Not Doing Everything

The patient was an 11-year-old female who had been generally healthy until the past 3 months. Polyuria and polydipsia suggested diabetes insipidus. A splenic mass had been removed, but now there was a symptomatic mass in the left femur. The recommended aggressive course of therapy included amputation of the leg. But was aggressive treatment in the patient’s best interest, given what appeared to be metastatic cancer? As chair of an ethics committee and ethics consult service, I have facilitated many similar conversations about end-of-life care.

This time was a little different. The conversation was with my brother. The patient was his elderly German Shepherd dog. Since we lived 1,000 miles apart, it occurred over the phone. Besides those features, the conversation followed a typical trajectory over two evenings. The day after our last conversation, my brother made his decision. The vet made a compassionate house call to end the pet’s suffering.

There have been remarkable advances in veterinary medicine.* A recent New York Times article raised the ethical question about how much money and effort is appropriate for a dying pet.

I do not share my brother’s predilection to form emotional bonds with animals, but I know many people who do. My observations reveal no fundamental difference between how pet owners make loving decisions for their pets and how most people make wise decisions about end-of-life care for themselves and their relatives. At least until someone interjects that vague, loaded, and misleading question, "Do you want us to do everything?"

At what point does aggressive treatment merely prolong the suffering?

The U.S. health care system does a very poor job addressing that question. In many ways, that question created modern clinical ethics. Perhaps the attitdudes of pet caretakers can give us insight that often gets eclipsed by political rhetoric about fictional death panels.

Western society’s attitudes toward animals have been evolving. As a child, I learned that humans were distinguished from "lower" animals because only humans used language, used tools, had emotions, or appeared distressed by ethical dilemmas. One by one, scientific research has disproved each of these characteristics. Genetics has shown a 98% homology of human DNA with that of other primates. Rather than merely trying to prevent animal cruelty, secular organizations such as People for the Ethical Treatment of Animals (PETA) seek to establish ethical norms for interacting with animals. This includes discouraging the use of furs, changing the architecture of zoos, and opposing practices in modern farming that crowd animals in cages. Religion weighs in on this subject as well. The relationship between humans and other animals has been the subject of the spring 2012 religion and science seminar at the Lutheran School of Theology at Chicago, and the subject of the Goshen College 2012 Conference on Science and Religion. Of course, Hinduism predates all this by millennia.

Life-sustaining technologies blossomed in the 1970s, partly due to advancements in medical science, and partly due to profitability from Medicare reimbursement, which began in 1965. Theologians, historically the experts on the meaning of life, began to debate whether technology was always a good thing. A Catholic voice from this era was the Rev. Kevin O’Rourke, a theologian at Saint Louis University who later moved to Loyola in Chicago. He passed away on March 28.

For decades he staunchly defended the difference between ordinary and extraordinary actions at the end of life, arguing that a patient may use, but is not obligated to employ, extraordinary measures to prolong life. Secular philosophers weighed in with similar analyses, which identified some treatments as burdensome. They defended, on the grounds of patient autonomy, the right of a patient to refuse to consent to overly burdensome medical treatment. The U.S. legal system concurred in a series of landmark cases. A generation later, clinical ethicists continue to debate this issue and to refine the means by which those decisions are made. In 2006, board certification became available in the subspecialty of hospice and palliative medicine.

Alas, many doctors are still reluctant to initiate discussions of end-of-life care with their patients. There are multiple reasons for this. Reimbursement is one barrier. Attempts to improve reimbursement for this activity in 2009 were abandoned when Sarah Palin mischaracterized the process as the establishment of government death panels.

Clinical ethicists would characterize these discussions as the epitome of patient advocacy. Can the acrimonious debate be enlightened by the choices of a pet lover?

Physicians need to carefully discuss goals of treatment rather than cop out and ask that horrifically inaccurate question, "Do you want us to do everything?"

I assert that it can. My brother now cares for two more German Shepherds adopted from rescue shelters. He is also my health care power of attorney. I anticipate his experience with his beloved pets will provide him with the wisdom and compassion to make choices for me should circumstances so require.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].

* Author's changes made 5/10/2012.

The patient was an 11-year-old female who had been generally healthy until the past 3 months. Polyuria and polydipsia suggested diabetes insipidus. A splenic mass had been removed, but now there was a symptomatic mass in the left femur. The recommended aggressive course of therapy included amputation of the leg. But was aggressive treatment in the patient’s best interest, given what appeared to be metastatic cancer? As chair of an ethics committee and ethics consult service, I have facilitated many similar conversations about end-of-life care.

This time was a little different. The conversation was with my brother. The patient was his elderly German Shepherd dog. Since we lived 1,000 miles apart, it occurred over the phone. Besides those features, the conversation followed a typical trajectory over two evenings. The day after our last conversation, my brother made his decision. The vet made a compassionate house call to end the pet’s suffering.

There have been remarkable advances in veterinary medicine.* A recent New York Times article raised the ethical question about how much money and effort is appropriate for a dying pet.

I do not share my brother’s predilection to form emotional bonds with animals, but I know many people who do. My observations reveal no fundamental difference between how pet owners make loving decisions for their pets and how most people make wise decisions about end-of-life care for themselves and their relatives. At least until someone interjects that vague, loaded, and misleading question, "Do you want us to do everything?"

At what point does aggressive treatment merely prolong the suffering?

The U.S. health care system does a very poor job addressing that question. In many ways, that question created modern clinical ethics. Perhaps the attitdudes of pet caretakers can give us insight that often gets eclipsed by political rhetoric about fictional death panels.

Western society’s attitudes toward animals have been evolving. As a child, I learned that humans were distinguished from "lower" animals because only humans used language, used tools, had emotions, or appeared distressed by ethical dilemmas. One by one, scientific research has disproved each of these characteristics. Genetics has shown a 98% homology of human DNA with that of other primates. Rather than merely trying to prevent animal cruelty, secular organizations such as People for the Ethical Treatment of Animals (PETA) seek to establish ethical norms for interacting with animals. This includes discouraging the use of furs, changing the architecture of zoos, and opposing practices in modern farming that crowd animals in cages. Religion weighs in on this subject as well. The relationship between humans and other animals has been the subject of the spring 2012 religion and science seminar at the Lutheran School of Theology at Chicago, and the subject of the Goshen College 2012 Conference on Science and Religion. Of course, Hinduism predates all this by millennia.

Life-sustaining technologies blossomed in the 1970s, partly due to advancements in medical science, and partly due to profitability from Medicare reimbursement, which began in 1965. Theologians, historically the experts on the meaning of life, began to debate whether technology was always a good thing. A Catholic voice from this era was the Rev. Kevin O’Rourke, a theologian at Saint Louis University who later moved to Loyola in Chicago. He passed away on March 28.

For decades he staunchly defended the difference between ordinary and extraordinary actions at the end of life, arguing that a patient may use, but is not obligated to employ, extraordinary measures to prolong life. Secular philosophers weighed in with similar analyses, which identified some treatments as burdensome. They defended, on the grounds of patient autonomy, the right of a patient to refuse to consent to overly burdensome medical treatment. The U.S. legal system concurred in a series of landmark cases. A generation later, clinical ethicists continue to debate this issue and to refine the means by which those decisions are made. In 2006, board certification became available in the subspecialty of hospice and palliative medicine.

Alas, many doctors are still reluctant to initiate discussions of end-of-life care with their patients. There are multiple reasons for this. Reimbursement is one barrier. Attempts to improve reimbursement for this activity in 2009 were abandoned when Sarah Palin mischaracterized the process as the establishment of government death panels.

Clinical ethicists would characterize these discussions as the epitome of patient advocacy. Can the acrimonious debate be enlightened by the choices of a pet lover?

Physicians need to carefully discuss goals of treatment rather than cop out and ask that horrifically inaccurate question, "Do you want us to do everything?"

I assert that it can. My brother now cares for two more German Shepherds adopted from rescue shelters. He is also my health care power of attorney. I anticipate his experience with his beloved pets will provide him with the wisdom and compassion to make choices for me should circumstances so require.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].

* Author's changes made 5/10/2012.

The patient was an 11-year-old female who had been generally healthy until the past 3 months. Polyuria and polydipsia suggested diabetes insipidus. A splenic mass had been removed, but now there was a symptomatic mass in the left femur. The recommended aggressive course of therapy included amputation of the leg. But was aggressive treatment in the patient’s best interest, given what appeared to be metastatic cancer? As chair of an ethics committee and ethics consult service, I have facilitated many similar conversations about end-of-life care.

This time was a little different. The conversation was with my brother. The patient was his elderly German Shepherd dog. Since we lived 1,000 miles apart, it occurred over the phone. Besides those features, the conversation followed a typical trajectory over two evenings. The day after our last conversation, my brother made his decision. The vet made a compassionate house call to end the pet’s suffering.

There have been remarkable advances in veterinary medicine.* A recent New York Times article raised the ethical question about how much money and effort is appropriate for a dying pet.

I do not share my brother’s predilection to form emotional bonds with animals, but I know many people who do. My observations reveal no fundamental difference between how pet owners make loving decisions for their pets and how most people make wise decisions about end-of-life care for themselves and their relatives. At least until someone interjects that vague, loaded, and misleading question, "Do you want us to do everything?"

At what point does aggressive treatment merely prolong the suffering?

The U.S. health care system does a very poor job addressing that question. In many ways, that question created modern clinical ethics. Perhaps the attitdudes of pet caretakers can give us insight that often gets eclipsed by political rhetoric about fictional death panels.

Western society’s attitudes toward animals have been evolving. As a child, I learned that humans were distinguished from "lower" animals because only humans used language, used tools, had emotions, or appeared distressed by ethical dilemmas. One by one, scientific research has disproved each of these characteristics. Genetics has shown a 98% homology of human DNA with that of other primates. Rather than merely trying to prevent animal cruelty, secular organizations such as People for the Ethical Treatment of Animals (PETA) seek to establish ethical norms for interacting with animals. This includes discouraging the use of furs, changing the architecture of zoos, and opposing practices in modern farming that crowd animals in cages. Religion weighs in on this subject as well. The relationship between humans and other animals has been the subject of the spring 2012 religion and science seminar at the Lutheran School of Theology at Chicago, and the subject of the Goshen College 2012 Conference on Science and Religion. Of course, Hinduism predates all this by millennia.

Life-sustaining technologies blossomed in the 1970s, partly due to advancements in medical science, and partly due to profitability from Medicare reimbursement, which began in 1965. Theologians, historically the experts on the meaning of life, began to debate whether technology was always a good thing. A Catholic voice from this era was the Rev. Kevin O’Rourke, a theologian at Saint Louis University who later moved to Loyola in Chicago. He passed away on March 28.

For decades he staunchly defended the difference between ordinary and extraordinary actions at the end of life, arguing that a patient may use, but is not obligated to employ, extraordinary measures to prolong life. Secular philosophers weighed in with similar analyses, which identified some treatments as burdensome. They defended, on the grounds of patient autonomy, the right of a patient to refuse to consent to overly burdensome medical treatment. The U.S. legal system concurred in a series of landmark cases. A generation later, clinical ethicists continue to debate this issue and to refine the means by which those decisions are made. In 2006, board certification became available in the subspecialty of hospice and palliative medicine.

Alas, many doctors are still reluctant to initiate discussions of end-of-life care with their patients. There are multiple reasons for this. Reimbursement is one barrier. Attempts to improve reimbursement for this activity in 2009 were abandoned when Sarah Palin mischaracterized the process as the establishment of government death panels.

Clinical ethicists would characterize these discussions as the epitome of patient advocacy. Can the acrimonious debate be enlightened by the choices of a pet lover?

Physicians need to carefully discuss goals of treatment rather than cop out and ask that horrifically inaccurate question, "Do you want us to do everything?"

I assert that it can. My brother now cares for two more German Shepherds adopted from rescue shelters. He is also my health care power of attorney. I anticipate his experience with his beloved pets will provide him with the wisdom and compassion to make choices for me should circumstances so require.

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. E-mail Dr. Powell at [email protected].

* Author's changes made 5/10/2012.