Euthanasia: Part 1

There's a little secret most people don't know. This secret is: on the whole, hospitals don't manage mortality well - especially those without robust palliative programs in place. In fact, hospitals can often bungle the end of life, their non-palliative super-specialists not really understanding where the true mortality comes in, and how the process of dying needs to be

parsed and expanded out for optimal management. The best end of life management happens with what looks like slowing down the process to assess where a patient truly is on the trajectory of dying, and managing the vicissitudes to perfection, aiming for stability or reversal if possible, or steady rapid or slow deceleration if not.

This is where euthanasia comes in. I have indeed had cases which defy logic, which blow the mind in terms of missing the mark. One case - of which I will tell only certain salient details at this point - is particularly illustrative of the presumably unwitting premature attempt to decelerate care in some patients (often the most fragile patients at the end of life, those who cannot advocate for themselves and don't have family love and support, or financial backing to counter the ego-driven clinical push). I was handed over a patient who had end-stage COPD to admit for GIP (general inpatient hospice management), and was told by the physician who had managed up until this point, that this patient was "transitioning," that is to say actively dying.

In reviewing the patient's clinical status and regimen upon admission to us, the regimen that this transferring physician had put in place - someone who happened to be a palliative care physician in addition to a hospital physician - I was surprised. The patient was not clinically actively dying and the regimen was grossly inappropriate, poorly tailored, and heavy-handed without nuance or understanding of where things were. In fact, the patient was being heavily sedated with the presumption that they were "dying," but clinically did not have the features of active dying. I overhauled the regimen and the patient woke up, and did much better. The patient was alert, speaking, and fully able to interact.

I have had a number of these types of patients, individuals who are being managed by people who strikingly know nothing about managing mortality. It might be easier for a clinician to decide on a deceleration when it is seemingly straightforward in irreversibility like brain death, or end organ failure; although still, there is much nuance to manage with the trajectory of dying. Yet, overall, clinicians simply do not know what they don't know, even the most specialized of them, and there is an arrogance when it comes to mortality, thinking so erroneously that it is a no-brainer to manage, just throw a few meds with crazy dosing at it and see what sticks.

Most clinicians, in not knowing mortality, will at some point be mistaken and push an agenda forward that needs to be slowed down. When we don't take mortality seriously, don't study it, understand it, learn its nuances, how it presents, how it evolves, we make mistakes, we jump the gun on assuming there is death when there is not, and longevity when there is not. Death is a powerful moving target on which we need to keep our close eye. If one is truly getting mortality right, there will be no need to iatrogenically make blunders like accidental euthanasia.