Choice at the end of life

A bill to legalise voluntary euthanasia and assisted suicide is currently being considered here in New Zealand. Passionate campaigners both for and against have put forward compelling reasons to support their case. At one extreme are those who believe that human lives are sacred and only God can determine when they should end. At the other extreme are those who believe that each individual has the right to control the timing of his or her own death. Logically it is not possible to agree with both views, but perhaps there is scope for some compromise between them.

The term euthanasia, according to its Greek origin, means a “good death”. Much as I dislike the idea of deliberately ending a life, I do think there is a place for assisted dying for patients who are already finding their situation unbearable, or who wish to avoid likely suffering and loss of dignity in the future. But such cases are a minority. When I was in medical practice I got to know many patients with terminal or incurable conditions, mostly advanced cancer, and I do not believe that most of them would have wanted euthanasia or assisted suicide even if these options were legally available – though I remember a few who did. Similarly, recent surveys have found that many people with severe permanent disabilities have no desire for euthanasia, and are often worried that they might be pressurised into having it if the bill becomes law.

There are some strong arguments against euthanasia, but I think they need to be qualified. Looking at some of them in more detail:

“Euthanasia goes against the sanctity of life and the will of God.” This is the position of the Catholic Church and many other religious traditions. While respecting this belief myself, I do not think it justifies withholding the option of euthanasia from those who hold a different view. For this reason, when an anti-euthanasia submission was recently presented to our local congregation after Mass, I did not sign it.

“There is no need for euthanasia because symptoms and suffering can be so well controlled with modern palliative care.” I disagree with this one. Only a minority of dying patients have access to specialist palliative care. Even with the best of care, there are a few terminally ill patients whose symptoms and suffering cannot be relieved. And what about old people who may not have any specific life-limiting disease but would welcome death to release them from weakness and frailty, aches and pains, failing physical and mental faculties, loneliness and lack of purpose?

“Euthanasia may be undertaken too lightly, and against patients’ real wishes.” This is a real risk. Some people will feel obliged to request euthanasia to avoid being a burden to others. Well-meaning medical staff can judge that some patients’ lives are not worth continuing, when the patients themselves might disagree. This can also apply to the withholding of life-sustaining treatment, which could be called passive euthanasia. I have just read It’s Not Yet Dark, a memoir by the late Irish film maker Simon FitzMaurice. He describes being discharged from a hospital without being offered home ventilation because doctors had assumed that someone with his diagnosis, namely motor neurone disease, would not want their life prolonged. In his case they were quite wrong, and he was able to obtain a ventilator and spend several more worthwhile years with his family. A less informed and articulate patient could not have achieved this.

“There could be deliberate abuse.” Going further down the “slippery slope”, legalised euthanasia could provide a cover for murder. Family members might want to dispose of a sick or elderly relative, in order to make their own lives easier, or to get hold of an inheritance. Euthanising incurable chronic patients, who require expensive and time-consuming care, could be said to enable the more efficient use of scarce health care resources. Recent history has shown the potential for mass killings by authorities in the name of racial cleansing or medical research.

“There can be psychological damage to the staff involved.”  The same applies to clinicians carrying out abortions, and veterinary surgeons putting animals to sleep. There is certainly scope for conflict and distress when those trained to preserve life are called upon to end it, depending on whether they believe they are doing the right thing, and on the method used. Prescribing a fatal quantity of drugs, for the patient to take at a time of his or her own choosing, would seem a less harrowing experience for a doctor than administering a lethal injection – although the end result would be the same. Besides affecting staff, unnatural deaths can have a deep impact on the family and friends of the deceased. Consenting to euthanasia of a sick pet, and hearing about the suicide of a colleague, have counted among the most distressing events in my own life.

In summary my own view is that euthanasia and assisted suicide can be justified occasionally, though literally as a last resort, on condition that the patients concerned have given informed consent; if other treatment options have been carefully considered and excluded; if clinicians with religious or ethical objections are not obliged to take part, and if there are safeguards against abuse of the system. I suspect that many people who support euthanasia in theory might sign up in advance when still in reasonable health, then decide not to go through with the option when it actually came to the point – but having a sense of control is a very important aspect of coping with illness, and I believe patients should be allowed that choice.







Medical cannabis

Access to medical cannabis is tightly restricted here in New Zealand, and progress towards a more liberal approach is slow. I understand that doctors are allowed to prescribe Sativex on an individual basis for such conditions as advanced multiple sclerosis or intractable epilepsy, but that many are reluctant to do so, and that patients have to meet the high cost of the product themselves. And following a recent law change, people with terminal illness can now use home grown cannabis without fear of prosecution for themselves or those who supply them. But using cannabis outside of these circumstances still carries heavy penalties; according to the police website, these range from a $500 fine for possession to a 14 year jail term for supply or manufacture. This despite the fact that cannabis, with its analgesic, anti-inflammatory, anti-tumour, anticonvulsant, antispasmodic, anxiolytic and sedative effects, has been used for healing purposes for thousands of years and is now legal in many other parts of the world. Cannabis oil can be taken by mouth, inhaled, or applied to the skin.

My personal interest in this topic began in an unusual way. Unlike many students I never tried cannabis at university, because I moved in fairly conventional circles and also had an aversion to smoking. Then last year I was intrigued when a homeopath suggested that Cannabis sativa would be a good remedy for me. Shortly after this I came across a series of online documentaries called The Sacred Plant promoting the value of cannabis for treating cancer, epilepsy, arthritis, multiple sclerosis, other autoimmune disorders, and AIDS. While this series was focused on the benefits of cannabis, with minimal discussion of any potential downside, it convinced me that this plant has huge medicinal potential and has been unfairly stigmatised. Heavy recreational use can certainly be harmful especially for adolescents, but it seems wrong to criminalise sick people who are seeking the plant’s therapeutic effects.

Formal research on patient populations has been hampered by the legal constraints but there are some published clinical trials, besides many laboratory studies and a wealth of anecdotal evidence, supporting its use. The National Cancer Institute in the USA has produced an excellent review, including a detailed version for professionals and a simpler one for patients, not limited to the cancer setting. Cannabis can alleviate symptoms of pain, nausea and vomiting (including that caused by chemotherapy), lack of appetite and weight loss, anxiety and insomnia. Importantly, it also has potential for treating the disease which underlies these symptoms. Like any effective drug cannabis can have unwanted effects and interactions, but these usually seem to be mild in comparison with those of many orthodox medications.

Two main constituents of Cannabis sativa are THC (tetrahydrocannabinol) and CBD (cannabidiol). Both have medicinal properties but THC is mainly responsible for the “high” sought by recreational users, whereas CBD has minimal psychoactive activity and can be freely purchased over the counter in many countries including UK, Australia and many states of America. The plant also contains hundreds of other chemical compounds, found in varying proportions in the seeds, leaves and stalks and depending on which strain is used, and there is still much to learn about how its extracts can best be prepared and used medicinally.

My own health is reasonably good but I do have a few medical problems of a kind that could be helped by CBD, and am tempted to buy some on my next overseas trip. But I doubt it would get past the clever beagle dogs who patrol Auckland Airport to sniff out illicit drugs.

Cold water swimming

Inspired by Floating, Joe Minihane’s memoir about swimming in seas, rivers and lidos around the UK, I plan to do more outdoor swimming this year. I have ample opportunity here in New Zealand, being lucky enough to live in a house with a pool in the garden and ten minutes walk from the sea. I already swim most days during the hot summer months but intend to try extending the season.

Swimming, especially in cold water and sea water, seems to confer mental and physical health benefits over and above those to be gained from exercise in general. Mechanisms for this include the physiological stimulation of being in cold water, the meditative state induced by rhythmic movement and deep breathing, being surrounded by nature, and absorption of the minerals present in the sea. Many people feel an immediate uplift of mood and energy when they go for a swim. Regular swimming over a period of several months appears to reduce stress, helps to regulate the immune and endocrine systems, and reduces inflammation. Regular swimmers catch fewer colds, and there is preliminary evidence that swimming can help in the management of numerous medical disorders including anxiety and depression, eczema and psoriasis, hypertension and diabetes. However it takes time for the body to adapt to the demands of cold water swimming and reap these health benefits. So it is important to build up the practice gradually, and to be aware of the potential hazards as outlined below.

The shock of getting into cold water can throw all body systems out of balance, causing the sudden onset of breathing difficulties, muscle spasms, raised blood pressure and disordered heart rhythm. Cold water shock can be fatal due to a heart attack, stroke or inhalation of water. Hypothermia can ensue after more prolonged immersion and is manifest by shaking, weakness and confusion. To avoid hypothermia it is important to wrap up and warm up after the swim. Individual tolerance to cold varies but my understanding from various websites is that water temperatures below 15C are always dangerous, and that beginners should probably not start below 20C. Wild swimming in rivers or seas carries the risks of infections, injuries, and drownings due to powerful currents or tides.

Being a person who gets cold easily I considered buying a wetsuit, but after a trial fitting decided against it. I found the suit so cumbersome to take on and off, and so constricting to wear, that I felt it would detract from the pleasure and benefit of swimming. I got leggings and a neoprene jacket instead and am proud to report that yesterday, the last day of winter, managed to swim one length of the pool …

J contemplating water

Taking tablets

“Healthy living” – good diet, regular exercise, enough sleep, stress reduction, positive outlook – and natural therapies can achieve a lot, but in many cases of medical illness they are not enough on their own. I am thankful to have found effective drugs to control my own episodes of high blood pressure and cardiac arrhythmia. At the same time I can well understand why around 50% of people with chronic disease fail to take some or all of the medication prescribed for them.

There are many reasons for non-compliance (or non-adherence). Side-effects: the experience of unpleasant symptoms in the present, or concern about possible permanent damage in the future. Reluctance to accept a need for ongoing treatment: especially if the benefits cannot be felt immediately, if healthcare professionals have not explained them clearly, or if there is genuine uncertainty about the pros and cons of longterm medication. A desire to avoid artificial chemicals. The financial cost of the drugs.

All these are valid points and there is no doubt that some prescriptions are unnecessary or harmful. But assuming that taking the drugs is indeed the right thing to do, here are some personal observations about how the physical form of the tablets (or pills or capsules) might affect compliance. These aspects may not be considered by the prescribing doctors, though I expect nurses and pharmacists appreciate them more.

Size: while this is partly determined by the chemical makeup of the drug, big tablets are hard to swallow, and small ones can get lost.

Colour and shape: many generic drugs are presented as small round white pills which are hard to tell apart, and this can lead to mistakes in dosage. Coloured tablets of different shapes are much easier to identify. Incidentally, there are some interesting studies showing that the colour of a tablet affects patients’ reports of its effects.

Strength: having to break tablets into halves or quarters is tedious and often inaccurate. Tablet-cutters can help, but it is better if low-dose versions are available.

Frequency of dosage: again this is partly dependent on the properties of the drug, but if it is possible to get a controlled-release preparation to be taken once daily this is preferable to divided dosing.

Such practicalities were not mentioned in my pharmacology course at medical school, as far as I recall. Perhaps they seemed too simple and obvious to be considered in an academic context. I certainly paid them little attention when I practiced as a doctor, not always being aware what the tablets I was prescribing would look like when dispensed. I now realise that size, colour, strength and frequency of dosage can be quite important to patients, especially those who have problems with eyesight or memory. Here in New Zealand it is impossible to get some of the low-strength and controlled release preparations that are available in the UK and elsewhere, and make patients’ lives easier.


Bach flowers: medicine or magic

After taking a few years out from my Bach flower remedy practice due to illness in the family I am now available to see clients again, so it seems timely to revisit the topic on this blog.

The remedies are intended to restore emotional balance. Common presenting problems include anxiety, grief, relationship difficulties, lack of direction in life, and the hardships of physical disease. I am continually impressed with how well the system works: 80 of my first 100 clients reported an improvement, and this figure is in line with the experience of other practitioners. But it is not always easy to reconcile my background in orthodox medicine with my interest in holistic therapies like the Bach flowers. I have to acknowledge there is no accepted scientific explanation for their mode of action, and that when tested in the artificial context of clinical trials they usually perform no better than placebo.

Leaving aside the question of whether the remedies have direct effects, a consultation with a Bach practitioner can be therapeutic because it empowers the client – as the jargon goes – “to take responsibility for their own healing”.  The interview does not follow a set structure, and it is up to the client to decide what they want to talk about and how much detail to reveal. The practitioner listens, and asks questions for clarification, but does not probe for extra information or offer unsolicited advice. The selection of remedies is a cooperative process, with the practitioner making suggestions but the client helping to choose what flowers they need, and sometimes seeing their problems in a new light as a result. The combination of up to six flowers is tailored to the unique individual’s state of mind rather than a symptom or diagnosis.

This is very different from the assessment process used in orthodox medicine and psychiatry. Traditionally, in the orthodox system, the doctor is in charge while the patient takes a passive role. The consultation follows a standard format, with a series of questions followed by examination and investigations, aimed towards establishing a diagnosis. The drugs, surgery or radiation prescribed will usually have evidence-based benefit for the disease concerned, but inevitably carry some risk of side effects. The orthodox approach often works very well, especially for acute conditions and those that are clearly defined, and is sometimes life-saving (as was clearly brought home to me in 2015 when my husband required heart surgery, described in my short memoir Across a Sea of Troubles).

The orthodox approach with its armamentarium of marvellous medical and surgical technology, and the holistic approach which draws on the universal principles of healing and self-help, are truly complementary to each other and can be used together – I think of them as representing the “yin” and “yang” of healthcare. Unfortunately there is considerable antipathy and misunderstanding between practitioners of the two schools and the concept of integrative medicine, which combines the best of both, has not been widely accepted.

While Bach flowers can be used on their own for minor mental or physical imbalances, they are not sufficient as a sole treatment for anything more serious. I often advise clients to seek a medical assessment if they have not done so already because physical diseases, for example over- or under-activity of the thyroid gland which is common especially in women, can present with psychological symptoms.

Clients are attracted to therapies like the Bach flowers because they are natural and safe, treat them as a “whole person” rather than just a case of a particular disease, and provide them with a sense of choice and control.  More information about Bach flowers can be found on this page.

Complementary therapies in cancer care

This short overview is based on a talk I recently gave to the members of Sweet Louise, a New Zealand charity for the support of people with incurable breast cancer.

Complementary therapies can be loosely defined as those not included in orthodox medical training or practice, though this can change, for example acupuncture has been used in pain clinics for many years. Some therapies involve physically touching the body – examples include massage, reflexology, acupuncture. Others involve taking substances by mouth – herbal remedies, homeopathy, flower essences, special diets. Then the mind body therapies such as relaxation, meditation, yoga, visualisation and guided imagery, energy healing. And creative therapies with art, music, writing and dance. Several types can be combined.

They are often known as “natural” therapies, and the same ones may be called “complementary” when used alongside orthodox medical treatments, and “alternative” when used instead. The “integrative” approach combines them both but has been slow to get established, perhaps because of prejudice and misunderstanding on both sides. All these therapies are grounded in the “holistic” approach, which aims to balance the whole person in body, emotions, mind and spirit, and mobilise the potential for self-healing. This is in contrast to the approach of conventional medicine, which uses powerful drugs, surgery or radiation to suppress symptoms and destroy disease, and in which patients have a passive role. Both approaches have their place and can often be used alongside each other.

Surveys show that as many of two thirds of women with breast cancer are using one or more natural therapies, and there is good evidence that they can improve quality of life – helping to relieve physical symptoms such as pain and nausea, mental symptoms such as anxiety and depression, reducing the side-effects of radiotherapy and chemotherapy. They appeal because, in general, they are safe and natural and many of them are pleasant to receive. When I was practising with the Bach flower remedies, many of my clients told me they wanted a therapy that treated them as a unique person, rather than just one more case of a diseased body part.

While all the modalities have specific effects, their benefit is partly due to their positive influence on mind-body relationships. The self-help element, especially with therapies that require some active user participation, enhances a sense of choice and control. Spending time with an understanding therapist in a relaxed setting is comforting. Expectation of improvement can help to bring it about. Such general factors are important, and it is a mistake to devalue them as “just placebo”.

A key question is whether using these therapies can lead to a longer life expectancy or even to remission of the cancer. Many individual cases of remarkable recovery have been reported. But there are few formal research studies on this aspect, and it is a difficult thing to investigate for many reasons – for example treatments are used in individual combinations rather than standard protocols, and patients’ beliefs and motivation affect the outcome.

Some of the therapies carry risks, for example herbal remedies can have adverse interactions with prescribed drugs; massage and acupuncture occasionally cause physical injury. They can be expensive. The field is not tightly regulated and, while most therapists are skilled and honest, there are a few self-styled practitioners who cause more harm than good by making unrealistic promises of curing cancer while advising clients to refuse conventional treatment that would have been effective.

More detail about these topics, with case histories, can be found in some of my non-fiction books.

Fitbit and Zumba Gold

Having read a lot lately about the health benefits of exercise, and the health dangers of sitting down too long, I resolved to spend less time at my desk and more time on the move.

I replaced my wristwatch with a Fitbit Alta HR, in order to track my level of activity. I have always liked walking – though since getting a car I no longer do all the supermarket shopping on foot – so there has been no difficulty in meeting my goal of 12,000 steps per day. Sometimes I do more than that, and get a message on my iPhone about being an over-achiever. The Fitbit also provides heart rate data, and I was pleasantly surprised to be told that my cardiovascular fitness is “excellent”. Another pleasant surprise was that, assuming the reports are accurate, I sleep better than I thought I did and usually meet my target of seven hours per night. Fitbit also measures other physiological variables, and displays text messages, as well as telling the time. Whether wearing this sophisticated technological device does any harm to the body is not known.

So far well and good, but I know my physical coordination could be improved, so I have joined a Zumba Gold class. According to Wikipedia, Zumba draws on diverse traditions including cambia, salsa, merengue, mambo, flamenco, chachacha, reggaeton, soca, samba, hip hop, axe and tango. The “Gold” version is less strenuous than the others, being designed for older people and beginners. Along with about 15 other ladies of a certain age, and the occasional lone male, I spend an hour a week trying to follow the teacher as she dances along with the upbeat music. Hopefully, if I keep practising, the moves will become easier to follow and the class will be more fun.

I already quite enjoy Zumba, certainly much more than I ever enjoyed sports and gym at school. But, apart from walking and swimming in the summer, I have never been very keen on taking exercise for its own sake and am in no danger of getting obsessive about it. Besides, too much exercise can be bad for the joints and the heart. There are other ways to keep well, and a research finding that especially appeals to me is that proximity to a purring cat not only reduces stress, but can improve cardiovascular function and even help to prevent osteoporosis.