Death by Prescription. Pt 4.

      The justices of the Supreme Court of Canada have decided , in their wisdom, that it is a patient's privilege to demand termination of their life, if they feel that there is no other way to relieve them of pain and suffering.   They do not demand or require guidelines. That is someone else's  problem and they do not seem to care who's.

     " No need for suicide legislation: Academics (opine)" screams the headlines from a newspaper that I respect   'It's illogical" says Professor Amir Attaran, Prominent Law Professor at the University of Ottawa.  He goes on to comment,  "We don't legislate to regulate how doctors withdraw life-saving treatment."  Pardon?  That's not how it looked to me when I was practicing medicine.  Indeed, lawyers seem only too eager to challenge decisions that doctors make in good faith.  Increasingly, lawyers are egging patients on to initiate legal proceedings that are very lucrative to over-lawyered communities.
      Lawyers would, of course, like to place all of the responsibility on physicians, many of whom are forced into making decisions that their inclinations and professional ethics find abhorrent.  Many of the lawyers themselves are the reluctant satraps of political masters whose main aim is to satisfy their political masters.
      The Canadian Medical Association, the College of Physicians and Surgeons, The College of  Family Physicians and their ilk want to look good to everyone.  Still, it is difficult  to  understand why organizations like the CMA are not taking a more proactive position on behalf of the physician members who feel a moral commitment to preserve life and find that assisting suicide is contrary to the Hippocratic principles that induced them to become physicians in the first place.  The first step towards rationalizing this is to establish guidelines that receive wide publication and approval both within  the profession and outside it.  Any physician who is  going to  facilitate this new course for medical practice must at least know that it is approved and sanctioned by society generally.
        Even then, physicians who want no part of  this must be respected as long as they make their views known to their patients.  It  is  certainly no part of their duty to refer their patient to a practice that does not meet their concept of moral and proper practice, despite the opinion of Healthcare and Legal administridiots.

Anti-vaxxers - Ignorance or Fraud?

      In 1998, a British  physician and twelve of his colleagues published a small case series  in the Lancet, a prestigious British medical journal that suggested MMR (measles, mumps, rubella) vaccine may be  related to  autism.  MMR vaccination rates began to drop almost immediately as a result of that.  Subsequent studies  did not confirm  any such relationship and ten  of the twelve authors refuted the interpretation of the data on the basis of insufficient evidence.  Further, it emerged that Wakefield et al had failed to disclose that they had been funded by  lawyers who were engaged by the parents in legal suits against vaccine producing companies.  Ultimately, Wakefield et al were found guilty of deliberate fraud and fabrication of facts apparently for personal gain.   Wakefield was removed from the General Medical  Council of Britain's  register and was no longer permitted to practice medicine, emigrated to America, to lead and encourage the development of the 'Anti-Vaxxer' movement which would lead a significant group, many of whom should  have known better, back  into the dark ages.
      So how is it that so many allegedly educated elitists buy into this absurd theory that measures that have done more to promote health and  eliminate horrible disease are not healthy, are not natural and therefore should be avoided.  How is it that these allegedly educated dopes cannot understand that what is natural is for people to die of infection, of pneumonia and indeed  even of sepsis from an  infected finger?  Can they not understand that it is natural for one  in five children to die  in childbirth along with a  goodly number of mothers?   Can they not understand that pain and suffering is natural and that it  is quite unnatural to remove those natural  warnings?  Do they not take antibiotics when infected or painkillers when in pain?  You bet they do!   Can they not understand that freezing to death is natural and that central  heating and burning of fossil fuels is unnatural?  Can they not understand heat and humidity are natural and that air conditioning is horribly unnatural?    Those poor feckless milksops are to first to cry out for those unnatural balms that they so despised, as soon as they perceive it will  spare them a little pain and suffering.  
       Of course they really do understand what it is all about.  They want to parade their ignorance as though it were knowledge.  Some believe that their unscientific and uneducated views are "equal" to  those of  scholars and scientists who have spent their lives studying those topics.   They are not, but unfortunately they can still do immense damage and inappropriately enjoy some credibility, while the herd  immunity that the last generation ensured persists and offers them protection.  Fortunately,  most sensible folks protect their children, but we are likely to see more outbreaks of these once well  controlled diseases as immunity wanes.
        Meanwhile, the pseudo scientific simpletons will continue to consider themselves as a elite group entitled to  parasitize  on their fellow beings.
         Dr. Wakefield and his ilk will thrive as long as they can recruit the self righteous and the gullible!

Death by Prescription. Part 3.

Depression and Longing for Death.

      In 55 years of medical practice I have seen very many cases of severe depression.  Many of them so profoundly depressed that they would have welcomed death.  In the early days there were few effective drugs and there wasn't much to offer them, except what later became known as cognitive therapy.  It didn't have such a grand name then, we just called it supportive treatment, then psychotherapy, perhaps so we could bill for it.  It was very time consuming and not every doctor's cup of tea.  In extreme situations the greatly stigmatized ECT was the only option and despite the massive emotional outcry against it, saved many lives.
      I had a patient many years ago who wanted to die so badly that he drove himself out to an isolated side road in Saskatchewan one night,  locked himself inside his car and slashed both of his wrists. As fate would have it, as he lay there exsanguinating, waiting to die, a Royal Canadian Mounted Police patrol car passed by.  In sparsely populated Saskatchewan that in itself was remarkable.  They stopped, broke into the car and  took the semi-conscious patient to the hospital to be transfused and sutured.  To cut a long story short after appropriate treatment including both pharmacotherapy and psychotherapy this man was able to resume a productive work and family life and function normally. 
      Although I have no doubt that in the early phase of the integration of the euthanasia culture it will be very carefully exercised and would not have been available to this man, I have been around long enough to observe just how permissive our culture is.   I am also cynical enough to know that measures that will save the health care system will become increasingly palatable as it becomes financially threatened and once the thin end of the  wedge has been introduced there will be no turning back!  It just isn't possible to get the Genie back in the lamp!!

Death by Prescription. Pt 2.

       Not all that many years ago, when I was on sabbatical at Duke University in N. Carolina, I was privileged to meet a particularly gifted  neurologist who was a consultant to the University Stroke Unit, the department where I  was spending some of my sabbatical time.  We used to lunch together occasionally, and in the course of our conversation we discussed 'do not resuscitate' orders.  Understand, we were not talking about euthanasia.  My position was that if a patient had written an advance directive stating that in the advent of a catastrophic event and the patient had previously documented, while of sound mind, that he did not wish to be resuscitated, there was no debate, the wishes of the patient must be obeyed.
    " Not necessarily so," said  the Neurologist,  who was the sort of doctor I would like to be looking after me when I arrive at my neurological emergency.
     "It's obvious, " I said.
     "If the patient had that view when he was not suffering from  any acute medical  situation, he might just have a different mind-set when confronted with an acute life threatening emergency."
      "How would you determine that?" I asked.
      "I did try to devise a research project to answer that question once," he said.
      "Well, send me the results?" I asked.
      " I terminated the project without writing it up"  he answered. "Let me explain.  I reviewed a cohort of patients who had opted for no resuscitation in  the event of a disabling stroke and requested that I be called in the event of their sustaining such an event.  First, of course, I sought and obtained the collaboration of all my colleagues on the stroke unit.   My plan was that I  would try to establish contact with each of these patients, despite the fact that many of them were unable to  speak.  I devised methods of communication so that even many of the patients who could  not speak or communicate easily would be able to answer yes or no to their previously expressed view.  I am sure there were many shortcomings in my pilot project, but I did not receive a single confirmation that despite the neurological catastrophe none of the patients wished to adhere to their previous decision to die.   They had changed their minds!   You understand why I decided to cut short the project on the basis that the results would be more likely to add to the confusion than shed light on it.". 
        As far as I am aware, no-one has attempted to validate the previous decision of  DNR in terminal stroke or other life-threatening  conditions.  If the Neurologist's impression of an almost universal last minute change of mind  about the 'Do Not Resuscitate' order held, no DNR order would ever be valid again.   It might even be that we are not resuscitating patients who have changed their mind but are unable to communicate their reviewed wishes!
       Death by no prescription is a tricky business too!
   
      
      

Fatuous Fat Recommendations!

            Included with  my Canadian Medical Association Journal  this month was a separate page with the title "Adult Obesity Recommendations 2015" devised by the Canadian Task Force on Preventive Health Care.  It was a particularly fatuous document, not that its recommendations were invalid but rather they were behind what generally known and often practiced in  the 70s and were considerably more lukewarm in their suggestions than what we were practicing in the Department of Family Medicine Behavior Modification Weight Loss Clinic at University Hospital in Saskatoon in those years.   The administridiots (mostly not physicians I am pleased  to say) who decided such things decided that the modest (very modest) budget I submitted was worthy only of the B-budget, which meant that it had as much chance of being granted as a snowball in hell.  (Unfortunately it did not have the chances of a snow-ball in Saskatchewan.)  So, a dedicated few nurses, doctors, dieticians and physios committed their Monday nights for the best part of  a year for no recompense whatsoever.  We hoped that University hospital and the Medical College might view an "up and running" program more positively.   It is ironic that all the grant money went to the more 'glamorous'  programs, because preventing something is not news no matter how inexpensive, while a single dramatic exploit was worth a fortune.
          After a year or so, those dedicated souls who kept  this clinic going got a little fed up contributing their Monday nights 'for  free' and when the hospital budget scheduled us in  the 'B' category once again the following year, they very reasonably opted out and the Weight Clinic closed down.
             So now, forty years later, a Canadian Task Force paper has distributed guidelines recommending measures that we were practicing in the seventies!  
              I wonder how much that cost in both time and money!  No wonder the Health Care System is broke!

If enough folks are  interested in pursuing the actual content of the guidelines, let me know.

             

Death by Prescription.

     It's finally here.  At last doctors can regard killing patients as a legitimate part of their duties.  For thousands of years, physicians regarded the preservation of human life as their most sacred duty, with relief from pain and  suffering as a close second.    The battle to prevent death and destruction, pain and suffering  was the reason that many of the brightest and most dedicated went into  medicine and not,say, engineering.  The science of medicine was always fascinating and intellectually stimulating, but there was a lot more to it than that.  A doctor was part scientist, part philosopher and part priest.  Now, don't go getting your knickers in a twist over that last role.   The confessional was the first psychiatric out-patient clinic and probably did as much to relieve human pain and suffering.
      As soon  as dispensing death becomes a part of the  role of a physician, before a single  death is dispensed, a revolutionary change will  have taken place in the aeons of medical tradition.  There are going to be two very major changes.  The first, will be in physicians themselves.  There is now a new, hitherto prohibited treatment, that can be dispensed when all else has failed.  Incurable  diseases, that caused terrible pain  and  suffering can now be alleviated by a death prescription.  So all of those patients condemned to that fate can be relieved of their  pain  and suffering.  But what if a cure turns up?   Medicine is full of such stories. A hundred years ago that could  have included a myriad of incurable diseases,  tuberculosis, syphilis, and a huge encyclopedia of infectious diseases.    Suddenly, some physician, committed to saving lives, by brilliance or  serendipity, stumbled upon a cure.  Penicillin cured incurable diseases by the million,  streptomycin did the same for tuberculosis and an endless parade of miracle antibiotics made the incurable suddenly curable.   All those incurable tuberculosis patients housed  in sanatoria throughout Ireland during my youth, wasting away and waiting death were suddenly and miraculously curable.  Good job we  didn't have the death option then!
Next week, I will tell you of an unofficial piece of research on patients'  death decisions that never saw the light of day. This one might surprise you!
      

The Pathologist.

           It is hard to believe that the time I am writing about was almost a half century ago.  Tempus, as they say, surely does fugit.   For reasons related to health I was out of sync with my graduating class and was desperately looking for an internship job.  

            When I  showed up at Dr Pickles, the medical director's (They used to be doctors in  those days!)  office on Monday morning I was greeted by a pleasant smile .

            "I have good news for you," he said to me  "Although all the regular internship positions have been filled, there's a vacancy in pathology, that normally would have to be filled by a second year pathology resident.  He cancelled out at the last minute, so we can offer that position to you for four months and that will bring you into sync with the regular rotations.  It will be quite a valuable experience as well as allowing you to earn some money "

            I was relieved to have a job, but a little apprehensive about my ability to do justice to a position normally occupied by a person with two years more experience than I had.

            "Thank you, sir, but do you think I'll be able to manage it satisfactorily?"

            "Oh don't worry about that.  You'll be working directly under the supervision of Dr. McMurray, and she'll give you all the supervision you'll need.  It will be a wonderful educational experience because there are no more senior residents between  you and your consultant.  You'll get the opportunity to do things that a junior rarely gets near."

             Monday at eight-thirty I arrived at Dr. McMurray's office, ready to start work.

            "Good morning," the pleasant -faced middle-aged secretary smiled.  Then, in a slightly remonstrative way, added, "Dr. McMurray is down in the morgue doing an autopsy.  She said that you're to go down there right away.  She starts at eight sharp, you know.  Don't worry  though, I'm sure she will take into consideration that it's just your first day."

            "Gee, I'm sorry, I thought we started at nine."I answered apologetically.

            "Just take the elevator at the end of the corridor down to the basement and turn left.  You'll see a big gray double door in front of you.  Walk right in."

          I followed the directions and saw the door..  I turned the handle and walked in.  Standing at the operating table was a woman clad in operating room attire, a scalpel in her hand and so pregnant that she could barely reach the corpse.

            "I glad you could make it," she said irritably. "now get yourself gowned and gloved.  I need a hand."

            "I'm sorry, Doctor, I thought we started at nine.  I should have checked with you.  It won't happen again."

            As I slipped off my jacket and tie and secured the rubber apron that protected from neck to ankle I felt like a butcher about to butcher a carcass.  I pulled on a white gown, tied it up at the back and stepped up to the mortuary slab.

            "Okay," said Dr. McMurray, "step up here and get another suture around the esophagus, above the one I've already secured, I can barely stretch that far, with this in front of me," she said pointing to her swollen belly.

           I leaned forward, slightly nauseated from the pervasive  smell  of  formaldehyde and still a little shaken from what was the rather bizarre picture of a very pregnant woman doing an autopsy.

            "Okay, cut right here, between the two sutures, then dissect away from the posterior thoracic and abdominal wall right down to the duodenum, and then cut between the lower two ligatures that I had secured earlier.  That way we can get the whole segment of bowel out, without spilling gastric content all over the peritoneal cavity.  Unless, of course, you puncture the bowel wall.  And, by the way, don't get a fright when Jim starts the saw going.  She introduced me to the autopsy room orderly.

              Jim was the operating room orderly.  He nodded his head at me and smiled.

              "Ah, you'll get used to all this stuff quickly enough, doctor.  Just don't mind the noise."  He added this as he continued a transverse scalp incision and then pulled the apron of scalp forward to cover the face and got busy with an electric bone saw.

            Meanwhile, I continued the dissection carefully, anxious to avoid the humiliation of perforating the bowel, let alone the miasmic odors that would follow.  The loud vibrations of the saw cutting through bone provided the background for the next half-hour, and the effluvium of bone dust was added to the other odors.  Meanwhile Dr. McMurray carried on dissecting and supervising me at the same time.  Following the gross dissection, Dr. McMurray showed me how to section the removed organs and place the specimens in formalin for later histological microscopic examination.  We were all finished before noon.

            "Do we have another to do this afternoon ?" I asked.

             Dr. McMurray laughed.

            "We don't kill all our patents, you know.  I've assigned you to Tom Morgan, the chief laboratory technician.  A good pathologist has to be able to do and to supervise everything a technician can do."

             I thought it would be imprudent to mention that I had no interest in becoming a pathologist.

           My first solo  (almost) autopsy will follow later.

Secrets!

                               I just read a shocking story in  the Toronto Star.    Three Toronto colonoscopy clinics have had have had hepatitis outbreaks since 2011.  The Public Health Dept says eleven patients  were infected and that the source of the infection was thought to be tainted sedative injections. The article alleges that Toronto Public Health and the College of  Physicians and Surgeons of Ontario (CPSO), kept the outbreaks secret.  Further, reported the Star, in 2012,  nine patients contracted life-threatening infections, including meningitis, at a Toronto pain clinic.  This was also thought to be through improper handling of  multi-dose and single dose medication vials.  Stoppers were not wiped down with 70% alcohol as required according to a confidential report.  One of the clinic doctors is facing a disciplinary hearing and another is under investigation by the College.  A class action lawsuit in  under way.
                               The NDP Health critic questioned the competence of the CPSO  to regulate such out- patient clinics and in addition criticized their lack of transparency, suggesting that early openness and action may have avoided subsequent cases.
                                The CPSO makes a great show of 'disciplining' individual physicians, sometimes quite inappropriately and to the point of harassment.  Perhaps it should be paying more attention to some of the bodies over which it has jurisdiction and supervising that they meet the required standards.

Cookbook Medicine.

           The World Health Organization which would like to portray itself as the ultimate authority in defining what is ideal medical care often leaves much to be desired in  its recommendations on how to treat or prevent illness, according to a study by Dr. Gordon Guyatt.of McMaster University.    It appears that the WHO recommendations, often referred to as guidelines, are put together in  much the same manner as cookbook recipes.  They are often based on weak evidence resulting in  less than optimal care.  Dr. Guyatt's study concluded that 73 of 289 strong recommendations were based on low quality evidence and warranted only conditional recommendations.
        " Historically, WHO recommendations have been extremely untrustworthy and not evidence-based," said Dr. Guyatt.  Evidence based medicine requires that high quality studies are the basis of such recommendations
          Looks like the UN is no better in many of its medical recommendations than in its political ones!!