Why not choose death? – Sunrise Rounds | Sunrise Rounds



Another piece on the question of physician assisted suicide (see Four Myths About Doctor-Assisted Suicide and Suicide by Choice? Not So Fast). I am not quite sure the distinction is quite as clear as Sunrise Rounds makes it out, but he lays out the concerns and issues very well. Quote:

The physician-patient relationship by definition focuses on life, and the end of our lives is still about life, not death, and can be lived with quality. To undermine the foundation of the physician’s role is to deprive the patient and family of that opportunity. If we truly wish suicide to be a realistic alternative then perhaps someone else, like perhaps funeral home directors, should do it. At least that relationship is clear. Why does that sound ridiculous? Because funeral homes are about being dead and doctors are about being alive. Why don’t we just keep it that way?

Why not choose death? – Sunrise Rounds | Sunrise Rounds.

See also his follow-up post on the ethics and practices of prescribing morphine as a pain-killer.:

Morphine: too much or too little


What is the best disease from which to die?


A somewhat odd article, although not without merit, that our success in reducing the risk of heart attacks means that more of us will live long enough to suffer more drawn out diseases, with poorer quality of life. I am not sure I buy this completely, but it does underline the importance of quality, not just quantity, of life.

Though ideally we’d all live to a great old age and drop dead from a heart attack, to delay such an end through healthy behaviors is likely to prevent such an end in the first place. Eventually, science will offer better treatments for the other diseases that living longer makes us all more likely to contract, but for now, we all have to live with the truth that decreasing the risk of dying from one disease has increased our risk from dying from other, arguably more horrible ones. And though realizing this hasn’t diminished my enthusiasm for helping patients to decrease their risk of dying from heart disease, it does refocus me on the quality of life that such interventions are trying to buy them.

What, then, is the best disease from which to die? Unfortunately, the one we’re the best at preventing.

What is the best disease from which to die?.

170 Million Years of Healthy Life Lost to Cancer in 2008


While the headline is largely meaningless without any comparative data on other diseases such as heart disease, it nevertheless is useful in highlighting that cancer strikes far too many people at too young an age. Highlights of the study:

The main contributors to the total cancer burden (i.e., total DALYs) in most world regions were colorectal, lung, breast, and prostate cancers, which accounted for 18% to 50% of the total. When liver, stomach, cervical, and esophageal cancers and leukemia were added included, 65% of the total cancer burden is accounted for.

The researchers highlight the fact that the contribution of colorectal, prostate, and breast cancer to the total cancer burden has nearly doubled in recent years, from 11% in 1990 to 20% in 2008.

They also note that the contribution of different tumor types to the overall cancer burden varies by world region.

Worldwide, for men, the main contributors to the total cancer burden were lung (23%), liver (28%), and stomach (20%) cancers. However, when the researchers considered the impact of cancer on survivors, measured as years left with disability (YLD), the main contributors were a little different. Prostate cancer was the main cause of YLDs in 93 countries, including the Americas, most European countries, Australia, New Zealand, and much of sub-Saharan Africa, whereas colorectal cancer was the main cause of YLDs in 37 countries, such as eastern Europe (including Russia) and Southeast and Eastern Asia (including Japan).

For women, the main contributors to the total cancer burden worldwide were breast cancer (in 119 of 184 countries) and cervical cancer (in 49 countries). The researchers note, however, that cervical cancer contributed more to premature death than did breast cancer in 23 countries, mostly in sub-Saharan Africa and in Central and South America.

The largest cancer burden of all was for men in Eastern Europe; this was driven by colorectal, lung, pancreatic, and kidney cancers.

170 Million Years of Healthy Life Lost to Cancer in 2008.

Meredith Israel Thomas: Lots of Tears With Less Than a Few Months to Live

I posted an earlier post by Meredith Israel Thomas (Grieving for Who I Was Before Cancer), given her honesty on the grieving process. Now, I have seen that she will not make it through, with only a short time to live. Very sad. Pithy quote:

Three weeks ago I was walking in Cape Town, South Africa and three weeks later I was told I will be dead within weeks to a month or so. Life leaves us all with a lot of questions, but I know I don’t blame anyone and they just better find a fucking cure for this disease before Niomi and the kids of all my friends who have been diagnosed have to fear this horrible disease.

Meredith Israel Thomas: Lots of Tears With Less Than a Few Months to Live.

How to Die – NYTimes.com


A good piece by Bill Keller of the NY Times on death and dying, and the need to focus on the person and his or her family, not in terms of potential cost savings. Quote:

During Anthony Gilbey’s six days of dying he floated in and out of awareness on a cloud of morphine. Unfettered by tubes and unpestered by hovering medics, he reminisced and made some amends, exchanged jokes and assurances of love with his family, received Catholic rites and managed to swallow a communion host that was probably his last meal. Then he fell into a coma. He died gently, loved and knowing it, dignified and ready.

“I have fought death for so long,” he told my wife near the end. “It is such a relief to give up.”

We should all die so well.

How to Die – NYTimes.com.

Year 1, Week 8: Life Goes On


Life goes on, as we follow the predictable chemo cycle as it moves into the recovery phase, and yet have time for nice walks and the like.

Some further observations on Swiss cancer care, following a post-chemo clinic follow-up:

  • An interesting mix of thoroughness and sloppiness. Blood counts are taken but weight and blood pressure are not, even though weight loss is an important indicator;
  • Different advice between the oncologist and the dietician, the oncologist basically saying no restrictions (apart from raw foods given low immunity) and the dietician taking a more nuanced approach, saying within reason as long as your body can tolerate any changes (e.g., richer food);
  • The ongoing lack of standard follow-up med sheets to provide clarity – learning from this round has enabled us to be better equipped for the next round, but this really should already be in place (in addition to the table I have prepared!);
  • No electronic file integration between the hospital and the oncologist (essentially like a private practice) but the oncologist keeps all his patient notes on his computer, and essentially types them while reading them out loud to the patient, a good practice; and,
  • We have warmed up to the oncologist who is proving to be generous with his time and explanations, open to our concerns and questions, and has the right degree of directness and frankness to inspire confidence, even when discussing some of the uncertainties.

I finished Joseph Anton and the second half is more about Rushdie’s campaign to have greater personal freedom (some wonderful security vignettes populate the book, as he ‘claws back’ his right to a more normal life) as well as the broader campaign for freedom of thought and speech, and how he had to learn how to play that role. He in particular treasures his time in the US where security restrictions, after the first few visits, were essentially dropped and he was able to have a normal life.

The messiness of his personal life continues, as he suffers from ‘old rich man’ disease of falling for a model, and a bitter but eventually reconciled divorce with the mother of his second child. If some of Adele’s lyrics on failed romances and break-ups are harsh, some of Rushdie’s make these appear gentle in comparison, although not with the women with whom he had children.

As a sadly ironic backdrop, is the man of the fatwa lives, as far too many of his friends are struck by cancer, including the wife of his first son, who bore the brunt of raising Zafar when his movements were most constrained.

The one quote is when he notes his ‘little battle’ coming to an end, as prologue to 9/11:

…. And he too refused anger. Rage made you the creature of those who enraged you, it gave them too much power. Rage killed the mind, and now more than ever the mind needed to live, to find a way of rising above the mindlessness.

He chose to believe in human nature, and in the universality of its rights and ethics and freedoms, and to stand against the fallacies of relativism that were at the heart of the invective of the armies of the religious (we hate you because we aren’t like you) and of their fellow travellers in the West, too, many of whom, disappointingly, were on the left. If the art of the novel revealed anything, it was that human nature was the great constant, in any culture, in any place, in any time, and that, as Heraclitus had said two thousand years earlier, a man’s ethos, his way of being in the world, was his daimon, the guiding principle that shaped his life – or, in the pithier, more familiar formulation of the idea, that character was destiny. It was hard to hold on to that idea while the smoke of death stood in the sky over Ground Zero and the murders of thousands of men and women whose characters had not determined their fates were on everyone’s mind, it hadn’t mattered if they were hard workers or generous friends or loving parents or great romantics, the planes hadn’t cared about their ethos; and yes, now terrorism could be destiny, war could be destiny, our lives were no longer wholly ours to control; but still our sovereign natures needed to be insisted on, perhaps more than ever amid the horror, it was important to speak up for individual human responsibility, to say that the murderers were morally responsible for their crimes, and neither their faith nor their rage at America was any excuse; it was important, at a time of gargantuan, inflated ideologies, not to forget the human scale, to continue to insist on our essential humanity, to go on making love, so to speak, in a combat zone.

It ends on an anti-climactic note, appropriately enough, as his restrictions in the UK are dropped at long last.

I also read Christopher Hitchens short book, Mortality. Not too much new, as much of the material comes from earlier pieces in Vanity Fair (some which have been removed from their website – to help sales of the book?). My earlier post Christopher Hitchens on Mortality | Brain Pickings has some of the better ones, with this one on cancer etiquette  that I liked:

But it’s not really possible to adopt a stance of ‘Don’t ask, don’t tell,’ either. Like its original, this is a prescription for hypocrisy and double standards. Friends and relatives, obviously, don’t really have the option of not making kind inquiries. One way of trying to put them at their ease is to be as candid as possible and not to adopt any sort of euphemism or denial. the swiftest way of doing this is to note that the thing about Stage Four is that there is no such thing as Stage Five. Quite rightly, some take me up on it….

So my proposed etiquette handbook would impose duties on me as well as upon those who say too much, or too little, in an attempt to cover the inevitable awkwardness in diplomatic relations between Tumortown and its neighbours. If you want an instance of exactly how not to be an envoy from the former, I would offer you both the book and the video of The Last Lecture…. It should bear its own health warning: so sugary that you may need an insulin shot to withstand it. Pausch used to work for Disney and it shows….

I hit over 100,000 total page views last month which sounds like a lot but of course is not in the blogosphere and my most popular posts in September were (apart from weekly updates and pages):

  1. Lifestyle Changes Could Prevent 50% of Common Cancers
  2. MD Anderson ‘Moon Shots’ Program Streaming Advisory
  3. ‘You Learn’ – Poem by Borges
  4. I am a physician and guns are a disease
  5. Really? Using a Computer Before Bed Can Disrupt Sleep – NYTimes.com

And lastly, I have essentially completed the publishing process for my book, having uploaded the contents to the Amazon and Kobo, and working out the last few glitches on iBookstore for the iPad edition. Kind of amusing in a way the amount of work required to ‘dumb-down’ the formatting and graphics for the Amazon and Kindle editions, and seeing just how basic it looks on the Amazon devices (Kobo does not yet have a previewer!). But it is done, with the iPad edition the richest in layout, graphics, and visuals. I will do a soft launch a few days before the hard launch to make sure everything is working as it should.

Weather has been good here, and so we have discovered some new walks and parks that are most enjoyable.

A somewhat mixed Thanksgiving for us, being here in Switzerland while our kids are back in Canada, the first time we have not celebrated together. But so it is, and we Skype.

Happy Thanksgiving to my Canadian readers.

Is there pain after death? | Sunrise Rounds


While much of the focus of advance directives and end-of-life planning is centered around the person dying, a reminder that there can be ongoing effects on those remaining should the loved one suffer pain and suffering in the last few months. Sobering. Quote:

When we think of end-of-life planning, we focus on those immediate moments for the patient and family, as well we should. The opportunity to live one’s life well, even at its end, should not be denied, and must be the first goal of palliative medicine and hospice. However, we cannot overstate the need and potential to protect and even nourish future generations by treating pain of all types in patients with terminal illness, and in families sharing that passage.

There is pain after death, and I suspect it is the cause of much waste, anger and tragedy in our society. We must strive to prevent that suffering. Good things are possible, loved ones can be together, memories shared, and solid foundations laid. Patients, families, doctors and caregivers must protect and treasure even this difficult time of a person’s life, because as one life ends, others are beginning.

Is there pain after death? | Sunrise Rounds.