Response

Abstract

Dr Van Mol misunderstands the reference to the consensus statement regarding deactivation of cardiovascular implantable electronic devices in my recent article in CHEST.1Tucker KL Aid in dying: guidance for an emerging end-of-life practice.Chest. 2012; 142: 218-224Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The statement is cited not to suggest device deactivation is aid in dying, but as an example of how medical practice in an evolving arena benefits when such a statement or clinical practice guidelines are promulgated, offering guidance on an emerging practice. It is timely for guidelines to emerge regarding the practice of aid in dying, which has been openly available for 15 years in Oregon and more recently in Washington, Montana, and Hawaii. It is likely to become more widely available nationwide as the consensus grows that the option harms no one, galvanizes improved communication and care for all terminally ill patients, and offers a peaceful death to the relatively few patients who choose it. The consensus is based on evidence. Health professionals who embrace evidence-based medicine, including the American Public Health Association, have carefully examined evidence from Oregon and have concluded that the availability of aid in dying poses no danger and offers a desired choice for some patients; accordingly, the association adopted policy supportive of aid in dying.2American Public Health Association Policy statement database: patients' right to self-determination at the end of life. American Public Health Association website.http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1372Google Scholar Other national medical organizations have also done so.3American Medical Women's Association American Medical Women's Association Position Paper on Aid in Dying. American Medical Women's Association website.http://www.amwa-doc.org/cms_files/original/Aid_in_Dying1.pdfGoogle Scholar Physicians willing to provide this compassionate option to patients experiencing a dying process they find unbearable, despite excellent pain and symptom management, will welcome guidelines that offer advice on handling requests for aid in dying and setting forth best practices. Physicians who opt not to provide it cannot be compelled to do so, although it would be appropriate to refer a patient to a willing colleague, as is the case with device deactivation. The intent of a physician caring for a terminally ill patient ought to be to support his or her patient in making an informed, reasoned decision that allows the patient to achieve death in the manner most consistent with his or her values, beliefs, and desires. How one dies may be greatly significant. As one philosopher noted, “We live our whole lives in the shadow of death, we die in the shadow of our whole lives.…We worry about the effect of life's last stage on the character of life as a whole, as we might worry about the effect of a play's last scene or a poem's last stanza on the entire creative work.”4Dworkin R Life's Dominion. Alfred A. Knopf, New York, NY1993: 199Google Scholar Consider Talc Too in Poorly Controlled Asthma and Unexplained BronchiolitisCHESTVol. 143Issue 1PreviewThe case report of talc endobronchitis highlighted by Ong and Takano1 in an issue of CHEST (August 2012) is a useful reminder of a different mode of presentation of talc-related lung disease. They highlighted the four more common syndromes, but it is worth noting that talc-related lung disease should also be considered in the differential of unexplained bronchiolitis or poorly controlled asthma, as previously reported.2 In this case, the patient had documented asthma not responding to treatment, with evidence of unexplained bronchiolitis on cross-sectional imaging and no other explanation on intensive investigation. Full-Text PDF Premature Termination of Life Is Not Palliative CareCHESTVol. 143Issue 1PreviewAttorney Kathryn Tucker's1 guidance in an issue of CHEST (July 2012) for physician aid in dying is troubling. A citation error was apparent in a reference to the Expert Consensus Statement of the Heart Rhythm Society (HRS) regarding withdrawal of cardiovascular implantable electronic devices (CIEDs).2 Tucker1 wrote, “Provision of aid in dying does not constitute assisting a suicide or euthanasia.” The HRS statement reads, “Ethically, CIED deactivation is neither physician-assisted suicide nor euthanasia.”2 Full-Text PDF