Angry Doctor

Thursday, November 09, 2006

You can live with dignity...

"Our bodies break down, sometimes when we're ninety, sometimes before we're even born, but it always happens and there's never any dignity in it. I don't care if you can walk, see, wipe your own ass. It's always ugly. Always. You can live with dignity, we can't die with it." - House

I swear, the next person who uses the phrase 'dying with dignity' in a discussion on the Advanced Medical Directive (AMD) is going to get an earful from me.


Just what exactly is so undignified about dying with 'tubes' running in and out of your body?

How does having an endotracheal tube down your throat or an intravenous access or an intra-arterial line make your exit from this world less glamourous?

Or, how is choking on your own secretions and gasping for air *without* any tubes inserted into your body a 'dignified' way to go?

'Dignity' is in itself a social construct. We, as a society and as individuals, choose what to call 'dignified' and what to call 'undignified'. The fact is there is nothing inherently undignified in receiving life-support measures and treatment. People receive it all the time - from preterm babies, young people who suffered trauma, old people with serious infections, to people who are dying.

Dozens of SARS patients received extraordinary life-sustaining measures during the outbreak. Nobody called them 'undignified'. They were called 'heroes', as were the people who put them on these measures and treatment.

So what exactly is so different about dying from SARS as opposed to dying from cancer or heart failure that makes it acceptable for one group of patients to receive such treatment till the time their bodies fail despite all efforts, and 'undignified' for another group?

angry doc suspects that this 'dying with dignity' talk comes from a fundamental fear of our own mortality and a desire to have some sense of control over the manner and timing of our death.

Unfortunately an AMD doesn't really give you those choices.

You can't choose how or when you want to die by just signing an AMD.

You are allowed to state in advance that you do not want extraordinary life-sustaining treatment when your death is imminent, but don't pretend that you have a real choice over how you got there to begin with, or when it's going to happen. Chances are, if you need your AMD to be activated, you are not going to be looking your best or in a very sound state of mind. In other words, you are still going to look pretty undignified.

angry doc has no problems with people who decide that they do want an AMD signed, for whatever reasons they might have, but anyone who wants me to witness their AMD so they can 'die with dignity' is going to get some tough questioning.

The problem with not questioning the oft-quoted statement that signing an AMD means 'dying with dignity' is that people will let themselves believe that they have thought the whole issue through when all they have done is to parrot someone else's assumptions.

By all means sign the AMD if you want to reduce your final hospitalisation bill, sign the AMD if you want to spare your family from taking the decision on whether to initiate or continue extraordinary life-sustaining treatment, sign the AMD if it makes you feel better about your own mortality.

But don't pretend that signing one will guarantee that you will die with dignity, or that people who do not sign one will die without dignity.

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  • It's true that most poeple don't understand what a AMD can and cannot do, and the complications that being human bring to all decisions (fear, guilt, not wanting to let go). The benefit of AMD is to satrt people talking, but it's a small first step. They need to know what questions to ask, the benefit and burden of proposed treatments, they need to know what dying is and how comfort can be maintained, they need to know how comfort will be assured whether or not treatment is decided upon. THey need great communicaiton within the family and with the healthcare team. Too many decisions are based on fear, lack of information and misinformtion as it relates to the dying process, which is why I've just written a simple book to answer fears directly and help people focus on end of life questions and needs, and hopefully not live with the regret I've heard too often in my 30 years as a nurse, which is "if I had only known...."

    By Anonymous Anonymous, At November 09, 2006 4:50 am  

  • I think the point angrydoc (correct me if I am wrong) is trying to make is that we doctors know all along what this AMD is really about.

    As doctors we have been and are still advising patients and their relatives on what course of medical treatment to take and to what degree and extent it should be. Why? Because we see death on a regular basis in the wards. We know what dying is like. We know when it is time to let God take over. We know what the cost is and how that would be significant to the family on a practical basis.

    And we know that there are many people who do not understand death. And when the time comes, they make irrational emotional decisions and understandably so.

    And frankly signing an AMD in ignorance and misconception about what death is would NOT solve the problem of people not understanding death.

    What it would solve is merely adminsitrative, legal and political burden.

    What we should be doing is educating people about health care matters. About treatment options. About death. Not about some paper contract you sign!

    It seems to me there is now a "marketing" drive for the AMD!

    Am I right?

    By Blogger Dr Oz bloke, At November 09, 2006 10:07 am  

  • I suppose the 'marketing' campaign is what is making me uncomfortable.

    The Ministry purports to want to encourage discussion on end-of-life issues, but it seems that they have already decided that the AMD in its current form is a good thing, and that there "should be having hundreds of thousands of people signing on", as if it's 'sales targets' we are hoping to achieve rather than intelligent discussion.

    Several letters published in the media bring terms like 'choice' and 'dying with dignity' into the discussion, and the danger here is that people will assume that signing AMD in its current form equates with choice and dignity without having thought the premises through themselves.

    I think if we as a society are serious about looking at end-of-life legislation, we should look at what are the choices we want available for ourselves and see if the current AMD allows for them, or if there is a need to amend the legislation, rather than to encourage people to sign the AMD here and now before the discussion is even started.

    By Blogger angry doc, At November 09, 2006 5:55 pm  

  • Interestingly,

    how MANY MPs have signed the AMD?

    how MANY doctors have signed the AMD?

    how MANY nurses have signed the AMD?

    how MANY of the MOH people involved in the AMD marketing project have signed the AMD?

    Instead of going dancing hip-hop.....they should find better things to "walk the talk" :)

    Nevertheless I agree that more should be done to discuss about death and options. But I see they may be reading this blog? Morning headlines on Today paper! lol!

    By Blogger Dr Oz bloke, At November 10, 2006 10:47 am  

  • Certainly dignity was never one of my key concerns. Suffering is. Why hasn't Dr. Angry addressed the possibility that the AMD can be used to end suffering in terminally-ill patients instead of prolonging it?

    By Anonymous Anonymous, At April 06, 2012 6:54 pm  

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