Psychology quest wk
Decoding the Ethics Code, Ch. 8
Assume you have been called as an expert witness in a court proceeding. What considerations or limitations does the APA Ethics Code place upon you in terms of what you may disclose as part of your testimony? What potential challenges might this present to your professional relationship with your client?
Why do you believe the security of confidential therapy and health records is important to the ethical practice of psychology? What is the role of HIPAA in regards to the confidentiality of records?
Ch 9
What expectations does the APA Ethics Code require of researchers? What types of activities does the code specifically prohibit? Do you agree with the prohibitions? Why or why not?
Health Information Management
What would the reaction of an individual be if their mental health records were disclosed? I know what reaction I have seen from people who perceive their information has been released (even if not) but this personal account by this journalist is telling. http://www.bustle.com/articles/105954-your-mental-health-record-isnt-as-private-as-you-think-so-choose-your-health-provider in her link she does not tell her particular diagnosis, but does speak to the destructive stigma of mental illness
Notes below to help with question.
GETTING GOOD HEALTH CARE DEPENDS ON ACCURATE, RELIABLE INFORMATION. WHENEVER A PATIENT ENTERS A HOSPITAL, A CLINIC, OR A DOCTOR'S OFFICE, A MEDICAL RECORD IS ESTABLISHED THAT DETAILS THEIR MEDICAL HISTORIES, THEIR SYMPTOMS, LABORATORY TESTS, DIAGNOSIS, AND TREATMENT PLAN. THESE RECORDS ARE ORGANIZED, PROTECTED AND EVALUATED BY HEALTH INFORMATION SPECIALISTS. THESE SPECIALISTS WORK IN ONE OF THE NEWEST AND MOST EXCITING AREAS OF MEDICINE WHERE HEALTH CARE MEETS TECHNOLOGY. I INITIALLY STARTED THE PROGRAM TO HELP ENHANCE MY SKILLS AS A HEALTH CARE PROVIDER. AS A RESPIRATORY THERAPIST IN THE HEALTHCARE FIELD, WE COME ACROSS A LOT OF PATIENT RECORDS AND I NEEDED TO UNDERSTAND HOW TO RECORD THINGS AND HOW TO KEEP THEM UP AND ACTUALLY I WANTED SOMETHING TO DO WITH ADMINISTRATIVE AND MANAGERIAL AT THE SAME TIME SO THIS PROGRAM WAS ACTUALLY VERY HELPFUL IN COMBINING THE TWO, THE HEALTHCARE AND THE INFORMATION SYSTEMS TOGETHER. I'VE BEEN BILLING FOR FIVE YEARS AND, DURING BILLING, I REALIZED HOW IMPORTANT INFORMATION IS FOR REIMBURSEMENT AND, WITH THE STATE OF OUR HEALTHCARE SYSTEM NOW IN THIS COUNTRY, REIMBURSEMENT IS ONE OF EVERYONE'S CONCERN, FROM THE PHYSICIAN DOWN TO THE CLERK. HIM PROVIDES ME WITH THE SKILLS OF COLLECTING... OBTAINING QUALITY DATA THAT CAN ENSURE REIMBURSEMENT. I THINK THIS PROFESSION IS ONE OF THE BEST-KEPT SECRETS. ME AND A LOT OF PEOPLE THAT I KNOW HAVE FOUND THE PROFESSION ACCIDENTALLY. I STARTED OUT IN PRE-PHARMACY AND, IN LOOKING THROUGH A COURSE CATALOG AT THE UNIVERSITY WHERE I ATTENDED, I FOUND HEALTH INFORMATION MANAGEMENT AND THOUGHT IT WOULD INTERESTING. IT'S IN THE HEALTHCARE SETTING NOT DIRECT PATIENT CARE... MORE BUSINESS/OFFICE RELATED AND I THOUGHT IT WOULD BE INTERESTING. WHEN I WAS IN COLLEGE I WAS UNSURE OF WHAT CAREER AND WHAT DEGREE I WANTED TO GET WHILE I WAS IN COLLEGE. I WAS LOOKING THROUGH THE COURSE CATALOG AND CAME ACROSS WHAT WAS THEN CALLED MEDICAL RECORD ADMINISTRATION. I GOT ON THE PHONE AND MADE A CALL TO GET SOME INFORMATION AND GOT THE PROGRAM DIRECTOR ON THE PHONE WHO INVITED ME FOR A MEETING AND IN DISCUSSIONS WITH HIM ABOUT THE KINDS OF JOBS THAT WERE AVAILABLE AND ABOUT THE PROFESSION IN GENERAL, I FOUND IT TO BE VERY INTERESTING AND EXCITING. I THOUGHT IT WAS A GOOD MIX OF HEALTH CARE, BUSINESS, AND ALSO INFORMATION SYSTEMS WHICH REALLY APPEALED TO ME. HEALTH INFORMATION PROFESSIONALS HAVE ONE OF THE MOST IMPORTANT JOBS IN THE HEALTHCARE SYSTEM. THE ACCURATE COLLECTION, STORAGE, RETRIEVAL, AND SECURITY OF DATA IS CRUCIAL FOR PATIENT CARE TO BE PROVIDED CORRECTLY AND FOR HEALTH FACILITIES TO BE PAID PROPERLY. A HEALTH INFORMATION PROFESSIONAL MUST PROTECT THE CONFIDENTIALITY OF THE PATIENT. CONFIDENTIALITY IS SOMETHING THAT'S IMPORTANT BECAUSE PEOPLE CAN GET HURT BY BEING DISCRIMINATED AGAINST BECAUSE OF THE INFORMATION THAT IS IN THEIR HEALTH RECORDS. AND THEN THE OTHER SIDE OF THAT IS THAT PEOPLE WHO ARE AFRAID THAT SOMEONE MIGHT FIND OUT ABOUT A FAMILY HISTORY OF ALZHEIMER'S, OR SOMEONE MIGHT FIND OUT ABOUT THEIR CONDITION, WILL ACTUALLY NOT TELL THE PHYSICIAN. THEY'RE MORE AFRAID OF THE REPERCUSSIONS FROM THEIR EMPLOYER OR FROM THEIR FAMILY OR THEIR NEIGHBORS OR THE COMMUNITY THAN THEY ARE OF THE DISEASE AND THAT'S REALLY A SAD THING, BUT IT DOES HAPPEN. PEOPLE ARE AFRAID THAT IF THEIR PRIVACY AND CONFIDENTIALITY IS VIOLATED, THE OUTCOME WILL BE WORSE THAN THE ACTUAL DISEASE. AND SO WE TRY TO CREATE AN ENVIRONMENT WHERE PEOPLE CAN TRUST THAT THEIR CONFIDENTIALITY AND PRIVACY WILL BE PROTECTED AND THEN THEY WON'T BE AFRAID TO SHARE THE INFORMATION WITH THEIR HEALTHCARE PROVIDERS, AND THE HEALTHCARE PROVIDER CAN PROVIDE THE QUALITY OF CARE THAT THEY NEED IN ORDER TO TREAT THEIR CONDITION OR THEIR INJURY. A HEALTH INFORMATION SPECIALIST MUST MAKE SURE THAT PATIENT RECORDS ARE PROPERLY CODED. WE HAVE A FUNCTION WITHIN OUR DEPARTMENT WHICH IS CALLED CODING. AND WE HAVE A NUMBER OF INDIVIDUALS WHO LOOK AT EVERY RECORD OF EVERY PATIENT WHO'S SEEN HERE AT THE HOSPITAL. WHAT THEY'RE DOING IS THEY'RE EXAMINING THE RECORD TO DETERMINE WHY THE PATIENT WAS HERE AND WHAT SERVICES THEY RECEIVED WHILE THEY WERE HERE. THEY'RE CODING SPECIFIC THINGS CALLED DIAGNOSES AND PROCEDURES, WHICH HAVE DIFFERENT TYPES OF CODES. THOSE CODES ARE THEN SUBMITTED TO INSURANCE COMPANIES FOR REIMBURSEMENT PURPOSES AND THOSE CODES ARE ALSO WHAT GIVES US THE BASIS TO BE ABLE TO DO COMPARATIVE DATA ACROSS THE NATION ABOUT WHAT KINDS OF HEALTH CARE PROBLEMS THERE ARE IN THE UNITED STATES. A CAREER IN HEALTH INFORMATION IS DEMANDING. BUT RESPONSIBILITY AND DISCIPLINE BRING REWARDS AS WELL. THERE ARE MANY EMPLOYMENT OPPORTUNITIES AT DIFFERENT DEGREE LEVELS AND IT IS AN IDEAL OCCUPATION FOR SOMEONE WHO IS INTERESTED IN HEALTHCARE BUT MAY NOT WANT CLOSE PATIENT CONTACT. THE SATISFACTIONS OF MY JOB ARE MANY. THE DAY-TO-DAY OPERATIONS OF THE DEPARTMENT, IT'S SATISFYING TO SEE WHEN YOU HAVE A WORKFORCE THAT WORKS WELL TOGETHER AND IS PRODUCTIVE AND CAN HANDLE THE DAY-TO-DAY OPERATIONS ON AN ONGOING BASIS. AND CERTAINLY, THE INVOLVEMENT WE HAVE WITH CAREGIVERS AND WITH PATIENTS - IT'S SATISFYING TO KNOW THAT WE'RE PLAYING AN IMPORTANT ROLE IN THE DELIVERY OF HEALTH CARE. WHEN YOU LOOK AT A LOT OF THE HEALTHCARE DISCIPLINES, THEY TEND TO BE MORE PATIENT-ORIENTED. HEALTH INFORMATION MANAGEMENT REALLY RELIES ON THE INFORMATION, SO WE'RE DEALING WITH THAT PATIENT INFORMATION, AND USING TECHNOLOGY AS A WAY TO SERVICE THAT PATIENT. PROVIDING THE CARE, PROVIDING INFORMATION ABOUT THE QUALITY OF THE CARE BEING PROVIDED SO OTHER HEALTHCARE PROFESSIONALS USE THE DATA THAT WE COLLECT, GATHER AND SYNTHESIZE. SO, I THINK HEALTH INFORMATION MANAGEMENT IS A GOOD CHOICE FOR STUDENTS IF THEY'RE EXPLORING HEALTHCARE OPTIONS BUT DON'T LIKE THE BLOOD AND GORE OF NURSING OR PARAMEDICS OR SOME OF THE OTHER TYPES OF HANDS-ON PATIENT CARE OPPORTUNITIES, BUT WANT TO DO SOMETHING MORE THAN WORKING IN AN OFFICE. HEALTH INFORMATION SPECIALISTS CAN BE FOUND WORKING THROUGHOUT THE HEALTHCARE INDUSTRY OR IN ANY FIELD THAT USES HEALTH CARE INFORMATION. THIS INCLUDES: THE PROFESSION ALLOWS YOU A VARIETY OF PATHS TO PURSUE, THAT IT'S NOT STRICTLY "I'M GOING TO WORK IN A HOSPITAL, I'M GOING TO WORK IN THIS SETTING," BUT YOU CAN WORK IN THE FULL ARRAY OF BOTH HEALTHCARE AND BUSINESS SETTINGS THAT ARE LOOKING FOR... IT'S REALLY INFORMATION MANAGEMENT SKILLS. MEDICAL RECORDS AND HEALTH INFORMATION TECHNICIANS BEGIN TO ASSEMBLE PATIENTS' HEALTH INFORMATION BY FIRST MAKING SURE THEIR INITIAL MEDICAL CHARTS ARE COMPLETE. THEY ENSURE ALL FORMS ARE COMPLETED AND PROPERLY IDENTIFIED AND SIGNED, AND ALL NECESSARY INFORMATION IS IN THE COMPUTER. SOMETIMES THEY COMMUNICATE WITH PHYSICIANS OR OTHERS TO CLARIFY DIAGNOSES OR GET ADDITIONAL INFORMATION. TECHNICIANS ASSIGN A CODE TO EACH DIAGNOSIS AND PROCEDURE. TO DO SO, THEY CONSULT CLASSIFICATION MANUALS WHILE ALSO RELYING ON THEIR OWN KNOWLEDGE. TECHNICIANS THEN ASSIGN THE PATIENT TO ONE OF SEVERAL HUNDRED "DIAGNOSIS-RELATED GROUPS" OR DRG'S. THE DRG DETERMINES THE AMOUNT THE HOSPITAL WILL BE REIMBURSED IF THE PATIENT IS COVERED BY MEDICARE OR OTHER INSURANCE PROGRAMS USING THE DRG SYSTEM. TECHNICIANS WHO SPECIALIZE IN CODING ARE CALLED: TECHNICIANS ALSO USE COMPUTER PROGRAMS TO TABULATE AND ANALYZE DATA. USING COMPUTERS HELPS TO IMPROVE PATIENT CARE, AND CONTROL COSTS. THIS DATA MIGHT ALSO BE USED IN LEGAL ACTIONS, IN RESPONSE TO SURVEYS, OR FOR USE IN RESEARCH STUDIES. FOR EXAMPLE, TUMOR REGISTRARS COMPILE AND MAINTAIN RECORDS OF PATIENTS WHO HAVE CANCER TO PROVIDE INFORMATION TO PHYSICIANS AND FOR RESEARCH STUDIES. HEALTH INFORMATION MANAGEMENT HAS TWO DEGREE LEVELS: THE TWO-YEAR ASSOCIATE DEGREE TECHNICIAN LEVEL ALSO CALLED REGISTERED HEALTH INFORMATION TECHNICIAN (RHIT) THIS DEGREE PREPARES THE GRADUATE TO ASSUME TECHNICAL ROLES WITHIN A FACILITY SUCH AS CODING. TECHNICIANS ENSURE PROPER ENTRY OF PATIENT INFORMATION INTO THE COMPUTER SYSTEM. THEY MAY ALSO USE, ANALYZE, AND ASSEMBLE PATIENT INFORMATION FOR THE PURPOSE OF IMPROVING PATIENT CARE. REGISTERED HEALTH INFORMATION TECHNICIANS OFTEN SPECIALIZE IN CODING DIAGNOSES AND PROCEDURES IN PATIENT RECORDS FOR THE PATIENT'S REIMBURSEMENT AND FOR USE IN RESEARCH. SOME OF THE POSITIONS THAT A GRADUATE WITH AN ASSOCIATE DEGREE MIGHT ENTER ARE: THE SECOND DEGREE LEVEL IN HEALTH INFORMATION MANAGEMENT IS THE FOUR-YEAR PROGRAM OR REGISTERED RECORD ADMINISTRATOR. THIS PROGRAM PREPARES STUDENTS FOR MORE MANAGERIAL POSITIONS. WHILE THE LEVEL OF TEACHING IS THE SAME, THE PERSPECTIVE OF THE CLASSES ARE FROM A MANAGERIAL POINT OF VIEW. TODAY'S SUBJECT IS GOING TO BE PROMOTING THE USE OF ELECTRONIC HEALTH RECORDS. FOR THIS WEEK AND NEXT WEEK WE'RE GOING TO BE TALKING ABOUT THE ROLE OF THE MANAGER AND HOW THEY HAVE TO ADDRESS CERTAIN ISSUES REGARDING IMPLEMENTING THE ELECTRONIC HEALTH RECORD. THE GRADUATE OF THE FOUR-YEAR PROGRAM CAN BECOME A HEALTH INFORMATION MANAGEMENT SYSTEMS MANAGER. THEY MAY WORK ON QUALITY MANAGEMENT AND INFORMATION SECURITY, ENSURING THAT PROPER CARE IS PROVIDED, OR THAT A PATIENT'S HISTORY IS KEPT CONFIDENTIAL. FOR STUDENTS WHO ARE EVALUATING WHETHER TO GO INTO A TWO-YEAR OR FOUR-YEAR PROGRAM, IT REALLY DEPENDS ON KIND OF WHAT THEIR GOALS AND ASPIRATIONS ARE. WE HAVE SET UP CURRICULUMS SO THAT IT CAN BE EASILY TRACKED MEANING I CAN GET MY TWO-YEAR ASSOCIATE'S DEGREE IN HEALTH INFORMATION TECHNOLOGY, AND EASILY TRANSFER THOSE COURSES AND CREDITS TO THE BACCALAUREATE PROGRAM AND PURSUE THE BACHELOR'S DEGREE IN HEALTH INFORMATION ADMINISTRATION. WE HAVE SEVERAL PROGRAMS ACROSS THE COUNTRY THAT HAVE SET UP PARTICULAR PROGRESSION TRACKS FOR THOSE PROFESSIONALS WITH THE TECHNICIAN CREDENTIALS AND TRAINING SO THAT THEY CAN MOVE INTO MORE OF THE MANAGEMENT AND ADMINISTRATIVE ROLES. STUDENTS WHO ARE SUCCESSFUL IN HEALTH INFORMATION MANAGEMENT ARE DETAIL-ORIENTED, THEY ENJOY SCIENCE AND MEDICINE, AND HAVE AN INTEREST IN BUSINESS AND TECHNOLOGY. THE HIM PROGRAM MIGHT ENTER INTO THE WORKFORCE AS AN ENTRY LEVEL CODER OR AN EMERGENCY ROOM CODER. THERE ARE ALWAYS NEW AND EXCITING AREAS OPENING UP IN OUR PROFESSION, FOR EXAMPLE, ONE OF THE NEW JOBS THAT'S BEEN CREATED ARE PRIVACY OFFICER POSITIONS AND PRIVACY JOBS WHERE WE ENSURE PATIENT PRIVACY. GOOD HEALTH CARE DEPENDS ON ACCURATE INFORMATION THAT IS SAFELY STORED BUT EASILY AND QUICKLY RETRIEVED. HEALTH INFORMATION PROFESSIONALS PERFORM AN IMPORTANT ROLE IN THE HEALTHCARE SYSTEM AND FOR THE BENEFIT OF THE COMMUNITY. * *
If a psychologist works in facilitating appropriate care for an individual with a mental illness it may involve a number of other people besides this individual (e.g., family members, law enforcement agents, government workers, hospital staff, other mental health professionals, etc.). What are some of the issues in the video and the standards that they need to consider?
How can we Apply ethical standards for maintaining, disseminating, and disposing confidential records.
Evaluate the ethical considerations of expert testimony as they relate to preserving the rights of the client.
APA 2002 Ethics, Amphibology, and the Release of Psychological Test Records: A Counter perspective to Erard
What are some Challenges presented by the Health Insurance Portability and Accountability Act of 1996 regulations; Criticism of the Ethical Standard 9.04; Substantial harm to clients, the community and the profession of psychology
Is A Death of One's Own Ethical? See the transcript below to help with this question.
This is definitely a topic we need to think about. I think it is good to think about our own feelings ahead of trying to assist others who may be struggling with these issues. This is a timely topic. There is one physician being tried for providing patients with lethal doses of medication. Assisted suicide is legal in Oregon and in California, the Governor signed a Death With Dignity Bill. Depending on a person's personal belief system, and condition, we may need to counsel them in their thoughts at dealing with a life-threatening condition. Our job becomes allowing someone to explore their options, while at the same time making sure their decision is not due to depression or other mental illness.
Funding for this program is provided by the Robert Wood Johnson Foundation, making grants to improve the health and health care of all Americans. The Fetzer Institute, supporting programs that explore the mind, body, and spirit. The Nathan Cummings Foundation. The Kohlberg Foundation. The John D. and Catherine T. MacArthur Foundation. And by the Laurance S. Rockefeller Fund.
Corporate funding is provided by Mutual of America, building America's future through pension and retirement plans, encouraging dialogue, and discussion. The Spirit of America, Mutual of America.
Discovering what it's like to live in the light of death, it just blew me away.
We will all die, but how we die, what happens before we die, is under our control.
Fentanyl, 400 mcg.
We'll do it to the best we can, for as long as we can.
I am not afraid of dying. I don't want to die any time soon, but I'm not afraid of it.
Have you had enough breakfast?
How we come to the end of life now is different. It takes different answers, new solutions.
He wants his life to end--
Peacefully.
On his own terms.
You are doing a wonderful job. You're a wonderful sister.
I'm used to family and friends involved--
It is possible to achieve death on our own terms?
I've seen many people do it.
I'm Bill Moyers. Dying well, to many of us, means a measure of control over how and where we die. That basic fact has been lost in the bitter debate over the right to die. Under the media's glare, Dr. Jack Kevorkian framed the debate in the most simplistic terms, are you for or against physician-assisted suicide?
But talk to dying people themselves, and to their families and caregivers, and you learn that no one wants to die a minute too soon. How we take charge of those final days, however, depends on our personality, values, and beliefs, on the stage of our illness, on whether our pain is under control, how we bear the indignities, and whether the people around us understand what's happening and know our wishes.
Having choices is part of good care. It's not just a simple matter of voting death up or down. So in this third program of our series, Dr. Kevorkian is not heard from. We hear, instead, from patients, loved ones, and doctors who talk about suffering and a death of one's own.
Was this sort of your retirement paradise?
We had worked towards that and had everything in place for retirement.
Jim Witcher is a Texan who moved to northern Louisiana to do the work he loves, veterinarian, horse breeder, and meat and poultry inspector.
We had built this farm here where we also had horses and thoroughbreds and so I had two jobs. Suzie had two jobs of taking care of the house and then running the farm when I was gone.
How you doing, Eddie?
I'm doing pretty good, doc.
What you think about the baby?
That was a big baby. Good bones, big baby.
OK, sweetie. Let's fellow mama.
Come on.
Was it a good life?
Wonderful life.
This is where Witcher expected to die one day. He just didn't expect it to be this soon. In 1997, at the age when Jim and his wife Suzie we're dreaming of retirement, he was diagnosed with ALS, Lou Gehrig's disease.
It was just like a death sentence. That's the way it hit me.
ALS attacks the nervous system leading to gradual death by paralysis. The mind remains alert even as the body shuts down. With rapidly progressive ALS, doctors said Jim would live two to five years. When we met him, he was coming up on 2 and 1/2 years.
When somebody dies there's a finality to it. And you probably get angry, and then you get depressed. And then you accept it, and then you go on. With this, as each stage has hit him, it's like another death and you die each stage. And each stage you have to go through this being angry and depressed, and then you get on with it. And it's just an ongoing thing. And it's something we have to accept, I guess, until however the disease takes his life.
Every day I have to do more and more for him that he can't do anymore. OK, ready?
It started in my legs so it's progressed up my body and I'm fast losing control of my arms. Let's see. Help me get my hand up there where I can get started on this thing. It has affected my voice. It will affect my swallowing, and it appears, in my case, the breathing will go last. Now, all that I can do is operate this wheelchair.
Since Jim Witcher was first diagnosed with ALS, he has sought the latest treatment, going to specialists at Johns Hopkins University Hospital in Baltimore and trying out experimental drugs.
So he's fought this. We've fought it.
I've tried everything that anybody suggested that I thought, you know, had any merit.
This was a man who was a collegiate wrestler. He was very athletic. Always held down two full-time jobs. We've had a vet practice. We've had two farms.
I don't know why in the morning's it's so hard to get my muscles going.
Well, they've been still all night long.
I have been able to feed myself. It's not very pretty, but I'm still trying to do that, but I'm fast losing that.
I'll call and ask, but--
You lose gradual control of everything up past your throat. Breathing, eventually, unless you take a respirator that breathes for you, you gradually can't breathe, of course. By that time, your swallowing-- if you tried to swallow, you would inhale food or water into your windpipe because the muscles in your throat are gone. So you have to quit that.
Neurontin.
So as it progresses, the next thing that's likely to happen is you will lose your voice?
I am losing my voice at this time. Back it up so I can bend my chin down--
And then what happens? You lose your ability to swallow?
To swallow. That's probably what's going to happen next.
I'm going to pull you just a little bit. Get you past this. All right. Can you reach it? Here, I'll pull it this way. Got it? You just have to take it day by day. Every day is a new day, and before I get out of bed in the morning I'm asking the Lord for strength, physically to be able to care for him, for compassion that I need because I can fly off the handle pretty quick and get frustrated really easy and this is all a new road for me to travel to. And I know I need to do something that I don't know what or how.
That feels good.
I'm glad you still got good strength in your neck. I don't know what we're gonna do when you don't.
At first you look back maybe six months to realize well if I could do that six months ago now I can't.
While I got your head soaking I'll go ahead and get you shaved.
Then it's three months. Then it's a month that you can look back and know that you've lost something. And now it's daily. When I go to the grocery store I'm worried about, is he all right while I'm gone. What is he falls out of the wheelchair, or what if he needs a urinal? What if, what if, what if. And we're out here in the country, and I have nobody anywhere close that could come immediately and help him.
Now, there are ALS people that choose to go on a respirator for it to breathe with them, and a stomach feeding tube when they can't swallow. And those people can live possibly ten more years with that type of help. I have chosen just not to go that route. Once I get paralyzed and can't move my limbs and I'm not going to take a stomach feeding tube or a respirator, then I really wish that I could probably go on and figure out how to die at that time.
What are your options?
Well, I'm not suicidal prone, and I wanted to live as long as I could, but I would like to have it legal to have physician-assisted, hastened death to where I would either take an injection or if I could swallow it all at the time, just go ahead and take some kind of deal that would put to sleep. And I would like to have my family there, and my friends.
If you could do what's best for you, what would you do?
Maybe a month to go I could have committed suicide with some drugs that veterinarians probably have. I probably have lost that ability. You don't realize how much you lose in a month. I probably lost the ability. Can I have some water, please?
So if you could, you would have some doctor come and quietly give you enough morphine to help you die?
Once I get to that stage, yeah, that was what I'd want.
When is-- when do you-- what stage is it where you say to yourself no more?
When I'm totally paralyzed up to the neck, can't swallow, and at that stage.
What can you do? What could you do?
I'm not sure what I'm going to do.
What would be a good death?
A painless death, where you just go to sleep.
And you've done that as a veterinarian for your animals, haven't you?
Many times.
He made the choice that if there's any way that I guess he could have assisted suicide, that's the way he would prefer to go. And he went to a lawyer and he drew up legal papers not to go on the respirator and not to go the feeding tube so that's out of my hands and out of the family's hands. But I could not, myself, give him a lethal dose of anything.
The Witchers have two grown children. Their son, Jay, lives nearby with his wife, Pam, and three kids.
Come on.
They're struggling to accept their father's desire to hasten his death.
It's getting to a point where he's just going to be able to lay in bed and that's basically it. And you can't expect anybody in that situation to have to choose between taking a non-painful way out or having to suffer by refusing life support.
You might take a flying leap. Hey. What are you saying for Opa?
[BABY BABBLE]
That's the mic.
I would want him to have another choice then my belief system does not allow me to believe that the other choice is right.
Opa.
Opa! Yeah, it's Opa!
Yeah, that's Opa.
In our community it's not an issue that I think has been discussed, physician-assisted suicide. It's just not something that's considered or discussed here.
OK. Wait a minute. Let me help you down.
All right.
OK.
With my dad, I understand and I know what's going on, but I'm not in his shows so I'm not dealing with those emotions that he has had to deal with. I'm dealing with my emotions that, this is my dad's, he's fixing to die, and I want him to be happy and satisfied with whatever he's doing, but as far as talking in the community, nobody talks about it.
Can you say Opa?
Opa. Hey.
Hey.
Although Jay and his family are close by, Suzie has been reluctant to ask them for help in caring for Jim.
Pam, Jay's wife, teaches school. She's got a one year old, and a little boy that's fixing to be eight years old and a 15-year-old daughter, and that totally keeps her busy. In fact, I don't how she handles it. And Jay--
[INTERPOSING VOICES]
Yes.
Jay has two full-time jobs. And, what we hate to do is take away from whatever little family time that they can manage to get together and-- maybe this summer when Pam's not teaching school they'll be a little more time available, but right now it's just really an imposition to them.
When I reach the point where I can't swallow or even where I can't move my arms and do anything, do my computer or anything like that, or come out and look at my horses--
[WHISTLING]
Come here.
What I'd really like is just figure out how to go on and get it over with because this is a terrible ordeal for me. It's been going on for the 2 and 1/2 years. And it's an even more terrible ordeal for my family. And I just need to go ahead and finish it.
[TRAFFIC]
I think the first thing that runs through your mind are all the things that you wish you could do, that you hadn't done. Hopefully, you're in a place in life where don't have a lot of issues to resolve with people. And, fortunately, I was in that place. I felt I was in a very good place in terms of my family. I think the hardest thing for me was to tell people that the time was short, and for them trying to deal with it because they went into a lot of denial. And in some cases still are. That's been the hardest thing.
They just can't face the world with you.
Well, that'd be nice to think, but it's just seeing me die means they face their mortality too.
Good morning.
Good morning. Thank you so much.
You're entirely welcome. Have a nice day.
Thanks.
Kitty Rayl is 56 years old and lives alone. Until recently she worked as a purchasing agent with an alarm company. 18 months ago she had a hysterectomy to remove cancer. At first, the prognosis was good. Then--
About nine months later, after the original hysterectomy did, I began to have back pain and sure enough I had uterine cancer, which when it spreads is, the way my doctor described it, he said, it's not a good one. It's not one that has a history of being able to be cured, and the time is not very good. It's usually very short. It could be a matter of months up to, the longest he'd heard, it was like five years, I believe. So I was hoping for the five years, and it's come much quicker than I had hoped.
You're not going to have those five years.
No, I'm not. In fact, I doubt-- I'm looking at months at this point.
Kitty tried three rounds of chemotherapy to slow the cancer. The last one, just two months ago.
That was when I started having a lot of discomfort.
The treatments aren't working and the cancer is spreading. Kitty's chosen to be at home with hospice care, comfort care.
Hi.
Hi. How are you?
I'm fine.
How are you doing?
Oh, I'm doing good.
Good.
Fritza, Kitty's hospice nurse, comes several times a week. She's especially concerned with taking care of Kitty's pain.
OK. So how are you really feeling?
Other than just week, I feel fine.
OK. The pain is less?
Yes. It seems good today.
And how about yesterday?
Yesterday was not a very good day. It really bothered me.
Mm-hmm.
But Kitty wants more than pain control at the end of life. Like Jim Witcher she wants to control the time and circumstance of her dying. She can do so under Oregon's Death With Dignity Act, which allows her physician to help her die when she's ready.
As you know Oregon has a law that allows us to decide that we can deal with this if we want, in that we can get medication that helps us to die. What I'm watching for is just when I'm-- I just can't, it's difficult because I don't know. I don't know what the point will be when I say it's time to do this, but I don't want to be become a vegetable. I don't want to become so that have to just lay and somebody has to come and spoon feed me. And I don't know.
You don't want to be helpless, do you?
I don't want to be out of control. I think that's it. You don't want to be out of control. I've always been the one who wants control over things and I want control over my decision to do that. And I just can't think of anything worse than being helpless and there being nothing you can do.
OK. Boy, it's up a little bit today.
Is it? Well--
It's nice. Have you been moving around?
I have a little bit.
OK. It's not because you're hurting?
No.
No.
What are the considerations you're weighing for when to choose?
I don't really know. You take it a day at a time. So far I've been able to stay at home.
And I'll listen to your heart.
I'm getting very weak. It's even getting hard for me to get in and out of bed. So, when you're getting to that place, you're starting to go, ah, you know, uh oh. How am I going to handle this? What am I going to do? I don't know at this point what will press those decisions of what the next choice will be.
Of course there's a gamble, isn't it? That you might reach that point where you can't do what you've planned all this time to do.
Yeah, it's happened. Yeah. And I guess you just deal with it, but I would hope that I know the point.
But you clearly haven't decided to go somewhere else, you want to stay home?
I would prefer that, yes.
You'd like to die at home?
Yes.
I understand that. At this moment, it's up to you, you could actually ask your doctor for the medication?
Yes.
And she would give it to you?
Yes. I can do it tonight.
Safely under the law she's protected?
Yes.
You're protected?
Yes.
And you're just-- every morning when you wake up you do you wonder if this might be the day?
So far, not yet. Although, it's starting to enter my mind more in the last week or so as I've seen my strength go and it get harder and harder for me to manage. I know the time is coming, but this is a good day. I'm feeling fine. I've got a good book to read. My daughter's coming over later today so things are OK. Look at this one.
As her illness progressed, Kitty and her youngest daughter, Jan, began to organize the family photos, a way of passing on family history.
I know where--
OK. That's Mesa, Arizona. And your tree.
Both Kitty's daughters support her wish to be in charge of her dying.
She talked to us about, I guess, just her thoughts about it and that she was looking into it.
What did you think?
Well, I wasn't shocked. I think that anybody in this position would probably contemplate that. It wasn't a big surprise.
Had you all been talking about what happens now? About how you're going to manage it?
We're just-- at this point, we're pretty much taking it a day at a time and how I'm feeling and dealing with living issues here. And I don't think at this point--
We've talked some what about care options, and if we get to a point where we might need to hire a nurse full time or that kind of stuff, but I don't think we've talked about when you would maybe make that decision. I think she has gotten a little bit better about letting us know what we can do for her.
Caring is just really being here for her?
Yeah.
When she needs you.
Yeah. And I think it's important to be able to bring Isabel over here as much as possible.
Yeah, bah.
That's the hardest thing, my granddaughter. And my daughters. You know they're young and just getting on with their life and they're wonderful. And I just I'm sorry I won't be there to go through life with them. I think you should have control over your life and dying is one of those things that's a part of your life.
And it's not as if you want to leave prematurely. I mean, you're trying to take every day.
I wringing every day out. Yes. Yes. I want every day that I can get. You know, it's when you reach that point where it's no longer bearable. And I don't know what that will be. Then I want to be able to make that decision.
Jim Witcher's body continues to whither. As his physical condition deteriorates, the financial burdens mount.
I guess about half of my estate that I'd build up probably is gone now. We had 240 acres and we've sold off about half of it.
This wheelchair probably sells for about $24,000. The van, if we bought that equipped the way it is new, would probably be about $45,000. We had to do some remodeling on our house for me to roll him into a shower and bathe him. You're looking at another $12-15,000. It's astronomical.
Jim's illness would have wiped them out financially, if they didn't have good health insurance. It covers 80% of their medical bills and weekly visits by a physical therapist, but it doesn't provide for someone to do for Jim what Suzie does. And nothing compensates for the emotional impact on both of them.
He's had to accept so much, and give up so much. He has sworn that when I have to feed him, he don't want to live any longer. You know?
Do you get depressed?
Yes, sir. I don't see how you could not. And I think that's just part of it.
What do you do for it?
Try not to cry when he can see me. Pray.
For Suzie, the sacrifices of caring for Jim on her own are many. Most of all, she misses going to church.
I cried Sunday morning because I was looking forward to going and I knew I wasn't going to be able to. I hadn't been able to got to the last Sunday and I wasn't going to get to go to the next two. and I was a Sunday morning, Sunday night, Wednesday night. If the church doors were open, I was there.
Do you have help, Suzie?
Not at this point. The more I have to do for him, of course, I do the yard and the house and the farm and the shopping, and it's getting to where I have less and less time during the day to do the normal, everyday things that people have to do in the course of living.
Who's taking care of the caretaker?
That's something that we haven't done, and we've got to make some big decisions.
He's trying to get me to do things, but if I were in his shoes to have a strange person or somebody come in and hold my urinal or wipe my bottom or, the things that you have to do for him, you know. I don't want him to be embarrassed that way any sooner than he has to.
The caretaker really has it probably tougher than I do because of the emotional thing attached to it. And then just the tremendous workload that he puts on them. And you put off having people come in, I guess, longer than you should. And we've done that and it's a mistake.
Eight months ago Jim almost died when a blood clot reached his lungs. He agreed then to let us his doctor do a surgical procedure to prevent future clots. It has prolonged his life.
Hey Jim.
Hi Dr. Blanchard.
How you doing this morning?
Fine.
Good.
But today he's come to see Dr. Pierre Blanchard with a different agenda. I need to know what my options are. I guess what I'm concerned about is when I get to where I can't basically do anything but breathe and barely swallow, and have to be just-- somebody to take care of everything I do, I'm concerned about where I go from there. And what you can do for me, if anything.
I mean, anything we can do as far as comfort care is concerned, I think we can do then. And I think we can talk about hospice at some point.
I don't know the hospice.
I mean, you obviously know exactly what hospice entails?
I don't.
Well, I think I do, but--
It's pretty good. I mean, they will keep you out of distress.
They'll even send you home with a morphine drip and if I can get to it or I pushed the button enough and everybody else is out of the room, well then so what? It makes no sense to me that you can do things like that and get away with it. And why we don't just change the damn law and get things different.
Well, I guess there's such a moral/religious issue here in the south, especially about suicide too that that's probably impeded some of the progress in those areas.
What would you do if you were in my position? What would you want done?
Well, I'd want to be kept comfortable, that's for sure. I don't know if I could say what I would do. I can only tell you what I can do as your doctor, but I can't always say what I would do as a person. I guess you have to be put in that circumstance. It's not really easy to say I would do this, or I would do that. I have a great deal of empathy for the things that are occurring, that's for sure.
Well, if the law were changed in Louisiana to be like the Oregon law, would you have any objection to that?
I don't know if I could kill somebody.
The only thing that I think is unfair is I'm going to have to do it before I would really, really rather do it. And that's not fair. I'm going to have to do it while I can still swallow. And while I can still hold a straw, something like that. And there's no law against somebody putting something out in front of you. And then me doing it. There's nothing wrong with that.
No.
Because that's me committing suicide.
Yes.
And it's just I will have to do it before I really want to.
Well, I think there are definitions of discomfort and I still think that my experience with hospice has been that we can do things for people that don't keep things moving along for long periods of time. You just have the trust me for that because I've seen it.
So the law will help me die slowly.
Well, not in five seconds, but certainly not I don't think dragging it out.
OK. Lord, I understand the position you're in. And I know that. I just think it stinks. Just to be real honest with you. It's just-- it's not a mature way to look at certain end of life situations, such as mine. It's not a mature way to look at.
But as your physician, it would be hard for me just to absolutely take you away and it be my responsibility to shoulder that burden. I can assist you in making things comfortable. I can't really assist you in killing yourself. I think we should be all right.
All right.
Are you having any respiratory problems? Breathing problems?
None, except the fact that I can't sneeze and cough like I used to.
What strikes me is that Jim Witcher is my age. And when I look at him, I see a reflection of myself and ask what would I do.
Well, he asked me that too. And I said, well, I don't know. You never know until you're put in that circumstance, and that's not evading the issue. It's easy to agree with somebody if you want to, but I really don't know what I would do. I like life, but I don't know if I'd like that kind of life. I don't see much vasiculation, really.
What could you do for Jim?
I think that we can help give him support. We can help his wife by getting him help, to help deal with him as far as his activities of daily living. I think if things progress to the point that he is in any distress that we can give him medicine that will make him not be in respiratory distress.
Can you squeeze? A little bit there.
But he then loses control over that decision, doesn't he?
Yes, he does.
And he seems to me to be struggling for control. He wants to control--
He wants that, and he wants more than that. He wants more than what we're describing. I think what you say is true. He wants not for me to control the circumstance, he wants himself to be in control, and to dictate how things go when that time arrives.
Is that an ethical problem for you?
It is.
Well, you took an oath to save people not to kill them.
That's very true. I guess included in that oath, too, is to make sure that people have comfort and dignity in the way that their illnesses are dealt with too. So there's a little bit of a play there between those two.
If you were free to help Jim, if the law were not in your way, what would you give him? Morphine?
Yeah, I think the most direct way is potassium chloride. It's not painful, it stops the heart, and it's quick.
But the law says--
That would be a real no-no.
That would be--
Because I know that we give people in terminal circumstances morphine drips and whatever they die from we attribute it directly to their illness, but I guess the reality is that morphine probably contributes to it when you have to get to a high enough dose to suppress the breathing process.
I think if I were the doctor I could give him the medication, but I couldn't help him take it.
I could do that. I could do that.
You could give him the medication?
I mean, I could say, just, this is for comfort or whatever and he can do with it whatever he wanted to do.
Dr. Nancy Crumpacker has been a cancer physician for more than 20 years.
I've seen 50-100 patients die a year, my own patients. So I saw quite a bit of the end stages, and watched some of those patients go through what they considered suffering. And maybe that was not what they wanted.
Kitty Rayl has turned to Dr. Crumpacker for help in dying. Under the Oregon law, she can assist Kitty with advice and medication.
I'm getting weaker.
Oregon's Death With Dignity law requires patients to have a six month terminal diagnosis before a physician can help them die. Two doctors must confirm the diagnosis.
This back pain, you know, sometimes it's so bad that I really have trouble getting from--
And the patient must be mentally capable to make the decision.
It hurts.
Do you find that most of your patients are more afraid of pain than of dying Itself?
Yes. The conversations don't rotate around the actual death itself.
But the getting there.
But the getting there is. How we are we going to get there?
When I'm looking at myself, I'm going I can't do this anymore. I can't manage anymore. I can't get from one place to the other any longer. And it's coming.
Kitty first met with Dr. Crumpacker several months ago. Together they've completed all the paperwork necessary to apply for the medication that will hasten Kitty's death.
It's a matter of you getting on the phone and calling me, letting me know what your thoughts are. If you--
Then I need to talk to my daughters and find out whether they want to be here.
Right.
So I need to take those steps.
I can't participate unless I feel that she has thought about this, not just today, not just yesterday, but that it's something she's given a lot of thought to maybe over the years. And at least since she's had the cancer diagnosis.
You know, it's difficult for me to know at this point what the actual moment's going to be.
How can you predict? Yeah.
You know, and I guess I need to have in my mind that it's going to be a time that's available for you or I mean that's-- I'm a little--
When you've made up your mind that that's what you want to do and sort of have a time frame in mind, give me a call and we'll--
Work it out.
We will work it out.
OK.
Yeah. And, obviously, if you call me and then you get something set up and you decide at the last minute you're not going to do it--
Sure, I understand.
You are fully--
In control.
In control. You are in control.
When she chooses to end her life, if she does--
Is he does.
How will she do it?
She will take a prescription of barbiturate. And it's about two tablespoons of a bitter powder so my job is to try to make it not so bitter. And we just mix it in water and add a bunch of sugary syrup, something to kind of hide the bitterness, and you can swallow it in less than a minute, people do that. And swallow it in less than 30 seconds. And that takes effect and people go to sleep usually within about five minutes. And then they comfortably-- they're in a coma, then they die.
And the signs are that it's peaceful?
It's very peaceful.
And you will write that prescription when she calls.
Yes.
Will you be there when she dies?
You bet.
You'll mix the medication for her?
Mm-hmm.
Is that consistent with caring for the dying, when you're actually helping them to die?
If that's her sense, or anyone else's sense of suffering, that's what I want to do, is relieve that suffering. I am hastening an inevitable death of a terminal person who's competent, an adult, an Oregon resident.
Which means it's legal.
And it's legal.
Dr. Crumpacker was not the original cancer specialist to oversee Kitty's treatment. Dr. Kevin Olson was.
Hey Kevin.
They're colleagues in the same office.
What's going on with Kitty?
But when Kitty looked for a physician to help her die, she didn't go to Dr. Olson. She knew he was opposed.
I don't feel like I can actively participate in an assisted suicide situation. I can't write the prescription. I'm happy to talk to patients about what their issues are around that, but I just didn't feel I could or should be the one that actually does this.
Help me to understand why that's so.
Well, I think I haven't been trained in that fashion. I don't feel like I'm competent, but I think more importantly, my own moral framework is such that I don't think that I could do it and feel good about doing it. And feel that I was actually helping the situation. I mean, it might be somewhat arbitrary on my part, but because certainly I've given extra morphine to a patient who was in pain knowing that maybe that extra amount of morphine might be something that would hasten their death. But something visceral inside of me just tells me that this is probably not a direction I should go personally, and so I haven't.
Is that a matter of religious conviction to you?
Well, certainly, I spent 14 years in Catholic school so I'm well versed in the religious issues, but I don't know that it's because a priest or somebody tells me I need to do this. It just doesn't feel right to me as--
Is it your oath? You took an oath to save life, not end life?
I don't know. I don't know how to-- the oath really isn't the issue. It's just a matter of, at the end of the day when things are done and would I feel good about what I've done. And I just didn't think I could feel good about doing that myself.
Dr. Olson does oversee Kitty's hospice care, including her pain medication.
One of the issues that comes up a lot when you talk about helping patients die is that patients will worry that when the going gets really tough maybe the doctors or the family members won't have enough guts to do the right thing and give them the medicine that they need for fear of making things go wrong.
And here we have the amitriptyline.
The Oregon law is controversial, but all sides agree it has led to the use of more pain medication for the dying. Oregon has the highest per capita use of morphine for pain control in the country.
I always tell patients that if I'm ever going to err, I'm going to err on the side of giving you too much rather than too little because that fear of a painful death, of being in pain and not being able to do anything about it, is really an overriding issue with a lot of dying patients.
Have you used any of the Dilaudid since I was here?
I took some this morning.
OK. You did. How about yesterday?
Yeah. I took some yesterday.
When you were having so much pain?
They think that I would be able to get some of the pain to go away if I took more of certain ones of these, but they are just knock you out.
You use four of them each time then?
I was using three.
OK. Remember, I kind of suggested that you may take four.
I want to be able to read and be aware and I don't want to sit and sleep all day long. Or just doze off. I don't want to knock myself out. So we're trying to find something that will give me the quality of life I want and won't just totally knock me out, but we haven't gotten there.
Otherwise you have that nagging, lingering feeling of pain all the time.
There have been occasionally times a patient in the hospital, the nurses will say this he's clearly restless, he's delirious, and we're not sure if giving him more morphine might make things worse. He might stop breathing. I've not worried about that. I've said, listen, we need to make that patient comfortable. Sometimes the only thing keeping them going is that painful stimulus. And you relieve the pain, and they die shortly thereafter, but I feel in my heart that it wasn't me that took that patient's life, it was their disease process. And all I did is help them be comfortable in the last moments.
Is it a matter of control, you want to remain in control? As the doctor.
Well, actually, I mean, I'm happy to give the patient their own pain medicines and let them choose how to use it, but it's not so much that. It's that if my mission is to make them die that's a little different than to make them comfortable. And that's maybe where Nancy and I differ a little bit. Nancy doesn't see a distinction between that and--
What about that [INAUDIBLE]?
I don't see a distinction. I see the hastening death with a prescription by a patient at his or her home as actually a much better situation because then it really is, hopefully, all in the patient's control. In Kitty's case, I'll go out there, if we've arranged a time I'll say, Kitty, are you sure now's the time? I'm going to give her plenty of chance to doubt and to change her mind. There's probably a dozen patients I've had conversations with who have gone through all the steps who we've never gotten to the point of writing a prescription. They wanted to know that they could have that if the time came that they really wanted it.
The last time I talked to her she said she wasn't sure if she would follow through, but she liked the notion that she has the option if she wants.
I called hospice--
The key thing, I think, if patients are going to go this route is that they need to have a doctor who will take the time to really work through all the issues. And to really make sure that all the other avenues have been explored before they go into this realm. And Nancy's exceptional in that regard.
Thanks for coming over.
OK.
It's really good to see you.
Thanks.
I think the last time--
I cannot imagine taking that last act in which I'm taking something that I know is going to be the last thing I do.
I know. It's really hard. It would be hard. And obviously, you put it off to-- I'm not sure what's going to press that button and say, it's time. I can't tell you that. It'll just come. And we'll do it.
Jim Witcher wants to control the time of his death, but can't because of the law and his family's religious beliefs. Kitty Rayl has control, but doesn't know when she'll use it. More often than not, it's the doctor and loved ones who must decide for the dying. It's never easy. Some hard choices now confront Dr. Carlos Gomez at the University Hospital in Charlottesville, Virginia. One of his patient is terminally ill. And the standard amounts of medication are not easing his suffering.
Ricky are you hurting this morning?
A little.
A little? Do you remember who I am?
Ricky Tackett is dying of liver failure. He's only 44 years old.
You know, yesterday he acted so calm, and not at all what I was seeing at home, but it come out last night. That's what I had been dealing with.
Delirium? Agitation?
I mean, just, you could not get him--
Ricky's wife, Rose, has been caring for him at home with some help from visiting hospice nurses. But he's become too agitated for her to handle.
We went back up on the Dilaudid over night, and I went back up on it again this morning. I called Karen at 7:00. He's back up to 34.
He's getting quiet. He got really combative just a minute ago.
Ricky? Can you wake up enough to talk to me for second? Are you hurting in your belly right now?
Dr. Gomez is trying to determine the exact amount of pain medication to keep Ricky comfortable.
Does that hurt?
But he has another consideration. He's also trying to keep Ricky conscious enough to communicate with his wife.
He's gotten two good doses of his Dilaudid.
It's not working.
We've got a decision to make in terms of his level of consciousness. Part of the delirium is the medicines that we're giving him I'm afraid. I think when we back down he starts to get agitated. I don't want him to have that kind of agitation.
Wait a minute. What a minute.
[MOANING]
OK. It's all right.
And--
Let me hold your hand.
It seems to work for a little while so I'm just going to double the medicine right now. So he got [INAUDIBLE] just when?
Just now. I just gave it to him.
Just one milligram?
Mm-hmm.
Let's go ahead and give two.
OK.
OK. Ricky? I'm going to come back a little bit later on and talk with you, OK?
Sure.
OK?
Sure.
You said in there we have a decision to make. What's the decision?
The decision is there's a fine line between trying to keep him awake enough to be conversant and controlling his pain. And we usually are very good about that, but he's encephalopathic at this point. He's literally out of his mind. He's delirious. And part of his agitation, and part of his suffering, is the delirium. It's not just for him, but for his wife.
And so we tried to back down on his pain medicine yesterday thinking that he was too somnolent. He woke up a bit. I was actually able to talk to him, he recognized me. I got a call during the night that he was in pain and we started going up on his medicine again. And then this morning I called again, and he was still in pain, so we went up on his medicine again.
We come in there now, and I can't elicit pain. I palpated over the site, and he's not tender there, but he's clearly delirious and he doesn't recognize me this morning. So what do you do at that point?
And wouldn't the humane thing to do to really relieve the pain, just let him sink into unconsciousness.
Yes. Yes.
Can you make that decision? Or does his wife have to make it?
I think we make in common.
It's worse than you thought it would be?
I just stepped back and let them do it. And it's hard.
You know, you can be part of this any way you want. You know--
I know.
some days you could be more involved, and other days you can step away. We understand that.
But I also want her to be engaged in the decisions. I think we're reaching the point where the best that I can do for him is to sedate him. And let him die. I would prefer that he be alert and talking all the way out to infinity, but I can't do that.
What's the difference between this decision to sedate him and let him die, and what out there is called physician-assisted suicide?
That's a great question. There are several differences. One is an intent. I don't want this fellow to die. And I'm not trying to will his death. And I'm not actively trying to bring it about, but I'm also not willing to let him sit there and suffer. And is there a hypocrisy here? There may or may not be. Creating a myth, it makes me feel better about what I'm doing, that may be true, but there's a line that I'm very firm about and Rose knows it. His wife knows it and Ricky knows it, which is that I'm not going to do something to bring about his death, as a result of my actions, direct as a result of my actions.
Did we change-- oh, we must have changed the Dilaudid orders last night.
Am I willing to do things that may hasten his death? Sure. I'm not willing to give him fluids at this point. I'm not willing to put a feeding tube in him, for example. I'm not willing to treat infection at this point. Are all those exercises in assisted suicide? I don't think so. I mean, it's a language that I'm not comfortable with. I think one of the first principles of medicine is you do no harm. And if you can't act to make patient's life better, you step back and do something different. There's nothing medically that I think I can do at this point to make his life better. But I damn well can control his pain, his delirium--
You can make his dying better?
I can make his dying better. Absolutely. Not just for him, but for the family.
I just wanted to talk about what's going on with Ricky right now.
Before Dr. Gomez decides exactly what to do, he will try to understand clearly Rose's wishes and those of her dying husband.
The thing that I think is painful for all of us to watch is when he gets out of his head like that, his delirium. You kept saying he's not Ricky and you're right, he's not Ricky. The only way that I know how to control that right now is to sedate him because when we've tried to lighten up on his medicine he gets completely out of control. What it's going to mean, though, is that Ricky's probably going to be unconscious until he dies, or at least in and out of consciousness.
He may respond by squeezing a hand. He may intermittently look at you, but he's not going to be thrashing about the way he has been.
When he's violent, and all, he's not Ricky. And he can't control that for whatever reasons. And he's not been himself in a while. Occasionally, a few words, but then he's back to not being himself. And he wouldn't want to be that way. We discussed this when he was very clear headed. He wouldn't want this.
When he went back to Kentucky this last time, he'd been pretty clear with me that he wanted to have some time at home, walk through his church, say goodbye to his congregation, and so on. Was he able to do that?
We had about four beautiful days at home. He went to church. We stayed through the meeting. He didn't participate but he was there. Whatever made him feel he had to do though he got to do it. And sedation is welcomed, I think he would want that.
Yeah. I agree. It's always a tough call because the hope is always that you're going to be able to have some more quality time with somebody. And there comes a point where, it sounds like-- whatever Ricky felt like he needed to do he did, and it sounds like whatever you needed to do with Ricky you've done also.
Did you talk to him about dying? Did you two discuss it together? Openly? Honestly?
Yeah. Yes. I think the two weeks we were here before he had the opportunity to have a very good conversation with all his family, people in the church of what he wanted. And I think they had the opportunity and I hope that they would be satisfied with that time they got while he was of clear mind. And he poured his heart out to everyone, including Dr. Gomez. He's suffered enough. And he's tired and he wants to go home.
He's prepared.
Yes, but his body won't let him or something won't let him, you know? I don't know.
He was a minister?
Mm-hmm.
He is a minister.
Yes.
So faith is clearly--
He has a better place to go in our beliefs and that's why--
Does that make it easier?
Yeah. That is the only thing that makes it better for me. And he's tired. He has a right to say I don't want no more and I think we should grant him that. He's tried for us and I think we should give it up for him.
Everyday more of Jim Witcher's nerve cells shut down. His spinal cord degenerates. His muscles waste away. Are you any closer to a decision since I was here a month ago?
Of course, you know, you can talk big, but the doing it's a different thing, but my intentions are at the point to where I begin to really have trouble swallowing and before I lose the ability to sit in a wheelchair like this, I intend to go ahead and take some drugs.
Do you have those drugs?
Yes, I have the drugs. I'm a veterinarian and have a narcotic's license. You can always make a mistake, I guess. I think I have exactly what I need.
But if you wait, is there a danger that you might miss the moment that you won't be able to swallow it?
Sure. I know I can do it now. I want to live a little while longer so I'm going to push the envelope as far as I can.
If you missed the moment and you are unable to do it, would you want Suzie to help you?
No, because she couldn't do it. And she would feel guilty forever after. She would feel like a murderer.
Could I put the poison to his lips? Not now.
Hey, come here, Garrett. Get on this knee. Hey, boy!
The Witcher's daughter, Marcy, has come from Maryland with her husband Joe and their three kids.
The last time that they were here he cried and cried and said he didn't think he'd probably ever see them or his grandchildren again.
I love you.
How you doing?
I'm doing fine.
Now, Marcy, I do have those juice things out there too so-- whichever.
It's not just him suffering, it's the whole family because we're watching him and I know what he wants to do, but I don't want him to do it. But I want him to be at peace. It's a struggle trying to figure out, OK, do I side with you or do I side with my heart? Or do I side with what society says should be? Or what the legal system says you can do? I'm still struggling with what I feel.
Our Father, we thank Thee for these and all our blessings. Forgive us our many sins we pray, for Christ's sake. And dear God, thank you for letting us get back down here to visit with out family one more time.
I think all of us have an idea of what we think we'd do in a situation and when it comes to that time, we may change our mind, but he said when I get to where I can't do anything for myself anymore. Well, the first thing he said was when I can't wipe my bottom myself I don't want to live. The next step was when I can't feed myself I don't want to live. Well, I'm having to feeding now. And he still wants to live. He still wants to see his grand kids. So far as having said that by such and such time I'm going to, he has not set another deadline to meet now.
But now that I can't raise my hands, I'll get a bug or an itch on my nose, and I just have to-- it's just mind over matter.
I'd never make it. He is worried that he's going to have to be able to administer whatever he chooses to do to himself, and he's going to have to do it before he is totally incapable of doing it.
He would have to swallow it himself?
Yes, sir.
But with his hands--
I know.
How can he get it to--
I don't know. I don't know and I don't know that I want to ask. You know?
You haven't asked him?
Yeah, I have. And he hasn't really said so I don't know whether he's got something in the back of his mind that he thinks he can do or what. And it's not something I really want to talk about, you know? And I know I need to and probably need to for his sake, but I'm guilty of keeping just as busy as I can around here so I don't have to face it. I don't know how to explain it to you, but--
You're doing a good job. You mean, you just don't want to think about that moment?
Right. He's asked me if I want to be there when he dies. I don't know.
Getting a little reckless there, Davis.
Sassy! Sassy!
Yes! It's Sassy. You're right!
He wants his life to end--
Peacefully.
On his own terms.
On his terms instead of on the disease's terms. And I understand that, but who says you get to decide?
Do you remember Spirit?
Spirit remembers me too>
That's Spirit. I think that Spirit does remember you.
The spiritual side of me says that's God's decision. That's between you and God, dad and when God deems it necessary, then that's when it's going to happen.
Remember Sassy? Hey Spirit.
I always understood that suicide was wrong, was a sin, and it was not a moral thing to do. Dealing with this situation it blurs the lines.
What I'm talking about is my choice. This is what I want for me. And the only other thing I want is for society and people to talk about it, plan about it, plan their own, decide for themselves.
To assure that he's not kept alive with artificial means, Jim has signed a living will. Suzie knows what can happen without it.
My mother died of ovarian cancer. I remember when she got to the point where she could not eat anymore, and she refused to eat, I begged the doctor to put a Broviac tube in her because I was still fighting to save her. That meant she had to be taken into surgery, and have that inserted. And it probably might have bought her four weeks, you know, who knows. And looking back now, I'm so sorry I put her through that. It did not make her quality of life one bit better. I should never have done that. And I'm not going to do it to James because he's legally taken steps that he won't take it.
I saw my mother suffer horribly and it came to a point that I wished I could do something. I don't think I'd ever had the guts to help her die, but I feel really terrible that I sustained, you know, that I made her miserable for that many more weeks. And that's just no way to go for anybody.
The decisions doctors face with dying patients are not often addressed in medical school.
Ricky is back in the hospital.
Dr. Gomez wants his first year med students to start thinking now about how people die, and the issues that they will face as doctors.
He's intermittently lucid, but really not very well focused. I don't think he's in so much pain as he is delirious. His liver is basically shutting down. And Rose is there with him, his wife. He will probably die in the next two or three days, is my guess. He's not getting food. He's not getting water. He's simply getting pain medicine and something for his delirium. So, the question is--
Hi Ricky.
what am I doing for what purpose?
How are you?
If I felt that we could sustain Ricky's life in a way that he would want it sustained, this case would be entirely different. He says that he's ready to die. Now the question I've got is what am I going to do with IV fluids and nutrition? What am I trying to accomplish? What is his wife trying to accomplish? I think--
The students hear from Dr. Gomez that he's no longer providing fluids or nutrients to Ricky Tackett.
It just seems to me that that's almost assisted suicide.
Why?
Because water and food is just such a vital-- I mean, obviously, you have to have it every day. And it just seems like that's the same thing as taking away medications. You're taking away what he needs to live.
The level of responsibility that a physician feels about end of life decision making--
Susan Goins-Eplee, the university chaplain, teaches this ethics class with Dr. Gomez.
But yet, you're saying, if I remove hydration then I've done something that's going to hasten his death and you feel responsible for the fact that this man is dying. And you're not. He's dying because he's sick. And there's been a lot of intervention in between when he started to die and when he's going to die.
I don't seem to have much of a problem withdrawing ventilator in person in his condition or other cases that we've discussed, but especially hydration and somewhat nutrition, I feel a little uncomfortable with that. And I can understand if it's going to be an invasive procedure where you've got to put in a central line, you've got to put in a feeding tube, all those things. I understand not doing that because that's invasive. But the hydration seems like something you can do.
I will bet you that if I hydrate him or try and hydrate him most of the fluid is going to go into his legs and his lungs because he doesn't have enough oncotic pressure in his vascular system to hold the fluid in.
At least at this stage of the game, you feel like you're training to preserve life. Where you learn about-- you're learning everything that works in the body and that's your goal. And you know that's dying is part of it, but facilitating it or even accepting it, I don't-- you have to learn to deal with it somehow, but it's not something it comes right away.
So if you want me to explain--
Dr. Gomez holds off another night. Trying one last time to fine tune Ricky's pain medication. It still isn't working.
Last night, he doesn't know what he's doing, and he's got both hands trying to break my arm. And so I'm like, I'll step back and let the nurses do it. Maybe I'm agitating him. And I actually laid the cot out in the bathroom and tried to lay in there and I had to watch them try and use the restraints and hear him scream. You know, it was like, we have broke horses, and it was a whole lot like trying to break a wild horse. You know what I'm saying?
I do know what you're saying. I don't think it's a pain that's causing his agitation. I know he intermittently complains of pain. I'm not sure that that's what's doing it. I think it has to do with his liver failure. OK. So, Ricky. I can do almost anything I want as a physician to try and sustain his life and I will ultimately fail. If, on the other hand, the goal is more modest and different, and it has to do with accepting the fact that we are all mortals and that there is something, in fact, absolutely natural about the fact that we die. And that people whom you take care of as their physician are going to die then it begins to raise all sorts of different questions. Not that the hydration question isn't important, it's actually very important. And if you feel a little morally queasy which is what I think you're saying, I think it's a good thing. You should feel a little queasy. You should feel a little uneasy. It should make you think twice about what you're doing. These decisions should never be automatic or pedestrian because they're not. They involve the life of another human being.
Ricky was really clear with me that the one thing he did not want was to go out in pain or suffering. He was just very-- I mean, you heard it-- I'm sure many more times than I did. So, Dr. Korman and I've talked about it, I think this is probably the best solution. I want to sedate him but sedate him continuously rather than the Ativan every few hours, I want to put him on something that is like Ativan. It means that there's going to be no more waking up. OK? Even for the delirious stuff. That won't be there.
I would welcome that.
You would welcome that?
He doesn't want to be this way. That was his greatest fear, was having- he knew with liver failure the death you had to die.
We don't need to die like that.
Let's let him rest and let you rest.
That sounds fine.
All right.
The decision to increase Ricky's pain medication and withdrawal fluids and nutrition invites death through the door. One by one we die. Just as every life is a particular life, so each of us dies our own death. No matter how we plan for it we can never know for sure how death will come.
Nancy Crumpacker came by today, and we just had a little chat. She was talking--
Kitty has gathered her daughters, Jill and Jan, to talk about her last act and decide who should be there.
I guess I haven't really thought through are we going to have like everybody here, do you want to be here? Do you not want to be here? Nancy does want to be here and that kind of thing. So, I just-- you know, that kind of stuff.
Mm-hmm.
just think about it and talk about it later.
OK.
So, are you comfortable with that? OK.
I had already said that I thought I'd want to be here.
Yeah. I would too.
The other thing would be if you didn't want us here, which I can't imagine--
Oh, no. That's-- yeah, that's totally not good.
I mean, I think that would-- that's kind of a given at this point.
You're just so ready to crawl. You're just so ready. And then your mom and dad are going to have their hands full.
Do you think about what's on the other side of death? If there is anything?
My belief is that you come here to resolve issues with the people that are around you. And that you come back when you haven't resolved that issue because you got to do it again. You got to get it right. When you run into people that you've never met before and it's just like they're a soulmate. You can't believe that you have so much in common and that your thinking is so the same. Well, you've probably been with that person in a prior life. It works these issues out. I've got issues to work out with some of my family members. So I'm going to have to do it again. And I hope I come back with my daughters and my granddaughter.
There's a lot of things on the caretaker that I don't know whether anybody realizes it, but I get so tired and I think I just wish this were all over. I wish I didn't have to go through this. I want this to be over. And then I think, but that means he has to die. And then I feel guilty for having those feelings. When it's that person's desire, that if all possible they could have a physician-assisted, dignified death when there's absolutely no hope I think it's a kindness. I think it would be an act of love.
But the law won't let Dr. Blanchard love that way.
Or me, or his son, or his brother. Instead we're going to be asked to watch him suffer. An he will die an agonizing death. I mean suffocation or starvation. Both.
So at this moment, Suzie, you don't know exactly what you're going to do with the moment comes and he says I need help and I can't do it myself.
No, I don't.
You can always bear witness to somebody suffering, but there is something very powerful about your presence as the doctor in the room with the patient who is dying.
Ricky Tackett's suffering is about to end. Within the next hours he'll be terminally sedated. He died five days later. Kitty Rayl didn't get the months she thought she had coming. She died within two weeks of our last visit with her.
It became harder and harder for her to get in and out of bed and get in and out of her chair. I came home one day, and the hospice nurse was there doing something that she really didn't want to have done, it was really uncomfortable for her.
She said to us that she'd finally just got to a point where she felt like she had no dignity left.
And at that point she said I want to go ahead and do the pulls and I want to get on with it.
She said, call Nancy. I'm just ready. I'm tired of this.
Right.
When Kitty asked her daughters to call Dr. Nancy Crumpacker to bring the medication, Jill convinced her mother to wait until morning because their Uncle Tom was on a plane to Portland to see her. By the time Dr. Crumpacker arrived the next morning, Kitty could no longer swallow.
The thing that was really hard for me was I had been the one who said let's wait for Tom. Let's not take them right now. And then suddenly it's too late. So I had some guilt there about that.
But in the meantime uncle Tom had arrived.
Yes.
He had.
She spoke to him--
At that time it was too late to administer the medication.
So we kind of all just sat there and held her hand. Jill and Trish were on one side, and our cousin James and me were sitting on one side. And our uncle and Gerry, the other friend, everybody was just sort of gathered around and then finally there was just that last breath and--
You knew it.
Yeah.
Did she die the way she wanted?
I don't know. I don't know if she did.
The way she managed it did enable her to be surrounded by family, to be relatively free of pain, and to be at home.
See, in all of those ways I think it was the way she wanted it. You know, that final--
That's true.
48 hours.
That's true.
The seasons have turned at the Witcher farm in Louisiana. It's been six months since we last saw Jim Witcher. And now he is dying the very death he didn't want.
It is getting harder and harder for him to swallow. And he gets very tired chewing.
The creeping paralysis of ALS has reached his lungs and throat and the muscles of his diaphragm. If he sits up he can't breathe. And because of his difficulty swallowing, he isn't eating solids.
About ready for some more to eat?
One more breath.
Two weeks ago he had a crisis.
I came into the room and found him blue.
Suzie rushed him to the emergency room in town, 45 minutes away, but he still wouldn't take a respirator or a stomach feeding tube.
You're almost done.
Dr. Blanchard sent Jim home with an oxygen tank and hospice care.
What happens to you when you start to die is there is an inborn influence in you that tells you you've got to breathe.
Hospice workers visit several times a week, but Suzie still does the lion's share of the work, getting him up every day in his chair. Recently they hired a neighbor to help relieve Suzie who was buckling under the stress.
You want me to take your legs over?
She comes two days a week at their own expense. And what does Jim want Suzie to do when his next crisis most surely comes?
I want to try to honor his wishes and I won't. I won't call the ambulance or anything. It's not going to be easy. In fact, I guess it'll be the hardest thing I'll ever have to do. You know, I wish I could keep him alive. But I don't want to keep him alive suffering, either.
I love you.
I love you.
After our visit, Jim Witcher made a decision to refuse medication and food. By the end of the week he died. Suzie scattered Jim's ashes over the horse pasture.
On our own terms continues on the web. Explore the issues, share your stories, and hear from others. Find resources for help at PBS.org.
In the next episode, A Time To Change.
What would happen if you had to pay for this care yourself?
I'd be put out in the grass and go ahead put me under the grass.
My goal is for people to be able to die peacefully.
We can't make good deaths, but we can make better deaths.
We, the people, own the care system that we're now very unhappy with, so we could fix it.
Funding for this program is provide by the Robert Wood Johnson Foundation. Making grants to improve the health and health care of all Americans. The Fetzer Institute. Supporting program that explore the mind, body, and spirit. The Nathan Cummings Foundation. The Kohlberg Foundation. The John D. And Catherine T. MacArthur Foundation. And by the Laurance S. Rockefeller Fund.
Corporate funding is provided by Mutual of America. Building America's future through tension and retirement plan, encouraging dialogue and discussion. The Spirit of America, Mutual of America.
Full Program
A Death of One's Own
1h 27m 2s
Segments
Continuous Play
Death and Dying
2m 23s
Chronic Disease: Progression of ALS
6m 44s
Chronic Disease Treatment Choices
3m 16s
Assume you have been called as an expert witness in a court proceeding. What considerations or limitations does the APA Ethics Code place upon you in terms of what you may disclose as part of your testimony? What potential challenges might this present to your professional relationship with your client?
Why do you believe the security of confidential therapy and health records is important to the ethical practice of psychology? What is the role of HIPAA in regards to the confidentiality of records?
Ch 9
What expectations does the APA Ethics Code require of researchers? What types of activities does the code specifically prohibit? Do you agree with the prohibitions? Why or why not?
