Wednesday, February 24, 2010

the end of a life and ensuring one's last days are with minimal pain

An elderly aunt passed away last evening, after a short illness, but towards the end she was in great pain, when it was certain that little could be done to prolong life. I believe that persons final days should be in minimal discomfort. The word hospice care and the rules that govern it appear to be singularly absent in Sri Lanka.

In places where the hospice system is well entrenched, people either enter a hospice or are treated to hospice care principles, when there is little science can do to prolong life and then the inevitability of death is planned and prepared with dignity. In many respects dignity is defined as being able to pass the final days with least possible pain, if that has been something that was apparent earlier.

Pain management to put it mildly in SL is restricted to Panadol, and in places like the US is aggressively managed with pain killers. A common pain killer that is administered is morphine, a tried and tested remedy which in the days before anaesthesia was even used as an anaesthetic. The problem was that it was considered highly addictive and therefore to be used only carefully. In the case of hospice patients this issue should not arise as the patients comfort takes precedence as the former is unlikely to be an issue.

For some reason doctors in SL are very reluctant to liberally prescribe this, for fear of what I know not, and would like a comment from a practitioner on this as I am merely an amateur observer wondering why this method of treatment is not followed.

I again resort to my time tested answer to SL problems the lack of thinking, or lack of kalpanakaranna. If we take all the factors into account and determine what is in the patients interest at this stage, I would contend that there is no issue, but tradition, fear and old wives tales take precedence in making this simple decision.

An appeal therefore for like minded people to turn to a little bit of common sense, and picture yourself in the shoes of the patient, and determine if it was you, what would you prefer. especially if you knew you were exiting this world shortly and your pain could be lessened dramatically with a little side effect of not being completely there to the end. Leave a living will that gives specific instructions in these instances as to what to do so that your care givers will not be answerable to busy body third parties on the actions they take on your behalf.

1 comment:

Angel said...

I fully agree with you on each persons right to breathe their last in dignity, while being as comfortable as possible. Hospice care in SL (as far as I'm aware) is limited to a few institutions such as the Shantha Sevana Hospice and the Sai Hospice.

With funding being such a problem, and with post people with terminal illness passing away in government hospitals,I have always felt that doctors, nurses and other healthcare workers need regular training and "re-sensitisation" in terminal care. As an individual, all I can do is bring it up with decision makers (my last presentation to Consultants) and when I lecture to nurses and medical students.

We try to manage pain as best possible - it's not always or even usually limited to paracetamol! we don't whack patients with morphine because
a) it's classified as a dangerous drug under the pharmaceuticals schedule

b) serious and distressing side effects like painful colics and severe constipation, vomiting, a really troublesome dry mouth and in extreme cases, death because breathing is inhibited. This makes it a problem to "liberally prescribe"morphine, esp. outside the hospital setting.

That said, I have always tried to make sure that the terminally ill patients under my care were as comfortable as possible. Often the nurses would refuse to give morphine by IV injections - because it is dangerous. They have repeatedly questioned why I prescribed it. In such cases I give the injection myself, and record "given by Dr..... at ..... (time)"on the ticket, because that is how I was trained.

I can't generalise, or speak for all the doctors in SL. Just wanted to give a few thoughts. I'm sorry for your loss.... may your Aunt attain supreme peace.