“Terminal sedation”

Anemona Hartocollis has a long piece in today’s NYT about the fine line physicans and families walk with patients at the end.  New to me: in addition to pain, agitation and anxiety are now accepted reasons for giving patients a variety of CNS depressants, even though – or is it really because? – they are likely to hasten death.

Of course, it’s impossible to read a story such as this without imagining how it’s going to turn into more “death panel” hysteria.  My own view is that if someone wants to hold on to every last minute, the health-care system ought to cooperate.  But speaking for myself, I’d rather not die with a tube down my nose.  As a society, our fear of death – for ourselves and others – costs us enormously in money and pointless suffering.  Give me a long life, and a quick death.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

7 thoughts on ““Terminal sedation””

  1. "My own view is that if someone wants to hold on to every last minute, the health-care system ought to cooperate."

    Are you serious, Mark? And by "the health-care system" you mean what? If keeping them alive an extra week will cost $150,000, borne by the tax payer/insurance system — which means $150,000 that ISN'T available for health intervention earlier in life, you fully support this?

    I am not being snarky here, I am being deadly serious. I have heard the occasional claim that *by far* the bulk of US health spending occurs in the final months or so of life — unfortunately I've not heard this enough times, by enough different authors, in enough contexts, to know quite how trustworthy it is. However let's assume it is true and run with it. This, in turn, implies that a primary pathology of US health spending is in this desperate attempt to keep the aged alive; and this seems like precisely the sort of thing that should be debated by society as a whole — and debated reasonably, not pulling out grandiose rhetorical claims along the lines of "OF COURSE we owe everyone every moment of life technology can sustain, to agree to anything less makes you a Nazi".

    Certainly, for example, I would far rather (to choose random numbers) opt into a medical plan that, lifetime, expects costs of lets say $150,000; that encourages frequent checkups and tests — long life; AND that is fairly aggressive about pulling the plug when death is near; rather than what appears to be the US standard which is to spend, say $250,000 lifetime, little of it early in life, and most of it in an orgy of desperation in the last few weeks.

    Of course the Republicans have pissed in the well regarding this particular issue for some time now; even so it seems that there is scope for the world outside politics to bring up, and continue to push, the facts around this over and over again. Perhaps when enough people really know where and how the money is spent, they will be more sympathetic to UK NHS-style deliberation as to where money is best spent, rather than the current, rather foolish choices that (as far as I know) are rampant in the US system.

  2. My mother died in 1982. She literally ground down her teeth into paste. The doctor told me that she had stated "no pain meds." About 2 or 3 in the morning when I was sponging off her face from the sweat pouring off of her, I casually reached around to the holster that I had inside the rear of my pants. Dropped the pistol into my coat pocket and told the nurse to call the doctor. Had a go around with him, but when I got him to understand that I would drive to Tulsa for street heroin, or he could get a cut down and the pain med in. I might have hinted that I would not be able to make my mother's funeral service because I would be killing him. I might have frightened the hospital enough that nurses, interns, billing clerks, cooks and other personnel would shrink away from me.

    Mom didn't die in pain.


  3. Jeez, it's hard to know. We are in the midst of this right now: my wife's mother is in the ICU, has been for over a week, will be there for another week likely. The docs are telling us we have a reasonable chance of getting her back home for some good time. She has chewed up the cost of a nice home in Biloxi already, may be up to a nice Berkeley Hills house by the time she leaves the hospital – if she makes it. She's not having fun now, but if she can come home and have another couple-three years of good time and dandling grandchildren, this is okay.

    One of the wits out there said, everyone is in favor for death panels for other people's grandmas, but for their own grandmas they want the world turned upside down. We just don't know: the docs are optimistic. They would be, right? They remember the folks who did pull through from a dreadful state, and not the ones who went out on gurneys after three or four expensive weeks during which they had no fun. But I think you really can't tell, in advance, who will benefit.

  4. Just worth noting that using CNS depressants (generally opiate narcotics) for anxiety/agitation is fairly common even in non-terminal cases. (For example, we have a new baby born last week, and it was a fairly traumatic birth (everyone should be fine)); they gve my wife Versed (benzodiazepine) and fentanyl, partly for pain control but mostly for "anxiety"–fear and jumpiness (since once they'd done a spinal block, there wasn't any significant issue of pain.))

  5. I think Maynard has a point. The only thing I dislike more than the idea of an administrator's pen playing fast and loose with my life, is money NOT going to people whose lives don't simply need to be prolonged an extra month or two (bed-ridden, sedated, etc. no less) but actually need saving.

  6. Some of the expensive cancer medications are fairly predictable. They aren't $150,000 for a week – closer to $10,000 for a month. Sometimes that can mean a lot.

  7. Yeah, that sounds about right: My chemo is about $8000 every three weeks.

    My own view is that, if somebody wants to hold onto every last second of life, and they can pay for it, the health care system should cooperate. And the government sure as heck shouldn't get in the way.

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