Can preparation make death less daunting?

Every oncologist in Israel knows that on Sunday mornings – the beginning of the Israeli work week – a busy clinic awaits. The weekend provides ample time for symptoms to develop, be noticed and be questioned.

On the morning of Sunday, December 2, 2012, several patients greeted me. Nearly all offered me two things.

First, they gave me their reactions to my op-ed about Iron Dome, the air defense system designed to intercept short-range rockets. The piece had been published in these pages on that day.

Second, my patients conveyed their fright at having learned of a more abstract “missile” – their terminology – which, that day, had landed, metaphorically, in Israel. It had been alleged that Dr. Mordechai Shtalrid, a department head at Kaplan Hospital, had carried out euthanasia – so-called “mercy killing” – on his terminally ill 33- year-old daughter before committing suicide. The news rocked the cancer patients that I serve.

My patients were curious to discover whether I knew Dr. Shtalrid and, if so, what I thought of the gruesome scenario. Even though we practiced in related fields, I had been introduced to Dr. Shtalrid only once, at a professional meeting. We had exchanged pleasantries but had by no means come to know each other.

IT’S NOT uncommon, of course, for physicians to wrestle with the problem of an incurably ill, suffering patient. In Dr. Shtalrid’s terrible situation, the incurable, suffering patient was also his child. The story has prompted two types of questions; the answerable and, mostly, the unanswerable.

I’ve been bombarded by numerous queries for which I have no answer. For example: To what extent was Keren Shtalrid suffering? To what degree were efforts made to alleviate her pain? Why did Dr. Shtalrid take his own life if he believed that he was doing the best thing for his daughter? Was he afraid of criminal repercussions? Was Dr. Shtalrid more interested in relieving his daughter’s pain or dealing with his own perceived helplessness? Were any attempts made to overcome, or at least compensate for the “intractable pain” with non-medical modalities such as meaning-making techniques? On the other hand, the questions to which we can formulate answers pertain to what we might elect to do as the end of life approaches for us and our loved ones. In considering those questions, I offer a three-part model comprised of autonomy, religiousness and spirituality.

The model, which presumes overlap among the various factors, can be represented by a Venn diagram. Individuals gravitate to the respective factors in varying degrees.

Autonomy

Autonomy is typically defined as the ability of a person to make his or her own decisions. In a medical context, patients exercise autonomy most often when they provide informed consent prior to participating in clinical trials and while reflecting on end of life decision making.

Today, many people feel that the ability to make such decisions for themselves is an inviolate core value.

In fact, when sensitive medical decisions must be made, patients and family members tend to assert that they alone are at liberty to make such judgments. From that, one can deduce that people do not want society to meddle in personal choices involving “good death.”

Religiousness

Most Western religious traditions place a premium on what many refer to as “the holiness of life.” Non-theological philosophies don’t necessarily minimize such sanctity, but in a non-religious view, the holiness of life is unlikely to trump all other considerations.

While the Roman Catholic religion seems to propose blanket condemnation of active euthanasia, the Church generally sanctions passive euthanasia. Protestantism, according to Anglican minister Joseph Fletcher, offers “all possible colors in the spectrum of attitude toward euthanasia.” The former chief rabbi of England, Lord Immanuel Jakobovits, points out that “any form of active euthanasia is strictly prohibited and condemned as plain murder, but Jewish law seems to allow for withdrawal of any factor which may artificially delay death in the final phases of a person’s life.” These heady concepts are harder to comprehend when one considers them for the first time only when someone is dying.

Spirituality

There may be no completely satisfying definition of spirituality. I choose to define the word in an indirect fashion as referring to that which uplifts the soul. It is readily apparent, however, that my definition is subjective, even tautological.

Dr. Thomas Moore refers to “loss of soul” as the great malady of our time. Society in general and physicians in particular have lost interest in the soul and the spiritual dimension of life. We lack professionals who task themselves with healing the soul. But by caring for the soul, we may be able to find relief from distress. Most would agree with Victor Frankl that, on an intuitive level, the soul craves meaningfulness. When facing the specter of death, we may derive considerable solace if we persevere to find meaning even when we cannot avert the outcome.

IN 2005, the Knesset passed comprehensive legislation known as The Dying Patient Act that attempted simultaneously to respect patient autonomy and affirm the sanctity of human life. The law invites us to find a balance between prolonging life and avoiding suffering.

In theory, the law represents a giant step forward for professionals, dying patients and their families, all of whom must navigate the multiple ethical, legal and cultural dilemmas that arise at the end of life. However the law can be only as good as the way in which people adopt it.

The DPA is relatively new, and the level of its success is unknown, as is the degree to which physicians are able to use the tool to help patients evaluate the relative weighting of autonomy, religiousness and spirituality to their own lives.

In the USA, a growing number of states endorse a program known as POLST (Physician Orders for Life Sustaining Treatment). POLST seeks to provide a user-friendly template for recording the types of interventions that patients want and don’t want as death looms. American writer Ellen Goodman launched another popular program, The Conversation Project. Goodman intuited a way to bring conversations about death into the mainstream, so that they “could even be discussed around the dinner table.” One may download a starter kit from the Internet.

The case of the Shtalrids has, in fact, landed unexpectedly, like a terrifying missile. But even beforehand, death had been waging an unrelenting campaign against humankind. In this battle, there is no external system like Iron Dome which can shield us from the daunting nature of our own mortality. Rather, we must contend with death anxieties as individuals. Each of us might do well to begin to envision and grapple with various end-of-life scenarios. It shouldn’t take a tragic occurrence to get us to contemplate a tragic reality.

The author is chairman of the Institute of Radiotherapy at Tel Aviv Medical Center and co-founder of the organization Life’s Door. His blog (“52”) is hosted on JPost.com