Sometimes the Christian religious perspective seems to me to be that it's critical for death to be as drawn-out, painful and degrading as possible in order to glorify God.

My wife worked as a Mental Health OT with the elderly, and although she mostly dealt with anxiety and depression, she found the palliative aspects of it satisfying, even though she was, in those circumstances, dealing with dementia patients, which is hard for anyone to watch. She was always very cross about how late we leave it to prescribe drugs for alzheimers; apparently people can hold on to their sanity for quite a lot longer when using modern therapies, but the bar is so high for prescription that by the time they meet it they've already lost themselves.

She also did her first placement in paediatric OT. She found palliative in those circumstances an awful lot harder.

A friend of ours have a 1yr old daughter who's been diagnosed with a degenerative disease that is highly likely to end her life before the age of 10. At the moment she's fine, just a slight delay in her walking, so it's so hard to get to grips with the reality that she may have a short, painful existence. She starts her first round of enzyme replacements today, and will be having a bone-marrow transplant in the near future, which I'm told significantly increases her chances of surviving into adulthood, as well as significantly improving her quality of life (apparently she may be spared the mental aspects of the degeneration altogether), assuming she survives the op.

@custy

"for those who particularly want the wholly inadequate care private hospitals provide"

fixed

"for those who particularly don't want to wait three months for a non-emergence appointment and then another three months for a procedure"

:-)

Noelle:

Good points and I am in no way saying that individual caregivers who work in hospice and the like are blinded by religion. Politicized religion, the "Sanctity of Life" conservatives, deserve the vitriol.

Maybe a careful, nuanced approach like hospice is the best we can hope for...although the state of Oregon has moved beyond that with an assisted suicide provision, I understand?

My lay perspective was all sorts of shocked. Not by it being upheld, but that it was upheld using the tax power instead of CC/N&P. I think far more fascinating was the medicare state penalty issue, where the court seemed (7-2, no less) to take a harder line than South Dakota v. Dole in saying, no, the fed cannot bully individual states into adopting favorable policies by withholding funds. Considering just how much state law is commandeered in exactly that manner (uniform speed limit, legal age to drink, etc. through highway grants), that's a heckuva change.

The Supreme Court ruled that The Affordable Care Act (aka "Obamacare")is constitutional. More specifically, they ruled that the individual mandate is constitutional under the taxing clause in the constitution.

Shockingly Roberts wrote the majority opinion. (He's a Bush appointee who has been in the deeply conservative camp.)

For any con law nerds, the Court did take a chunk out of Congress' Commerce Clause powers today. But probably expanded it's taxing authority.

What ruling?

Yes. Today's ruling was a relief.

"Interestingly, the system I work in, which provides universal coverage for healthcare and runs in parallel to private insurance (for those who particularly want the wholly inadequate care private hospitals provide), costs the UK government less than half per capita that the US system (which makes shareholders in insurance companies rich and does not a lot else) costs US gov."

Preaching to the choir Custy. (As it were.) I practiaclly begged the Obama administration to keep the public option on the table and push for single payer. American politics being what it is, we wound up with the ACA.

Given today's surprising ruling from the Supremes. Maybe the way is paved for more significant reforms in the future.

I can't recommend hospice care enough for the dying. In the blog you link, had mom been transferred to hospice she'd be kept as comfortable as possible.

I had an elderly patient diagnosed with terminal cancer come to see me with one of her adult children years ago. She stubbornly asked why I couldn't just give her something that'd kill her now and get it done with. Her daughter was shocked. The old lady blurted out that we treat dogs better than we do humans. I told her what would happen if she chose hospice care. Her daughter didn't want her to forgo treatment and take this route, but let mom chose what she wanted without complaint. She died peacefully at home, with a skilled nurse helping the family through the process and access to the meds necessary to keep her comfortable. There are physicians and nurses and counselors and social workers who are very good at this. It is a very hard job, but everyone I know who chooses this work feels good about it. My own mother had in home hospice the last 2 months of her life. Those people were wonderful.

It's our culture that makes it hard. People have a hard time accepting death and knowing when treatment is futile. This includes many physicians. Where and how you're trained and what your specialty is all makes a big difference. Religion though? Nah. Some of the best palliative care folks I know are religious.

Interestingly, the system I work in, which provides universal coverage for healthcare and runs in parallel to private insurance (for those who particularly want the wholly inadequate care private hospitals provide), costs the UK government less than half per capita that the US system (which makes shareholders in insurance companies rich and does not a lot else) costs US gov.

There are many apologist "intellectuals" who would piously intone that her suffering was all part of God's plan and good for us. I am not a violent man, but....

Personal story that shows just how backwards our system is on this issue.

My Grandmother had a massive stroke in her sleep earlier this year. Because it went undetected for hours during the night, the doctors knew almost immediately that there was no hope of any meaningful recovery. She had left expilcit and legally binding instructions that no extraordinary measures were to be used to keep her alive. She made it clear that she did not want to be kept alive without quality of life. She was going to die, but she was not dead yet.

Because our laws do not allow doctors to help a patient expedite death in these circumstances, the only option was hospice care. She held on for a week while she starved to death. Yes, she was administered pain meds, but not enough to end her life.

This seems insane to me. The doctors all agree that the chance of recovery is zero. The patient has made it clear she does not want to live under these circumstances, and yet our law does not allow the doctors to help the patient. It results in suffereing for the patient, and even more distress than normal for the family who has to watch her die.

It's yet another area where religion has badly interferred with our laws and ethics. (Ironically my grandmother was a deeply religious woman.)

Another reason I'll never live/work in the USA.

But then you'll miss out on our magnificent vistas!

The moral of the story is, I think, just don't get cancer or wrench out your back while you're here.

But since we don't prescribe so many painkillers in the U.S., our health care costs are kept low and manageable.

Oh, wait...

Custy, you might be interested to know that according to conservative U.S. columnist Cal Thomas, we must brace ourselves because Obamacare is going to lead us straight into horrors like Britain's wasteful, ineffective, crumbling National Health Service:

http://www.calthomas.com/index.php?news=3632

Because anything that socializes the cost of medical care is Evil Incarnate™ and a failure by definition, you know.

Another reason I'll never live/work in the USA.

It's not apocryphal, but it is generally (at least by the time you get to palliative/hospice care) not about a doctor's fear of the patient becoming addicted. It is more a fear of the doctor going to jail for "over-prescribing" opiates. (So, less fundie psychodrama and more Drug War bullshit.) As a result of the extremely stupid one-size-fits-all guidelines put into place following the general recognition that rich people abuse drugs too and usually get their doctor to write them a prescription to help them do it, a whole host of doctors (particularly oncologists) are extremely gun-shy about prescribing pain management meds that adequately control the patient's expressed level of pain.

In a country like the United States with a combination of fundamentalist religion (God is testing you, so suffer, dammit!) and Drug War insanity, is it not sometimes difficult for doctors to prescribe enough palliative painkillers?. "We don't want you to get addicted, so we are not increasing the dose". Maybe this is apocryphal...or a rare case, but given how maniacal we are about opiates....? I don't know.

I am a firm believer in ethical, careful assisted suicide when one feels it is time.

*sighs*

There are ethical areas that health-care professionals do not like to discuss, for fear of what I shall (accurately) call The Daily Mail Reading Dipshit Treatment, which is to say: It's a complex area that Daily Mail Reading Dipshits are incapable of grasping the subtleties of, preferring instead to focus on a single part of it and lead a witch-hunt against those of us who have to understand the issue completely when we dare to do anything other than let human beings die in terrible pain and fear.

However.

I shall stick my head above the parapet on this one occasion and try to explain it.

In palliative care, we do not treat the patient's condition. We accept that we cannot cure them, and we cannot slow the disease's advance any further. Instead, we treat the symptoms of the patient's condition.

At the end of a terminally ill person's life, those symptoms typically include severe pain, discomfort and anxiety. Now, all treatments, particularly pharmacological treatments, come with a risk (often a guarantee) of side effects. Let's examine Morphine as an example drug here:

If a dying person is in pain, then we aim to give enough Morphine to control that pain. Simplistically, the more pain they're in, the more Morphine we give, the more Morphine we give, the higher the risk of side-effects and the more severe those side effects may possibly be.

There is an extreme end of that spectrum: The patient is in such severe pain that the correct dose of Morphine to treat that pain carries a high risk of the terminal side-effect, i.e. death.

The fact is, we do give those doses. It's the right thing to do, medically and ethically. Much as the religious right and Daily Mail Reading Dipshits would like to say that means we're killing the patient, that's absolute nonsense.

The patient's disease kills the patient; the patients disease has a natural progression that ends with death - The worst (assuming you think it's a bad thing) we can be accused of is shortening the duration of that disease progression, trading off a longer, harder time for a shorter, easier time.

The whole culture of life thing that makes us treat our elders (and the deathly injured or ill) worse than we treat our pets. Infuriating....just infuriating. And Christianity claims to be a religion of love. My mother is 80. I hope she goes quickly...

Jack Crow expresses it better than I do here:

http://the-crows-eye.blogspot.com/2012/06/sitting-vigil.html