patients and their families.
. Insurance companies must take the lead from Medicare and Medicaid, which recognize hospice care and reimburse for it.
Too many commercial insurers provide no hospice coverage or provide inadequate coverage, making access to hospice care difficult, if not impossible, for many patients.
Public policy is clear in Michigan: Assisted suicide and euthanasia are not acceptable. Other states need to establish similar public policy. And all states, including Michigan, need to take the next steps to put into place a system of end-of-life care that is readily available to all.
If we make hospice the norm, incorporate it into the system, we eliminate the need for assisted suicide and euthanasia. It can be done. Do we have the will to do it?
Dr. Kenneth Levine is medical director for Vista Care Hospice, a national hospice care provider with facilities in Phoenix and the East Valley.
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