Euthanasia and the right to die

 

Euthanasia and the right to die

 

Prahlad K Sethi1, MD and Nitin K Sethi 2, MD

 

Departments of Neurology Sir Ganga Ram Hospital, New Delhi, India 1 and New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, U.S.A 2

 

Address correspondence to:

Prahlad K Sethi, MD

Emeritus Consultant

Department of Neurology, Sir Ganga Ram Hospital

Old Rajender Nagar

New Delhi, India 110060

President Brain Care Foundation of India

http://braincarefoundation.com

http://braindiseases.info

On March 7th, 2011, the Law Commission of India, Ministry of Law and Justice in a landmark judgment recommended to the Government of India that terminally ill patients should be allowed to end their lives. By passing this judgment, India joins a small select group of nations that allow euthanasia in some form or other. This judgment has led to a vigorous debate in the media about euthanasia. Just what is euthanasia and what is the difference between active and passive forms of euthanasia? The word euthanasia is derived from Greek: eu ‘well’ + thanatos ‘death’. The Oxford dictionary defines euthanasia as the practice of killing without pain a person who is suffering from a disease that cannot be cured1. The Stedman’s medical dictionary gives a more comprehensive definition and defines it as the act or practice of ending the life of an individual suffering from a terminal illness or an incurable condition, as by lethal injection or the suspension of extraordinary medical treatment2.

            Before we dwell deeper into the subject it is important to understand a few medical terms namely the difference between brain dead (BD) and persistent vegetative state (PVS). By all accounts Aruna Shanbaug has been in a PVS for the past thirty odd years. When she was strangulated her brain was deprived of precious oxygen and blood leading to what we neurologists refer to as anoxic encephalopathy. Anoxic encephalopathy may also occur following other causes of cardiac and respiratory arrest. Most patients do not survive the initial anoxic insult to the brain, either their heart naturally stops after sometime (cardiac death ensures) or their brain dies (brain death ensures). We shall come to brain death later. Some patients though do survive thanks in no small part to sophisticated life sustaining measures such as ventilators and advances in critical care medicine. If these patients are followed the outcomes are varied. Some may “wake up” and start interacting with the environment (talking, responding appropriately to pain and so forth). Others may “wake up”, open their eyes and even yawn but when closely assessed have no meaningful interaction with their environment. It is these patients who after a period of observation are determined to be in a PVS. A person who is in a PVS shall never talk, walk or interact with his loved ones. In a way he is a vegetable. PVS is very different from BD. For a person to be brain dead certain strictly defined criteria need to be met. These criteria with minor variations such as length of observation, interval between repeat testing, number of physicians needed to certify BD are essentially similar across the world. The diagnosis of brain death is primarily clinical meaning that it is made after a thorough neurological examination conducted by a trained physician preferably one skilled in neurosciences (neurologist or neurosurgeon). In cases where for some reason the clinical examination is incomplete or in doubt, confirmatory tests such as an electroencephalogram (EEG) are available to confirm BD.

The question of passive euthanasia may arise in patients who are in PVS. It may be requested by one of the family member to “end the patient’s suffering”. Active euthanasia on the other hand is usually requested by a patient who is terminally ill and in pain such as those with advanced cancer or those suffering from progressive neurodegenerative conditions such as amyotrophic lateral sclerosis (ALS) which in its final stages leads to difficulty in breathing. Terminal patients with ALS are further unable to clear their own secretions and are unable to swallow or cough. These patients may request their doctor for a “mercy killing”. Please kill me and end my suffering and pain. A point to clarify here is that the question of euthanasia whether active or passive does not even arise in a patient who is brain dead. Brain death is now around the world medically and legally synonymous with cardio respiratory death. Once a patient is declared brain dead, he is dead. You do not have to wait for the heart to stop before you can say the patient is dead. As someone said rightly “you cannot die twice-once when the brain stops and once when the heart stops!”3. Hence in a brain dead patient, the law allows the physician to stop the ventilator and discontinue all other critical care support4. Remember the patient is already dead so there is no need for the ventilator to keep running. Hence the question of euthanasia whether active or passive is mute in a BD patient. Usually after a patient is declared BD the family is approached to consider organ donation. If the family decides to donate organs, the “dead patient” is kept on the ventilator till the organs can be harvested. If the family decides against organ donation, the ventilator is stopped and the body handed over to the next of kin.

So now let us move on to the topic of euthanasia. Active euthanasia (as for example mercy killing via a lethal injection or by giving an overdose of pain killers and sleeping pills) is currently illegal in almost all countries of the world. In most countries a physician who assists in active euthanasia can be prosecuted, lose his license to practice medicine and can even be jailed. Put in another way the law as it stands now condemns a physician for actively killing someone (even though the patient requests it) but does not condemn a physician for failing to save a terminally ill patient’s life (aka active euthanasia is illegal but not passive euthanasia). Netherlands and Switzerland are two countries where active euthanasia is practiced openly though the medical, legal and social implications remain active topics for both professional and public debate. The courts in these two countries have allowed physicians to practice active euthanasia under certain strict conditions. In these countries too it is usually physician assisted euthanasia (the physician prescribes the lethal medication but it the patient who self administers the lethal medication) is more widely accepted (both by the public at large as well as ethically and morally by the physician community) than active euthanasia (physician administers the lethal injection himself). In Netherlands the following guidelines if followed strictly have traditionally protected physicians from prosecution: the patient’s wish to die must be expressed clearly and repeatedly, the patient’s decision must be well informed and voluntary, the patient must be suffering intolerably with no hope for relief however the patient does NOT have to be terminally ill (mental suffering is acceptable as a reason for performing assisted suicide and euthanasia in a patient who may be physically healthy), the physician must consult with at least one other physician, the physician must notify the local coroner that death resulting from unnatural causes has occurred 5.There is an ever increasing demand for the “right to die with dignity”. In an essay in the International Herald Tribune the right to die was defined as follows: “every person shall have the right to die with dignity; this right shall include the right to choose the time of one’s death and to receive medical and pharmaceutical assistance to die painlessly. No physician, nurse or pharmacist shall be held criminally or civilly liable for assisting a person in the free exercise of this right.” A fundamental thought underlying the right to die is the belief that one’s body and one’s life are one’s own, to dispose of as one sees fit. So theoretically if one wants to commit suicide one should have the freedom/ right to do so. Opponents of the right to die point out that legalizing the right to die may lead to irrational suicides. Different religions have different thoughts of view when it comes to the right to die. Hinduism in fact accepts the right to die for those suffering from terminal illnesses allowing death through the non-violent practices of fasting to death (Prayopavesa). Some Jains practice Santhara by which they seek voluntary death through fasting. Since the decision to practice Santhara is taken while one possesses a sound mind and is aware of the intent it cannot be equated to suicide which is usually carried out in haste when a person is in the midst of depression they point out.

So euthanasia remains a very complex topic with medical, legal and social implications. A concept which is virtually non-existent in India but quite common in the United States is the concept of a living will. A living will is an advance directive and a legal document in which a person makes known his or her wishes regarding life prolonging medical treatments. In a living will a person indicates beforehand which treatments he would or would not want to receive in the event he suffers a terminal illness or is in a PVS and is unable to speak and make decisions for himself. So it reasons that the living will does not become effective till the patient is incapacitated. As long as the patient can make decisions with a sound mind he can decide what treatments he wants or does not want. However after he becomes incapacitated or enters a PVS the living will comes into play. If in the living will he has documented that in the event of suffering a cardiac arrest in the background of a terminal illness he would not want to be resuscitated and put on a ventilator, his wishes shall be respected by his treating physicians. A comprehensive living will can give a patient substantial autonomy over what happens to their body at the final hour of their terminal illness.

We wish to highlight here that passive euthanasia in the form of withholding extraordinary life supporting measures (such as the decision to intubate and mechanically ventilate a terminally ill patient) is already routinely practiced in critical care units across India on a daily basis. In our experience once the hopelessness of the medical situation and the gravity of the illness is explained to the relatives, they usually comprehend and request discharge from the unit so that the patient can take his last breath at home surrounded by family and friends. It is only when disagreement about termination of care arises among family members or when a conflict of interest is perceived by the family members with respect to the treating physicians (they want him to die so that they can free the bed/ ventilator) that these cases reach the attention of the media and the public at large such as in the case of Aruna Shanbaug. We hope that these misconceptions about passive euthanasia shall abate with better public education. The judgment on March 7th is indeed a landmark one and its implications on the Indian health system in the coming years shall be profound and keenly watched by all.

References

  1. Oxford dictionary online at http://oxforddictionaries.com
  2. Stedman’s Online Medical Dictionary at http://www.stedmans.com
  3. Sethi NK, Sethi PK. Brainstem death-Implications in India. J Assoc Physicians India.2003 Sep; 51:910-1.
  4. Sethi NK, Sethi PK. Brain death and decision dilemmas. Neurosciences Today. Jan-Mar 2003; 7:27-28.
  5. http://www.libraryindex.com/pages/573/Euthanasia-Assisted-Suicide

Hypothermia and Brain Arrest Protocol

Hypothermia and Brain Arrest Protocol

 

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Recently I attended the American Academy of Neurology (AAN) annual meeting held in Seattle. One of the topics of interest was the use of hypothermia to improve the outcome of patients after cardiac arrest or traumatic brain injury. Since the neurological outcome of patients presenting after a cardiac arrest (whether in hospital or out in the field) is usually dismal, I thought this shall be a good topic for me to discuss here.

The brain needs oxygen to survive and does not do well if deprived of oxygen. Hypoxia (lack of oxygen) occurs after cardiac arrest (the circulation of blood to the brain is interrupted when the heart stops beating as occurs in a cardiac arrest). If the circulatory flow is not rapidly reinstituted (meaning the heart is not restarted) irreversible neuronal death ensures.  The usual scenario is as follows. A patient suffers an out of hospital cardiac arrest. A call goes out to 911. The EMS team is on the scene shortly. The patient is noted to be either in cardiac arrest (we call this asytole) or the heart is beating but ineffectively and there is no palpable pulse (we call this ventricular fibrillation). The heart is revived by either injecting drugs or shocking (with the help of a hand held defibrillator) and there is return of palpable pulse. Alls well you might say but the story is far from over!!!

Even though the heart has been revived the brain has taken a hit. During the time when the heart had stopped, there was a lack of blood flow and oxygen to the brain and irreversible neuronal death has occured. So we have a patient whose heart is now beating but the brain is dead. This patient may never make a meaningful neurological recovery. Some of these pateints end up in persistent vegetative state (PVS) or minimally conscious state (MCS).

By the time, I as a neurologist am called to see the patient, there is precious little I can do. The brain is already dead!!! I can just prognosticate and tell the family that their loved one shall never have a meaningful neurological recovery. In other words, I help them in deciding when to pull the plug!!! Nothing makes me feel more helpless. I did not enter neurology to prognosticate, I entered neurology and medicine to save a life and heal.

So that is why hypothermia for cardiac arrest sounds so promising. Recent studies have shown that if the brain is cooled (there are different ways to cool the brain from using high tech cooling blankets and beds to more primitive but equally effective techniques like bags of ice) to 32-34 degree centigrade for 12-24 hours following cardiac arrest, neuronal death does not occur. Till the heart is revived, the brain remains viable!!!

This research has led to the institution of a Brain Arrest Protocol in some big academic centers. Once a patient who has suffered a cardiac arrest is received, hypothermia protocol is immediately instituted. This has resulted in improved survival rates in these critically ill patients. Patients not only survive but they survive with good neurological outcomes.

If the hypothermia is prolonged or if the temperature is lowered too low it can cause complications and increase the risk for sepsis and cardiac arrhythmia. Hence this protocol is at present still in its infancy but I have a feeling this shall become a standard of care very soon.

 

A neurologist reflects…..

Nitin Sethi, MD

Assistant Professor of Neurology

New York Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Saturday morning finds me in my favorite  coffee shop in the West Village reflecting on the week that went by.  It was a long week, even by my standards and I am happy to have the time to sit down and reflect on it. The week also saw me confronted with a moral and ethical delimma. Electroencephalogram (EEG) (this is a test to look at the brain waves) monitoring was requested for prognostication purposes on a patient in the intensive care unit. Patient had suffered multiple strokes and was on a mechanical ventilator. The purpose of getting the EEG was to get an idea of the extent of his cerebral dysfunction. His EEG showed some slowing of brain waves but otherwise surprisingly looked “good” given the extent of pathology in the brain and the fact that he was comatosed.

His wife tearfully was considering termination of care. Patient had a living will, in which he had clearly made his wishes apparent that he did not wish to live in a state where he was dependent on others, bed-bound and unable to participate in activities of daily living. Objectively as a doctor I knew he was not brain dead, my neurological examination told me that. I did know that his chances of a meaningful neurological recovery were very poor and likely he was heading to a persistent vegetative state (read more about PVS on my website http://braindiseases.info).

His wife had justifiably struggled to come to the decision of termination of care of her beloved husband. Next day when she finally made her decision to terminate care, the patient was noted to wince to pain as she walked into his room…..

There started the moral and ethical delimma for everyone, his wife as well as us doctors. Can we ever prognosticate sufficiently about the extent of someone’s neurological recovery? Can we ever be 100% sure about the extent of someone’s neurological recovery especially if we are attempting to make that decision soon after the neurological insult. Various neurological papers have attempted to answer this vexing question. We do have some leads. We know that a patient who loses brainstem reflexes such as pupillary light reflex (shine a light into the pupils and the pupils constrict) shall have a universally poor outcome. Tests like MRI brain, EEG and evoked potentials further help us in prognostication.

But what does meaningful neurological recovery  mean to the patient, his family and to us doctors? To us doctors it means being independent in activities of daily living, a patient conscious and alert and productive member of society. We have scales to help us grade this recovery. But meaningful neurological recovery might have a completely different meaning for the patient and his family. For his wife, the very fact that her husband is alive, someone she can reach out and touch may mean the world. True along with that shall come the burdens of caregiving.

Now what about the patient? True our patient made a living will, a will made when he was fully alert and in control of his senses. He made his choices known. But did he plan for a situation like this?  He is critically ill and the doctors are not certain what his chances for a meaningful neurological recovery are. Would he have liked to have his life sustanied if the answer was not black or white but a shade of grey?

The more I reflect on this, the more I realise that life is never simple and there are seldom easy answers. The struggle continues…..

Persistent vegetative state and minimally conscious state

In this post I thought I would talk a little about persistent vegetative state (PVS) and minimally conscious state (MCS). Though this topic may not concern many of you, I feel it should be discussed as the question of PVS is raised frequently by family members of patients who are in coma.

Doctor is he brain dead? Would he wake up? If yes when? Is he going to be a “vegetable” for the rest of his life?

So what is PVS and how does it differ from brain death. I shall try to make this simple and explain with the aid of a crude example. Let us assume a person suffers major head trauma in a motor vehicle accident. He is brought to the hospital and CT scan shows extensive bleeding in the brain. He is in the intensive care unit on a mechanical ventilator while his blood pressure is been supported with the help of medications (we call such medications vasopressors). Now a neurologist is called to see him regarding prognosis. On examining him the neurologist notices that his pupils are dilated and fixed (do not react to light) and the rest of his brain stem reflexes are also not elicitable (please see my previous post on brain death). An EEG is ordered to confirm the diagnosis of brain death. The EEG shows no cortical (brain) activity above 2 microvolts (meaning it is essentially a flat line) and is thus consistent with electrocerebral inactivity (ECI). SUCH A PERSON IS BRAIN DEAD AND CAN THUS BE REMOVED FROM THE VENTILATOR (OF COURSE WE TAKE THE FAMILY’S WISHES INTO CONSIDERATION). BUT FOR TECHNICAL PURPOSES HE IS DEAD. Remember what I said earlier one cannot die twice, once when the brain stops and once when the heart stops.

Now lets take the second scenario. The neurologist examines the patient and notices that he does not respond to verbal commands, does not respond to a painful stimuli such as a pinch but the brain stem reflexes are intact. His pupils react to light, he gags when the back of his throat is touched, he takes a gasp on his own when he is temporarily disconnected from the ventilator. THE NEUROLOGIST RIGHLY SAYS” PATIENT IS NOT BRAIN DEAD BUT HIS PROGNOSIS FOR RECOVERY IS GUARDED“. Time goes by say about a week. The patient is now still in the intensive care unit but at times responds when he is stimulated, does not open his eyes or talk but moves his arm if he is pinched. More time goes by say about 2 weeks. The patient is now opening his eyes. He now has a tracheostomy and slowly is been weaned off the ventilator. He is still not able to talk and does not interact with any of his nursing staff or his family. More time goes by, the patient has been weaned off the ventilator. He is now out of the intensive care unit and is transferred to the hospital floor. A neurologist’s opinion is asked for as “the patient does not respond”. The neurologist examines the same patient whom he had seen in the aftermath of the trauma. 10 weeks have gone by since the injury. The neurologist finds that the patient open his eyes spontaneously, at times even yawns, he is told by the family at bedside that the patient has sleep wake cycles (meaning he sleeps at night and then wakes up after some time just like any other “normal” person).  As the patient’s mother walks into the patient’s room, the neurologist notices that the patient tracks her with his eyes for a short time when she enters. But there is no meaningful interaction of the patient with his environment. It is as if the patient is there but not there. He does not make purposeful eye-contact with anyone. There is nothing in his actions to suggest that he is truly responding to those around him or interacting with them. The tracking movements of the eyes are semipurposeful and so is the yawning behavior–more like a reflex if not anything else.

A person like the one above may be labelled as one who is heading into the persistent vegetative state (PVS) category. You can imagine the delimma for the family members if you tell them that though the patient may remain “alive” for years, he shall never have any meaningful neurological interaction and hence it is better to let him go. “BUT DOCTOR HE IS ALIVE, HE YAWNED TODAY, HE LOOKED AT ME WHEN I WALKED INTO HIS ROOM”: they will say.

Patients who are truly in the PVS shall never recover any meaningful neurological interaction with the environment–this is by defination. But as is true in medicine, everything is not black and white. there are shades of grey. Patients who meet the criteria for PVS but then who later on start showing “some” recovery. Some purposeful goal directed behavior starts emerging. So a new category of minimally conscious state has not come into the literature. There have been some studies done to show that the brains of these patients do actually respond and they are far from a PVS. A lot of research is now been carried out to determine how we can benefit these patients.

If the right procedure is followed and the neurological examination and relevant investigations are carried out and repeated if required after an interval of time, most of these patients can be rightly categorised into the brain dead, PVS or MCS category thus avoiding confusion and anguish to the family members.

Nitin Sethi, MD