Clinical Geriatrics

While I have been writing this column in Clinical Geriatrics for some time now, I thought you might appreciate the following “Physician’s Perspective” from an Internal Medicine resident still in his first year of training. Clearly, learning to be a board-certified internist takes more than memorizing a list of differential diagnoses, understanding medication use and side effects, and developing physical examination skills. It requires a mastery of the Six Core Competencies established by the Accreditation Council for Graduate Medical Education (ACGME) and a great deal of self-reflection, experience, and clinical interaction.

Steven R. Gambert, MD, AGSF, MACP
Editor-in-Chief, Clinical Geriatrics

Dr. Gambert is Chairman, Department of Medicine, and Physician-in-Chief, Sinai Hospital of Baltimore, and Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Physician-Assisted Suicide: A Resident’s Dilemma

Markos G. Kashiouris, MD

Of all the medical disciplines, I find medical ethics—and more specifically, end-of-life issues—to be the most challenging. According to the Stoic ethical position, there is individual responsibility for one’s life and the corollary responsibility to seek a good death when life goes badly.1 On the other hand, according to the Theistic point of view, it is a mortal sin to seize control over one’s life and death.1 The U.S. Supreme Court ruled that people have no constitutional right to physician-assisted suicide. Having to face a request for assisted suicide when attempting to relieve a patient’s suffering was described as a very demanding experience that doctors generally would like to avoid.2

I came face to face with this scenario during my night float rotation when I was called upon to provide care to a patient as part of my coverage responsibilities. Mr. B, a 75-year-old male patient with widespread metastatic lung cancer who was placed on “comfort measures only,” experienced severe shortness of breath and chest pain. Other causes of chest pain and shortness of breath, such as acute coronary syndromes, pulmonary embolism, and pericardial disorders, had been ruled out, and there was the instruction from his regular medical team to keep him “comfortable.” While I was increasing the dosage of opioids at a reasonable rate, I explained to the family that I was going “up” with the dose and would also use boluses as clinically necessary. The family asked me to “make him comfortable immediately, even if this would kill him….”

At that moment I realized that they were indirectly asking me to give a lethal dose of opioid analgesia. I reassured the family that I would do my best to keep their loved one comfortable and safe. It required about 2-3 hours of careful monitoring to increase the morphine rate from 2 mg/hour to 10 mg/hour, add hydromorphone, employ nonsteroidal medications, haloperidol, and low-dose benzodiazepines to keep Mr. B comfortable. A communication with the attending physician confirmed that we were on the right track.

In retrospect, this clinical scenario contained a significant and challenging aspect of medical ethics, which can be simplified by just quoting Hippocrates from 400 BC:

“I will give no deadly medicine to any one if asked, nor suggest any such counsel….”