September 7, 2011:

As I write, my grandmother is medicated unto unconsciousness. A visiting hospice nurse dosed her up something fearsome on oxycodone and methadone at about 1530 this afternoon with oral instructions for the rest of us to keep her methadone level up over the coming days in order to give her relief against chronic pain. The odd thing is that grandma hasn’t had chronic pain recently, only acute pain when being moved and brief distress from coughing, and I told the nurse as much. Grandma has so far been out cold for eight hours, and my parents are of a mind to strangle the hospice team.

My parents have taken to referring to the hospice nurses as “little Kevorkians without medical licenses.” They say that from the start they discerned a disturbingly morbid sensibility among the nurses. I initially ascribed it to their being constantly surrounded by death. People who are squeamish around death and dying, I figured, don’t stand a chance in that line of work, and those who do function as hospice staff can be expected to adopt a morbid sensibility as a coping mechanism, if nothing else.

Today’s methadone fiasco, however, has changed my mind. The visiting nurse this afternoon blithely proceeded with three doses of oxycodone in short succession, followed by a dose of methadone in spite of very explicit instructions from my mother, a physician, not to administer methadone or any other long-lasting sedative because she didn’t want grandma getting snowed. My dad is upset because even though he was over at the family house for close to twelve hours today, he didn’t get to spend a waking minute with his mother; he initially postponed visiting her bedside because others were visiting, and by the time they left she was out for the night. Quite frankly, methadone was not indicated for my grandmother’s occasional acute pain, and the hospice nurse should have fucking listened instead of proceeding full steam ahead with the standard snow job.

Hospice nurses really like their methadone. Oops, I seem to have implied that they self-administer; honestly, though, hell if I care as long as they’re functional addicts. I don’t consider it advisable to be a Debbie Downer, and I certainly want any Southwest pilot who shows up at the gate drunk to be escorted off the plane, but the best performance assessments are actual performance assessments, not drug tests.

Folks, prescribing a heavy-duty opiate for nonexistent chronic pain ain’t performance. Unless, that is, the unstated goal is to empty the catheter bag on Dylan Thomas’ grave and have the patient go gentle indeed into that good night. I was under the impression that hospice was there to provide palliative care, not to play euthanasia roulette. Then again, what do I know? Actually, I did notice a certain lullaby quality to the nurse’s tone of voice as she gave grandma her morphine shots this afternoon. Oy vey.

Here’s another lovely thing about Hospice of Humboldt: it has a single physician on staff who, as far as we know, writes all orders without seeing the patient in question. He certainly hasn’t examined grandma, although he’s given orders on her care to the nursing staff. That’s what’s known in medicine as prescribing without a good faith prior examination, a big professional no-no and a great way to get one’s name on the dishonor roll in the Journal of the California Medical Board, along with docs who are caught running MediCal scams and having sex with their patients. On the other hand, if Medicare pays the same amount whether the physician examines his patients or not and no one gets chewed out by the authorities, what’s the big deal? As a little brat of a psych inpatient once told my mom, “It’s only wrong if you get caught.”

And hey, Bill Frist did it. If Senator Doctor Frist, junior member of the August Body from Tennessee, could do it, why not peon docs? Qualis rex, talis grex. As it happened, that was a major Republican talking point during Bill Clinton’s impeachment. You can’t have average Americans thinking that oral sex and cigar masturbation are acceptable, after all, or they might start doing those things. (Nah, strike item two. Some practices don’t diffuse downmarket. Not without help from Spencer Gifts, in any event.) It was perfectly acceptable, on the other hand, for Dr. Frist to openly thumb his nose at long-established medical ethics because he did so in defense of life. Life! (“Bill Bennett, please report to the Capitol steps to express outrage. Bill Bennett, please report to the Capitol steps to express outrage.”) Life broadly defined, that is, specifically to include a terminally brain damaged woman who was at the center of a bitter family dispute because she had spent over a decade being fed like a French goose. But Senator Frist, august member of the August Body, put on his doctor’s hat, took one look at the video and saw life in Terri Schiavo’s eyes! Any good, upstanding surgeon, HMO hustler, and Congressional blowhard would gladly breach medical ethics and meddle in a sordid family dispute over care for the living dead in defense of LIFE!

Stick to cardiovascular surgery, asshole.

In fairness, Bill Frist was far from the only person who needed a punch in the face over that pathetic media circus. So did a huge swath of the pro-life movement and their bottomfeeding media enablers.

Ironically, these ass hats crashed through a poor family’s life like bulls through a china shop over a sideshow that was practically inconsequential to national healthcare policy. God only knows how many hospice patients were simultaneously being helped off the mortal coil a bit faster with contraindicated opiate blasts. That, unlike Terri Schiavo, might have been a meaningful policy concern for Congress to address, perhaps as an element of sober Medicare reform, but I’m not thinking like a Congressman. Congresscritters aren’t normal people. They’re rodents that chew up the national civic fabric for money and sport. I don’t mean to tar by association the good rats that I’ve known, but I have no choice.

This disturbing matter of hospice as opium den-cum-short-term departure lounge raises a related question: might it be better to allow formal euthanasia than to have dubious characters scurrying around in the shadows, administering hearty doses of opiates to uncertain ends? This is a tough question. It’s a bad idea to trust anyone providing a pat answer one way or the other. Bans on euthanasia arguably help creeps like Jack Kevorkian turn themselves into badass cult heroes. On the other hand, they also keep the same creeps from putting pressure on the old or the sick to make a quick exit. Just among prominent American clinicians, those who have gotten into legal trouble for killing the sick have run a hell of a gamut: Jack Kevorkian, a bizarre, self-promoting media whore and videography freak; Anna Pou, a hospital physician in New Orleans who euthanized several severely ill patients during a massive medical care meltdown caused by Hurricane Katrina; Orville Lynn Majors, a nurse in Ohio who claimed, I believe credibly, that he only killed patients out of mercy; Charles Cullen, a nurse in Pennsylvania and New Jersey who looked for all the world like Jeffrey Dahmer with a needle. Cases like these are truly ones about which reasonable people can disagree.

Much has been made of the euthanasia policies recently adopted in Oregon and the Netherlands. As a rule of thumb, political liberals and palliative care activists point to these policies as very rational, successful experiments, while political conservatives and pro-life activists denounce them as moral disasters that enable murder by physicians at the behest of selfish family members.

My gut feeling is that the liberals are a lot closer to the truth. When pro-life activists claim that large numbers of Dutch are using their country’s euthanasia law to get rid of inconvenient elderly relatives, my gut reaction is, don’t bet on it. It could be true, but it doesn’t have the ring of truth. Barry McCaffery, Bill Clinton’s nutty drug czar, made wildly exaggerated public statements about the Dutch murder rate in an intellectually dishonest attempt to blame the Netherlands’ lax marijuana laws for violent crime. Our Puritan forebears had a deep mutual contempt for the Dutch, their first hosts after they went into exile from England, who criticized their guests for beating their children with their “loose hands.” Given this history, statements from the American right about the Dutch using euthanasia to murder their elderly should be taken with a grain of salt.

I can speak with more authority and conviction about right-wing criticism of the Oregon law. I have lived off and on with relatives in Oregon for several years, and I can state for a fact that some of the claims made by pro-lifers about liberals on the left coast, e.g. that they don’t reproduce because they hate babies and children, are absurd libels. The idea that Oregonians are a bunch of suicidal, murderous, nihilistic freaks with a cruel disregard for human life and no respect for the elderly is lunacy, too.

As far as respect for the elderly is concerned, assisted suicide isn’t really as cruel as long-term warehousing of the elderly in nursing homes, most of which are hellholes. Or letting 50,000 elderly Frenchmen roast to death in the summer of 2003 because, heat wave be damned, solemn tradition forced their younger relatives to spend that very week stuck in traffic on the A7 freeway. Speaking of slanders of suspect foreigners that Americans ought to take with a grain of salt….

Nah, that one’s true. At least that’s what the French papers believed when they reported it.