Thursday, March 17, 2016

When Should You Put Your Mom Down?

** Satire Alert ** Dr. Mors provides some practical guidance for dealing with some "difficult decisions" that many of us will face in the not too distant future about putting down our parents, if current trends continue.

How To Make A Decision You Never Want to Make
By Doctor Justin Mors, Psy.D.

Bill H. is a salesman for a computer networking equipment company in the San Francisco Bay Area. He's usually a pretty macho guy, but when his 72-year-old mother, Rose, told him that an oncologist had diagnosed her with cancer of the jaw and that nothing more could be done, Bill burst into tears. He knew what he had to decide, and it wasn’t going to be easy.

Bill is a long-time client of mine. He called me later that night. Punctuated by sobs and silences, our conversation lasted nearly an hour. "I really don't know what to do," Bill said. "When do you put a parent down? How do you decide? She is old-fashioned, so she doesn’t believe in suicide.

"I know she is wrong, but somehow I can’t blame her for sticking to her old beliefs. She's from a generation that thought that it was a person's duty to fight for life until the last breath. I hate to euthanize her, and some of our family members would probably hate me for it, but I can’t bear to see her suffer." Bill is an only child, but he has some fundamentalist Christian cousins back in Texas who he knows are going to put up a big stink if they got wind of any notion of their aunt being put down.

Bill admitted he was making a lot of money in his programming job, and he told me that he had considered funding some experimental non-covered treatment that might help his mother out of his own pocket. But then he reconsidered. He decided she wouldn't want to be a burden on him.

He has his own life to live, his own bliss to follow. His goal is to retire when he is fifty, and by his canny investment strategies, he expects to be reaching his goal in two years. He never wanted to get married and have a family. And he's chomping at the bit to take advantage of the nest egg that he's been building so he can finally be free of a job. He's got a bucket list a mile long. He spends every vacation mountain climbing, and there are a lot of very big mountains on that bucket list. He knows his mother wouldn't want him to have to give up his dream on her account.

Caring for parents who are sick can cause huge amounts of stress. And we hate being forced to see our parents weak and ravaged by sickness when we would prefer to remember them as they were when they were full of vitality. We hate to see them suffer, we really do.

In our era, medical practice provides ways to mercifully shorten both their suffering and our own. But even so, oftentimes it is just plain painful to decide when to let them go. And sometimes we face opposition from narrow-minded people who don’t understand the progress we as a society have made in the area of compassionate end of life.

Bill and I spoke three or four times over the next couple of weeks while Bill agonized over the decision. The oncologist had urged him to euthanize his mother right away before Rose’s condition worsened, but Bill had clearly decided against that. He was apparently planning to put her down "when he was ready," and he thought he wasn't ready yet. One evening, he said he'd talked to a compassionate care counselor who'd told him that Rose would tell him, maybe not in words, when it was time to go, that Bill should watch and listen to for cues. He asked if I thought this was the right course.

At the time, I couldn't quite say. But if I had been able to articulate what I thought that night, it would have been this: Human beings, even when severely disabled or devastated by illness, avidly cling to life, sometimes even to the last breath, even when their lives have no quality at all--from a rational point of view.

They may cling to outmoded beliefs that it is wrong to end their own lives. Or they simply may not be able to decide for themselves when it's time to die, because especially under those circumstances they often aren’t capable of such abstract thought.

I personally didn't look to my wonderful parents, Ted and Betty, to tell me when it was time for them to go, one diagnosed with congestive heart failure, the other with colon cancer. The responsibility and the hard decision, it seemed to me, was mine, not theirs. Right after each of them was diagnosed, I made quiet arrangements with the end-of-life specialist to have him put them down before they endured any prolonged suffering—-my own choice, not a hard and fast recommendation for others.

In the context of this most personal decision a child ever makes, as in many other types of decisions, there are no universal truths.

Bill ended up postponing the decision for two months, until the tumor in his mother’s jaw had swollen to grapefruit size. When he called me again, I told him it was obviously time, and he finally went ahead and had her put to sleep.

Later, he called this the most wrenching period of his life. His relationship was floundering because Bill had been torn between the claims of his mother and his lover. His lover was upset about the time Bill spent attending to his mother’s affairs. His lover would complain about being left out because Bill started to visit Rose occasionally towards the end, even though she didn’t even recognize Bill some days. He told his lover that it didn't matter so much that she didn't recognize him, he recognized her, but that sentiment just elicited a snort from his partner.

After Bill finally ordered the euthanasia, in spite of the fact that he was convinced he had done the right thing, he missed his mother more than he ever imagined was possible. It was hard for me to relate to him at that point, his emotionalism seemed so unmanly and irrational. Bill cried deep wrenching sobs as he told me how much more horrible he felt because he knew he had no right to expect any sympathy.

Weeks later he told me he was plagued with recurrent dreams. In the dreams, he was a two year old with pneumonia. His mother was rocking him to comfort him while he fretted and feverishly pushed her away. When the dream ended, he would partly wake up. He would sit up in his bed and wail and reach his arms out for her just like he was still a little boy, until he would realize it was only a dream. Then he would continue to wail because he experienced the pain of her loss again every time the dream ended. His lover called him pathetic and began to sleep on the couch.

For months afterwards, Bill was depressed, and he could not bring himself to make all the sales calls he needed to meet his quotas. Predictably, the inheritance Bill had a right to expect from his mother’s estate had dwindled during the time he had delayed. And, as Bill had feared, his cousins were outraged when they somehow heard about the euthanasia. Fortunately, with the compassionate end-of-life laws on the books, there was nothing the cousins could do but complain.

The message in this is that his prolongation of his mother’s life took its toll on both his relationship and his finances. The wait had only delayed both the grief and the reckoning he eventually had to face with his narrow-minded relatives in any case. I frankly told him that was a shame.

To help your parents let go of life is as integral a part of the parent-child relationship as to make a cheering phone call on Mother’s and Father’s Day or to drop by for some of Mom’s home cooked food from time to time.

Above all, it is vital not to forget that our first responsibility is to take care of ourselves and get on with our lives.

One doctor I know tells patients that euthanasia should be performed "when the sick or aged person can no longer live a fully-human life. Sometimes the patient is willing and able to make the decision about when it is time to go—and sometimes only the child in conference with the end-of-life specialists knows when that really is."

The Netherlands has led the way for compassionate end of life care for many years. The same year that the laws were changed in our country to allow euthanasia and assisted suicide, tens of thousands of cases were performed in the Netherlands. Of these, about half the patients did not request or consent to being put down. One Amsterdam doctor explained in an interview that it would have been "rude" to discuss the matter with the patients, as they all "knew that their conditions were incurable."

One nurse practitioner in a rehabilitation center tells her patients, “I would not want to live if I couldn’t climb mountains any more.” She and the attending doctor, who have a responsibility to help keep the managed care costs down for the HMO that runs the center, find this can be very effective when she speaks to a bed-ridden or wheelchair bound invalid. More often than not, her patients will see her point, spare their children the difficult decision, and ask for an end-of-life injection themselves the next time the doctor comes around.

But I know other adult children—a growing number, according to doctors—who, like Bill, allow their parents with poor quality of life continue to live on and on, most of them because they have old-fashioned if not outright medieval beliefs. Like Bill’s fundamentalist cousins, they claim sanctimoniously that euthanasia is fake mercy.

They say that compassion should lead one to share another's pain, relieve it as far as possible, and comfort the ill and dying, not to kill a person when we cannot bear the person’s suffering. Note the use of the emotionally charged word “kill” instead of “compassionately end a life.”

Euthanasia opponents who believe in God say that because God is the giver of life, God alone has the right to decide when to end it. They believe that suffering can have a great benefit for the individual and for the world when the person who is suffering “offers it up” (which begs the question of whether there is a God at all or why a God would want such offerings). They say that a final illness is can be a grace-filled transitional time of preparation for eternal life and that it should not be cut short by human intervention.

Opponents also paint a narrow-minded picture of the current state of health care practice when they protest that people should not be encouraged into suicide. And they are outraged at the thought that people may be euthanized without their consent.

Those out of touch moralists don’t have a clue how maudlin it sounds when they say that true compassion means that we care for people--not we kill them when they are ill or defective in some way that makes us uncomfortable. There’s that judgmental use of the loaded word “kill” again.

Such beliefs fly in the face of everything we know in our day about the primary importance of taking care of our own needs. As my favorite philosopher Ayn Rand sagely wrote in her books, survival of the fittest mandates that we minimize the costs to society and realistically not waste our time and money on those too weak to take care of themselves.

Admittedly, it is hard to think clearly at such moments, but one must keep in mind that what good parents want above all is what is best for their children. You can console yourself with the assurance that if they were able to think clearly at the time, your parents would really want not to be a burden, distress you with their pain, or cause you financial loss.

As my conversations with Bill reminded me, keeping them alive past when it is time for them to go is not to anyone’s benefit.

Legislation for what is cynically called compassionate end of life care has already been passed in many states, and euthanasia with or without patients’ consent is already commonplace in the Netherlands and other countries. This satire is based on an article in Slate magazine titled “When Should You Put Your Dog Down?” By Jon Katz. Because so many of the ideas Mr. Katz propounded in 2003 sound like what people say these days about "mercy killing," I wrote this fictional article.

There is nothing new in the attitudes expressed in this little satire. I found a good example of the very same attitudes described in a work of fiction from the middle of the twentieth century, in Curtain: Poirot's Last Case, which was written in the 1940s. Agatha Christie wrote it during WWII when thought she might die in the London bombings, then it put away in a bank vault. It was finally published in 1975, the year before Christie died.

Judith, Captain Hastings' beautiful twenty-one year old daughter, and a sympathetic character loved by both her father and by "Uncle" Poirot, was one of the group gathered together at the guest house in the book; she was in love with a married doctor who was married to an invalid wife. Judith quite vehemently expressed her philosophy several times without much authorial comment. She was adamantly sure that when anyone is making anyone's life miserable or is useless, that person should be eliminated. "Old people, sick people should not be allowed to ruin the lives of others!"

When a murder case was discussed in which a father was killed by one of his daughters because he was too controlling, Judith said, "I think she was very brave." When asked what her lover the doctor would think, Judith blurted out that he thought the victim had it coming to him. "Some people just ask to be murdered." "I don't hold life as sacred as you people do," she interjected.

In a conversation at dinner table in the story, "everybody knew" that the "unfit" should not be kept around to drain the resources of the "fit" and contaminate the gene pool. The only real question seemed was whether the unfit should be put out of the way if they didn't ask for it. She called killing such a person putting someone out of their misery. "It shouldn't be up to the patient." And, she added, especially when a loved one's life is useless, "someone who loves them" has to take the responsibility," and be brave enough to do the right thing even at risk of being tried for murder.

Nowadays in 2016, most people don't talk openly about getting rid of defectives so they don't contaminate the gene pool (even though we quietly kill most babies with defects before they are even born in these dark days). But the idea that a sick parent should be put down when the time comes, which already seemed perfectly obvious to educated upper class unbelievers in the 1940s, is obviously getting more acceptable to everyone every year--except to a dwindling few who still hold that life is sacred. These days the deterrent of possibly being prosecuted for "mercy-killing" is being stricken from the laws in many places, and we don't even have to sully our own hands. In more and more countries and states, a Doctor Death or his nurse assistant will do the dirty deed for us.

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