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Rehabilitation Matters

About all rehabilitation

Physician-assisted death

This is a controversial topic that is of direct relevance to rehabilitation. Many of our patients have lives that, to an outside observer at least, seem impoverished and lacking meaning and quality. Luckily often we are incorrect (or insufficiently imaginative), and patients do consider they have both a purpose, and a good quality of life. But not all do.

Most of us will know several patients whose life consists of being helped to get up each morning, receiving two brief visits during the day, and a longer visit at night to be put to bed (not at a time of the person’s choosing). In between they watch television, listen to the radio, or, if they can, read. Social contacts are few and far between, and there is no longer-term goal other than survival. Some of these people will also have pain and discomfort. Many are unhappy.

Another typical situation concerns nursing home care. I was involved in a case of a person lacking mental capacity with some short-lived (5-10 minutes) episodes of awareness 1-5 times a day, who regularly pulled out the feeding naso-gastric tube, that went to court. An argument was put forward that, although her life was intolerable to her and she would not have wanted to be in this situation, if she were placed in a suitable nursing home that offered opportunities to interact socially when awake, she would be happy and want to be alive. The reality is that there are no placements that can provide that environment, regardless of available money. A solution that is not deliverable is not a solution.

A recent article, drawing on recently published evidence, makes a strong case against Physician-Assisting Death (PAD). It demonstrates that the so-called slippery slope of gradually increasing the scope of eligible situations is a valid, real risk. On the other hand, the solution proposed in a vivid sentence, “Meaningful and committed human connection—not 2 g of secobarbital—is the right prescription.”, is a clear example of a solution that is not deliverable.

So, next time a patient with severe disability and who has mental capacity requests assistance in dying, you will still have to ask “Would that be respecting the choice of my patient, or am I starting to slip down a slippery slope?”

One solution, when they lack capacity, is to discuss with them the choice of stopping any life-sustaining treatments they might be on and/or stopping taking food and fluid and offering palliative care support. This is termed ‘Voluntary Stopping Eating and Drinking’. It is a recognised process with publications on it. This will respect their decision, it is (surprisingly) often not obviously distressing or uncomfortable. The clinical, ethical and legal aspects have been explored carefully.

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