Speaking from the bedside: palliative medicine and euthanasia don't mix

One of the reasons often cited in favour of euthanasia is the need to avoid pain. No-one wants to die in pain, and no-one should. However, many myths exist about managing pain at the end of life. As a result there is also much confusion and ignorance about the possibilities provided by palliative care. For instance, a journalist said to me recently that "in opposing euthanasia you intend people to die in agonising pain with no way out." In caring for 400-500 people each year for the past 19 years in Ireland, Scotland, US and New Zealand I have not witnessed any such death.

Statistics reveal that around one-third of patients with cancer report pain, rising to three-quarters in the advanced stage of cancer. For many patients such pain is easily managed. In patients with more complex pain, relief can be achieved by the involvement of a palliative care team with specialised knowledge and skills in this area.

Pain is more than physical. The experience of pain is a highly complex phenomenon with physical, behavioural, cognitive, emotional, spiritual and interpersonal aspects. This multidimensional nature of pain must be acknowledged in the assessment and management of patients.

Pain is most difficult to control when the emotional, social and spiritual aspects of distress are significant. There is now a large body of scientific evidence that highlights the role of anxiety and depression, fear, particular pain related beliefs and coping styles in the mediation of pain perception. There is a distinct overlap between symptoms of depression, symptoms of cancer and the effects of cancer treatments. A diagnosis of depression is often missed in patients with cancer. One study of elderly hospice patients found that psychological and social pain were identified as worse than physical pain.

Perhaps once or twice a year a patient, or more frequently their relative, expresses the view that she/he wished "it was all over". Such comments invite a careful, detailed and sensitive exploration by me as a doctor, with the help of a multidisciplinary team, into why the patient or relative feels that way. Physical pain on its own is never the main reason. In my experience, the problem for patients is that they want to live and their advancing illness cannot be contained. Herein lies their distress. Contrary to popular opinion, the reason for such requests is not pain, but despair and loneliness.

Euthanasia is not a treatment for despair and loneliness. Rather, these symptoms point to the need dying patients have for emotional support from accessible professionals with good communication skills. This requires an ability to acknowledge, empathise with and get to know the patient, balance reality with positivity, treat the whole person and be prepared to discuss every aspect of the patient's life affected by their cancer if the patient so wishes.

With time and careful attention to the patient and their family/whanau, their distress can be resolved or greatly eased. On a daily basis and multiple times each day palliative medicine physicians do this successfully . What is required is an intensive form of care; the same care patients receive in an intensive care unit, differing only in so far as it is dependant on skilled professionals rather than on high-tech equipment.

An unwavering commitment to holistic care and intensive personal support is a distinctive feature of palliative medicine and palliative care. For this reason there is a fundamental contradiction between the philosophy of palliative medicine and the push for legalised killing of the dying. Thus, I and other palliative medicine physicians are particularly disturbed by moves afoot in New Zealand to combine palliative care with the option for euthanasia in the very same facility.

As Palliative Medicine Physicians in Western Australia noted recently: "We do not see any benefit in the Voluntary Euthanasia Bill. If it were passed, it would not assist us in our care for our patients. On the contrary, we see enormous potential for unintended harm, as has occurred in Holland. We reaffirm our commitment to our patients: we will continue to provide care for you to the best of our ability, guided by your choices, but we will not kill you."

And as the World Health Organisation statement notes, Palliative Care:

• affirms life and regards dying as a normal process;
• neither hastens nor postpones death;
• provides relief from pain and other distressing symptoms;
• integrates the psychological and spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until death;
• offers a support system to help the family cope during the patient's illness and bereavement

At the same time Palliative Care Specialists support a patient's right to refuse treatment (such as surgery and chemotherapy) or to cease treatment deemed unnecessary (such as kidney dialysis, ventilators and admission to ICU). We also support the patient's right to choose where they will die.

Unlike euthanasia, palliative care aims to provide total care (body, mind and spirit) to the patients and support for their families. Euthanasia and palliative medicine must never be combined. Any association in people's minds between the holistic care provided by palliative care teams and the choice to be euthanased will only be confusing to patients and detrimental to the efforts of palliative care teams to bring healing and peace to people even while we can no longer cure them.

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Dr Sinead Donnelly MD, FRCPI, FAChPM is a Consultant in Palliative Medicine at Capital & Coast District Health Board, Adjunct Professor, School of Biological Sciences, Victoria University, Wellington and Senior Clinical Lecturer, Otago School of Medicine, Wellington.