Friday, January 23, 2004

Euthanasia, Part 2a: Prospects At The End Of Life - Pain

A 2002 comprehensive state-by-state review of end of life care found that dying people in America have inadequate access to pain control and specialized support services. Seventy percent would prefer to die at home; only 25% do. Most do not have access to hospice care or don't receive the full suite of available hospice services. Dying people fare better with access to palliative care, which is treatment that focuses on relieving pain and suffering rather than attempting to cure disease. But only 17% of community hospitals and 26% of academic heath centers have specialty teams for palliative care. The American Pain Society reports widespread problems with insufficient pain control at the end of life.

It's no wonder that many of these people decide that they want to kill themselves. But it doesn't have to be that way.

State-of-the-art pain treatment is phenomenal. It encompasses narcotic and non-narcotic painkillers; slow-release narcotics that don't cause heavy sedation; medicines that increase the effect of painkillers, such as muscle relaxants or low-dose antidepressants; biofeedback; hypnosis; acupuncture; nerve blocks; nerve stimulation; and even the surgical implantation of tiny painkiller pumps near the spinal cord. The American Pain Society estimates that over 90% of dying patients can receive adequate pain relief without being overly sedated, and that pain relief can be accomplished with sedation in the rest. But most dying patients are offered only narcotic pills or injections, in increasingly larger doses. With narcotics come undesirable side effects: nausea, constipation, depression, over-sedation. And doctors may be reluctant to prescribe sufficient quantities of narcotics for pain relief, either for fear that the drugs will be abused, or for fear that they will depress breathing and perhaps hasten death.

Why is there such an enormous gap between the possible and the actual? Because specialty pain treatments are complicated and expensive. Not many doctors are experts in pain management, and patients may not be referred for pain services even when they are available - only 20% of patients with chronic uncontrolled pain are seen at specialty pain clinics. Costs are also a complicating factor: insurance companies would certainly rather pay for an inexpensive morphine injection than an epidural medication delivery system. In many states, funding for skilled home nursing care is limited; thus, patients who can benefit from, for example, patient-controlled analgesia pumps may need to choose between the desire to die at home and the desire for appropriate non-sedating pain control. This is despite the fact that dying at home, even with a visiting nurse in attendance, is significantly cheaper for the overall health care system than dying in a nursing home or the hospital.

Pain, and the fear of pain, are major justifications for Physician-Assisted Suicide (PAS). Proponents of PAS have assured me that pain often cannot be controlled in terminal illness. If that is true, it might be a legitimate argument for the availability of PAS - but the pain control available to most dying people falls so far short of adequacy that the proposition can't even be said to have been tested.

Adequate pain control will be more expensive. Increased access to palliative care will require expansion of the health care system in a direction that is not generally profit-enhancing. But ethically, can we as a society ask dying people to choose between suffering and killing themselves, in order to save the rest of us some money?