And Death Shall Have No Dominion

15. October 2010

Recently the Federal Supreme Court acquitted a lawyer of the charge of attempted manslaughter. His client had cut her mother's supply tube in coma vigil. When is a patient allowed to die?

“This all is about the re-discovery of natural death, about what I call a loving omission at the end of life. That sometimes takes more courage than to do something.” The one who said those sentences is not thinking about euthanasia, not at all about assisted suicide. In his conversation with Anna von Münchhausen of the FAZ (Frankfurter Allgemeine Zeitung, German newspaper), Gian Domenico Borasio calls for omitting of more and more measures taken to postpone death a little by all means medical arts avail over today. Borasio holds the chair for palliative medicine at the Munich University.

Lady Justice decides when it’s time to die

This peaceful, often even happy falling asleep is getting increasingly rare nowadays. More and more the last hours are a fight against pain, a quiet vegetating until the body gives up – despite all the technical support. Is it a stroke of good fortune if it takes just a few days or weeks? If dying takes several years, the nerves of all involved are often on edge, sometimes also in court.

Living in a coma“ is the headline of a symposium, a platform where palliative specialists like Borasio exchange information with coma-researchers, ethicists, neurologists and lawyers, one of them is Wolfgang Putz. Just a few weeks ago, he made the headlines because he was acquitted by the Federal Supreme Court of the charge “attempted manslaughter”. The reason: He recommended his client to end the life of her mother, for eight years in a coma vigil, by cutting the tube for parenteral feeding. The daughter reported about conversations with her mother who had said she would rather die in such a situation.

Surprising return

It has its history, this argument about the power of physicians not to only saving lives but also omitting to die. This is how Eluana Englaro became famous tragically. In Italy, even premier Berslusconi intervened with an own legislation before a court allowed the death after 17 years of coma. Another case became famous as well the BBC made public mid July. Richard Rudd spent many months between life and death without any reaction to environmental influence. Just days before his severe motorbike accident, he had spoken about never wanting to be stuck in a hospital bed without being able to move or react. But nonetheless: When the physicians asked whether they should turn off the life-preserving technologies, a first clear and repeated NO-wink came from the patient.

“You cannot derive from the state of coma vigil that these people per se do not want to live any more“, says Rudolf Henke, head of the ‘Marburger Bund’ (German association of employed physicians). Andreas Zieger at the protestant hospital in Oldenburg/Germany as well confirmed this point of view in his lecture. “Waking up later is rare but possible” he tells from his many years of experience in treatment of patients with severe brain damages. Quite frequently it is the wrong diagnoses respectively the evaluation of the coma by the physicians which causes the surprise in such coincidences – also for the physician. Athena Demertzi, coma-researcher at the Luettich University reports about rates up to 40 percent. DocCheck reported about such a case some time ago as well. Especially during the first couple of days and weeks, the patient’s condition often changes several times between the ‘minimally conscious state’ and the much deeper ‘vegetative state’. Intensive examinations with numerous tests and fMRT examinations of the brain are normally done only during the acute state after the accident or stroke.

For about one year, a living will is binding for the treating physician. But often this meaningful document is missing. Then the presumable will – conversations with family members are supposed to clear matters but sometimes cause even more confusion. Because parents and life partners often don’t agree at all. Katja Kühlmeyer at the Interdisziplinäres Zentrum für Palliativmedizin (interdisciplinary center for palliative medicine) in Munich reports about this kind of experiences. The family for example often wants to continue treatment while the partner yearns for the end of the alleged torture of the beloved.

Dying people are not hungry

The decision for or against the “letting die“ brings along serious consequences: On one hand death, on the other hand provision of care without any ifs or buts. That for example might mean an organ transplantation for the needy coma patient including the same right as the active sportsman with high life expectancy has. The living will, states Borasio, time and again serves the protection against medical malpractice as well. The fear of death under severe strain pushes medical staff to provide their patients with enough fluid, food and oxygen. And that – as the palliative physician explains – is the wrong thing to do. At the end of life, the oxygen flow causes the mucous membranes to dry out. But drinking a lot does not help because often the kidneys don’t fully function any more. The dying person is not affected by hunger and thirst according to scientific observations. Only humidifying the mucosa is really important to make the patient’s last few days more bearable.

Palliativ medicine: Care FOR the last phase of life

For about 20 years, the suicide rate in Germany is continuously going down. Only the suicide rate of elderly people permanently grows – against the trend. The fear of losing dignity and independence causes many older people to end their own lives. Over the last half of the century, only modern technology has made it possible that there are more and more coma vigil patients, about 3000 to 5000 per year. In his “plea” in front of people concerned as well as those interested during the symposium, the lawyer Wolfgang Putz pointed out the self-determination of a person, also when he or she is in a coma. In his book ‘Wie wollen wir sterben?’ (How do we want to die?), the emergency doctor Michael de Ridder from Berlin pleads for a new culture of dying of patients where no treatment is left to be done and without any chance of improvement. And his belief that the physician even should support the gentle ‘falling asleep’ if required, raised not only applause like in the ZEIT (German newspaper) but also harsh protest.

“Palliative medicine is the care FOR the last phase of life not only DURING the last phase of it” – this is the headline of the lecture of Gian Domenico Borasio. If there is no hope for improvement left, the physician has to reconsider his therapy target: Is the original target still realistic? And is it in accordance with the patient’s will? Matthias Thöns of the Palliativnetz Bochum (palliative network) comments the acquittal of the Federal Supreme Court regarding the issue Putz: “This sentence finally enables engaged palliative physicians to take care of human beings at the end of the life in accordance with their will and with dignity – without being afraid of the prosecutor.

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