The Truth about Terminal Dehydration

In Wikipedia under the title "terminal dehydration" we find the following statements, "There can be a fine line between terminal sedation that results in death by dehydration and euthanasia." Also: "In the Netherlands, debate has broken out about terminal dehydration, which is referred to as versterven. There have been accusations that involuntary dehydration takes place in nursing homes."

This is no surprise.  It happens here, in the U.S.

Health care in the United States is facing a financial crisis. A recent study estimates that 27% of Medicare's annual budget goes to care for patients in their final year of life, or "end-of-life."  As Congress continues with the full implementation of Obamacare, America's Affordable Health Choices Act, health care reformers are looking for ways to reduce the end-of-life cost in America.

Nine and a half months after his grandmother's death, President Obama said in a town hall meeting that he took offense at the idea inferred by critics of his health care plan, that he wanted to "pull the plug on grandma."  This has become one of his famous quotes.

The requirement and use of end-of-life counselors referred to as "death panels" may have been taken out of America’s Affordable Health Choices Act, (although this is assumed and not verified), but the use of terminal dehydration to end a life becomes increasing more prevalent today.  The question is, and has to be, is terminal dehydration always voluntary?  How will the nation's new health care law use "navigators" in regard to this issue?  When morphine is administered carefully to sedate a person, rendering them incapable of drinking water, but not heavily enough to stop their breathing, is this palliative care or terminal sedation?

During the tenure of President George W. Bush, the use of a planning document that presented end-of-life choices for veterans was suspended. The document entitled "Your Life, your Choices" is now reported to be the Veteran Administration's preferred living will, promoted in hospitals and nursing homes that serve wounded warriors.  It provides a worksheet that lists circumstances common to the elderly and asks users to consider if and when their own life is not worth living.  The list includes living in a nursing home, being confined to a wheelchair, and not being able to "shake the blues." 

In an article published in the Annals of Internal Medicine entitled, "Voluntary Death: A Comparison of Terminal Dehydration and Physician-Assisted Suicide," the doctors note the advantages of terminal dehydration.  It "...offers patients a way to escape... without requiring transformation of the law and medical ethics."

Medical practitioners may supply intravenous doses of opioids providing the intention is to relieve pain, rather than to kill.  It is the principle of double effect, and is the treatment that hastens death.  It has been described as "a real and essential phenomenon in end-of-life care."

The doctors conclude, "No adult of sound mind should be forced to endure an existence that he or she rationally considers to be intolerable...  We do not view legalization of physician-assisted death as a matter of individual rights... The already available option of terminal dehydration deserves careful consideration as an alternative to physician-assisted suicide."

In the state of Oregon, physician-assisted suicide became legal in 1997 by a voter margin of 60% in favor of the new law.  Under "The Death With Dignity Act" ending one's life in accordance with the law does not constitute suicide.  Proponents refer to the law as a "wake up call" for the medical community.

But, the law has regulations in place to prevent the coercion of a sick person.  The law requires a diagnosis by two physicians who will confirm that the subject for death has a terminal illness that will lead to death within six months.  The patient must make two oral requests for the lethal medication, separated by at least fifteen days.  Furthermore, the prescribing physician and a consulting physician must confirm the diagnosis and prognosis and if either physician believes the patient's judgement is impaired by a psychiatric or psychological disorder, the patient must be referred for a psychological examination.  The prescribing physician must also inform the patient of feasible alternatives to assisted suicide including comfort care, hospice care, and pain control.

Because terminal dehydration is not legislated, there are no such restraints or precautions, and no such restrictions to its use are in place or practice. The truth is, terminal dehydration needs to be regulated also.  The same regulations used in assisted suicide should be used in terminal dehydration and terminal sedation. It could be argued that the use of terminal sedation, as prescribed in terminal dehydration, is really physician-assisted suicide in disguise.  And this is largely illegal in the U.S.

Could it be that Uncle Sam will change his costume and play a new role, and that it will be the Grim Reaper?  This is truly a scary thought.

Once the killing begins on a wide scale, and it already has with terminal dehydration, where will the boundaries be set, or limits established?  Are the injured or handicapped of all ages in danger of termination?

The treatment of a terminally ill cancer patient represents a different debate and should not be used to justify the termination of the elderly or injured. This is the most difficult of situations to discern. The terminally ill cancer patient has had a  physicians care similar to that required by The Death With Dignity Act. Still, fluids can and should be administered during the time the patient is medicated for comfort.

What does the near future hold for the ill and elderly? Will they have a chance at recovery?  What about those suffering from a stroke or dementia?  Will their termination be based on the cost of their recovery or the cost of assisted living that is needed? Will the person who is unwanted, or unproductive, be terminated? At what age should an elderly person be terminated?  Perhaps it is 90?

In our fictitious story Gram was terminated with the use of a living will to establish the authority of the doctor and nursing home to do so.  A living will used in this way represents permission to kill. 

What does your future hold?