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Pulling the Trigger

From the Comprehensive Cancer Center, University of California Irvine, Orange, CA; and The Johns Hopkins Oncology Center, Baltimore, MD

Address reprint requests to Frank L. Meyskens Jr, MD, Comprehensive Cancer Center, University of California Irvine, 101 City Dr S, Orange, CA; e-mail: flmeyske{at}uci.edu

It's near the end

The interminable end

Your suffering has been unbearable

Many months have gone by

...and you just won't die.

No more visitors:

Your friends were first

then your family

your ex

the white coats

and eventually, even the nurses...

except for one nurse,

and she is only here

because the guilt of your

daughter was too great.

You asked me

to put you to sleep forever,

to give you an easy death.

But how could you know

that 20 years ago

I shook violently at the moment

the barbiturate hit the brain

of our 16 year old miniature poodle

His bright eyes faded,

and closed,

his puppy-like head slumped

on my chest.

For many days thereafter,

quite unexpectedly,

I cried in private many times

But my sadness I could not hide

My kids asked:

"What's wrong Dad?"

"What's wrong Dad?"

And long walks, holding hands,

enjoying simple things,

being more a dad than usual

was the only answer I could ever give.

Even today, twenty years later,

when the end is near and interminable

and you,

my patient,

asks me to kill you:

my eyes mist,

my soul aches.

My answer always is:

You, as one who suffers, might well   deserve that option,

but I, as a doctor, can never be the  one who

pulls the trigger, to become

your executioner.

"For taking away the suffering" may be    the lure

for those who would be gods

But I, as a doctor, am just flesh and blood.

For those who talk so causally about    euthanasia

as just another medical procedure or    intervention

Have never been there when the    light departs into the void

And there is a shutter in the universe.

Frank L. Meyskens Jr

Father's Day, June 15, 2003

Commentary

This poem describes a physician and a patient pushed to their limits. They have fought to relieve the patient's suffering, but have been frustrated. Both long for the patient's death. It is at this desperate moment that the patient asks to be euthanized. The physician, reflecting on a past euthanasia, indicates that he will not do it, that he cannot do it—not for this patient, not for any patient.

In spare, unflinchingly honest language, Frank Meyskens describes the awful suffering that drove the patient to request euthanasia. He also gives us a rare, and sorely needed, glimpse of the uniquely personal and deeply felt response of one physician to a request for euthanasia. This poem is a powerful demand that, along with moral and legal principles, the personal perspective of physicians be given weight in the debate about euthanasia.

It is fortunate that the care of the suffering and dying does not often come to the impasse described in this poem. Otherwise, the suffering of patients and families would be unbearable and the work of caring for them undoable. But it does come to this at times. There are patients who suffer miserably despite the most determined efforts to relieve their suffering. They may have intractable bone pain, shortness of breath, nausea, depression, or other symptoms. Whatever the symptom, it is unquenchable. These patients are hard for their families (who often don't know what to do or say) to address. Helplessly witnessing such suffering can be unbearable, as is exemplified by the increasing loneliness of the patient in this poem. These patients can make their physicians feel helpless, too. When they are on my schedule, I may not look forward to the visit. When they call, I do not want to call back. For these patients, death can be a release from suffering. When they have nothing else to hope for, these patients may hope for death. But some, like the patient in this poem, even lose hope that death will come. They see no end to their suffering. Some of these patients commit suicide. Others, like the patient in this poem, ask to be euthanized.

The rarity with which I've been asked to euthanize patients makes the request all the more memorable. Like the physician in this poem, I have taken it personally. The request has made me feel that I have failed the patient. I have usually felt defensive and angry, at the situation, at the request, and even at the patient making the request. Since, like the physician in this poem, I will not euthanize a patient, the request and my unwillingness to accede to it have distanced me from the patient at a time when such distance can be least afforded.

Are patients who request euthanasia serious? Do they want their physicians to end their life? Some do. The physician in this poem takes his patient's request to heart. Most patients who request euthanasia, however, do not really want to be euthanized. What, then, do they want? A request to be euthanized, like a suicide attempt, is usually a cry for help. Patients who make this request want our attention. They want us to know that they have lost hope that their suffering—their pain, their nausea, their shortness of breath, their depression—can be relieved. If we have pulled back or disengaged, they want us to re-engage. They want us to recommit. They need to know that we believe that their suffering can be relieved. They want us to do something, anything, to restore that hope.

If most patients who request euthanasia don't really want to be euthanized and most physicians will not euthanize them anyway, what should physicians do? Ask for help. It sounds simple, but when those involved feel helpless and the situation seems hopeless, asking for help is often the most difficult thing to do. What kind of help is needed? There is no "right" kind. Any help at all will often break the paralysis produced by helplessness and hopelessness. Just asking can be a hopeful act. That said, there are two kinds of help that can be particularly valuable: expert advice on relief of suffering and increasing the size and capabilities of the care team.

Where do we get expert advice on relief of suffering? At the very least, we should seek the advice of a colleague or present the patient at a case conference or tumor board. But is this enough? Most oncologists, myself included, would like to believe that palliation of the suffering of the sick and dying is an essential part of what we do. Sometimes, there is even the tacit assumption that if we can't relieve the suffering of cancer patients, then who can? The facts, however, argue otherwise. To the extent that we focus on extending survival, we pay less attention to suffering - less attention to the suffering of our patients and less attention to our training to relieve suffering. Anyone needing evidence to support the latter assertion need look no further than the difference in attendance between disease-oriented and palliative care educational sessions at the annual American Society of Clinical Oncology Annual Meeting. In addition, the emergence of palliative care programs reflects this lack of attention on the part of oncologists and other physicians involved in the care of these patients. I am not arguing for oncologists to pay less attention to extending survival. I am arguing that relief of suffering requires just as much attention. Some oncologists make this a focus of their work; many do not. Regardless, our patients need concerted attention to their suffering. If we, as individual oncologists, don't provide it, we need to ask the help of those who can and do.

Why should we increase the size and capabilities of the care team and how are we to do it? If there was ever a situation that calls for a team of providers, it is the care of the dying. There are physical, psychological, social, and, for many, religious dimensions to their suffering. Their families, who are usually the primary care providers, suffer as well and need help if they are to stay the course. Physicians and nurses need help as the locus of care shifts from office and hospital to the patient's home. Hospice care, with its broad focus on the suffering of the dying and their families, is the most efficient and usually the most effective way to increase the size and capabilities of the care team. For patients, families, and their care team, who may be feeling helpless as cancer and suffering progress, the arrival of the hospice team can be an infusion of ideas, energy, hands ... and hope.

John H. Fetting

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

NOTES

Authors' disclosures of potential conflicts of interest are found at the end of this article.

Submitted May 3, 2004; accepted May 7, 2004.

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