Courtesy of New York Times.com | by BARRON H. LERNER, M.D. | Originally Published 02.06.2018 | 02.26.2018
Our dog’s brain tumor had worsened to the point that she was restless at all times and often walked in circles. She had mostly stopped eating and was partially blind. Like so many pet owners, our family finally decided to intervene rather than having “nature take its course.”
Akeela, our beloved boxer, had had her share of medical problems over the years, including a ruptured liver tumor and surgery for a parathyroid adenoma. But after the age of 12, she developed both a severe hormonal abnormality known as Cushing’s disease and a brain tumor that caused seizures.
Our girl dutifully kept going, willingly taking a very large amount of medications. But by this past September, her symptoms, which were probably caused by the spread of the tumor, had worsened.
The veterinarian took one look at Akeela and said, “This is not a happy dog.” We had to concur. The very traits that had once made her so distinctive — her joy, her displays of affection, her constant monitoring of the house — had waned.
My wife and two adult children and I held a family meeting. After some discussion, we agreed it was time to put her down and selected a date and a venue — our home. In the next couple of days, my children’s friends, our longtime nanny and many others who loved Akeela visited and said their goodbyes. There were a lot of tears, which we tried to hide from her.
The veterinarian who came to the house was very professional; she specializes in at-home euthanasia. Having heard the story and met Akeela, she concurred with our assessment.
But what did Akeela’s end say about my own practice of medicine?
In contrast to veterinary practice, the medical profession has long forbidden the notion of speeding death. The Hippocratic oath, which dates to Greece in the fifth century B.C., states that a physician must not “administer a poison to anybody when asked to do so nor … suggest such a course.”
Instances in which physicians have participated in euthanasia have generally been wholly unethical. These include a program started by Nazi physicians in the 1930s to kill mentally ill and chronically infirm persons and over 100 controversial deaths facilitated in the 1990s by Dr. Jack Kevorkian, a pathologist who believed that terminal patients had a right to determine when they died.
There is one current exception to the prohibition on physicians expediting death: physician aid-in-dying. In six states and Washington, D.C., physicians may legally prescribe medications that terminally ill patients may take when they so wish. Numerous protections are written into these laws, such as making sure that the person is really dying and has full capacity to make decisions.
I could think of stories similar to that of Akeela among my own patients. There was the blind woman who was bedbound, in pain and partially paralyzed from a stroke; another woman was skeletal from metastatic cancer and required constant sedation and analgesia. There have been many more. Some of these patients had explicitly expressed a wish to die, hoping that we doctors might, humanely, “end it all.”
My experiences with Akeela led me to reflect on these cases. If suffering was so obvious and not reversible, and there was a way to provide immediate relief, was my reflexive refusal to assist in the dying process always the right thing to do? And if the patient, fully understanding all of his or her options, was asking for death, didn’t this make him or her more worthy than a dog, whose suffering could only be assumed? I had little doubt that family members, seeing a loved one suddenly at peace, might have said what our vet said to us: “She was tired.”
But in my own practice, I can never countenance euthanasia. Hippocrates’ sentiments from over 2,000 years ago resonate for me. Doctors are in the business of healing bodies, not harming them — even if that “harm” potentially provides relief from the same type of suffering we find unacceptable in our pets.
The process of euthanasia involves two injections — one to sedate the dog and a second to stop the heart. Apparently, some dogs become agitated by the first injection, but Akeela quickly became very sleepy.
“She’s tired,” the veterinarian said.
As a physician, I was skeptical that Akeela’s response to the sedative truly indicated whether it was time for her to go. But on an emotional level, what the vet had said made sense. Because of her Cushing’s, Akeela had been panting on and off for months. And the worsening restlessness and circling had to have been taxing for her.
I took Akeela’s death hard. I truly believe that relieving her suffering was the humane thing to do.
Having said this, I am not opposed to telling my patients about physician aid-in-dying. Indeed, were they so inclined and prepared to move to a state where it is legal, I might help them make the transition. And if aid-in-dying became legal in my own state, New York, I would consider making a referral to a physician who might prescribe the necessary drugs.
Of course, for most patients, moving to another state near life’s end is neither desirable nor practical. And in many cases, the process could never be implemented in time. Fortunately, though, there are now better medications to treat the symptoms of dying and a specialty, known as palliative care, that can provide expert guidance in doing so.