Saturday, March 26, 2005

Doctors call dehydration a 'peaceful' way for normal people to die?

In the Philadelphia Inquirer article "Doctors call dehydration a 'peaceful' way to die" (Sat, Mar. 26, 2005), staff writers Stacey Burling and Michael Vitez seem to quote Ira Byock, director of palliative medicine at the Dartmouth Hitchcock Medical Center in New Hampshire, John Hansen-Flaschen, chief of pulmonary, allergy and critical care at the University of Pennsylvania Medical Center, and Paul Marik, director of the division of pulmonary and critical care at Thomas Jefferson University Hospital as saying "Even a normal, healthy person would feel little discomfort after the first few days of thirst." From the article:

... Schiavo, who could begin her eighth day without nutrition or water who this afternoon, will die of dehydration, not starvation, the doctors said. It will cause her kidneys to fail. Toxins will build up in her blood, eventually causing her heart to stop beating.

Dehydrated patients gradually weaken, drift into a coma, and appear to die painlessly, Marik said."It's a very painless and very compassionate way of dying," he said. Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors [Byock, Hansen-Flaschen and Marik] said.

WHAT?

I am hoping this is a misinterpretation by the Philadelphia Inquirer authors of the physicians' statements. Even a cursory search on google.com, let alone a more comprehensive search of the biomedical literature via specialized tools such as Medline and others, shows that there is a significant amount of controversy on the topic of palliative care and side effects of dehydration and withholding of intravenous fluids. Clicking on the following URL initiates a search via the simplest of strategies [ "palliative care" AND "intravenous fluids" ]: http://www.google.com/search?q=%22palliative+care%22+%22intravenous+fluids%22&hl=en&lr=&start=20&sa=N ).

From just the first few pages of over 8,000 hits from this topic, for example, appears this statement from the official journal of the American Society for Clinical Oncology :
Dehydration can result in serious symptoms in an otherwise healthy person, causing profound fatigue, postural hypotension, renal failure, delirium, and ultimately death. ("To Hydrate or Not to Hydrate: How Should It Be?", Journal of Clinical Oncology, Vol 18, Issue 5, March, 2000: 1156-1158.)
For a more diverse view from another country, Robin L. Fainsinger, M.D., Director, Palliative Care Program, Division of Palliative Medicine, Department of Oncology, University of Alberta, writes in "When to Treat Dehydration in the Terminally Ill Patient?":
Our palliative care group has argued that the viewpoint that dehydration in dying patients is never a cause of symptom distress, overlooks the fact that: - 1) dehydration is well recognized in nonterminal patients to cause confusion and restlessness, problems often reported in terminally ill patients; 2) reduced intravascular volume and glomerular filtration rate caused by dehydration is accepted as a cause for prerenal failure, with opioid metabolite accumulation in the presence of renal failure causing confusion, myoclonus and seizures, having been well documented (1, 2, 3).

I am inviting the authors and those quoted in the Philadelphia Inquirer to respond to the seemingly-fantastic statement that "even a normal, healthy person would feel little discomfort after the first few days of thirst."

It seems not only incredibly counterintuitive but also contradicted (or at the very least shown extremely debatable) in even the most cursory, third-grade-level information search. I am hoping this is just a a case of sloppy journalism, not unusual in the world of today's mainstream media.

-- SS

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Update, Satuday Mar. 26: I received a reponse from Dr. Byock. He writes:

It [the Philadelphia Inquirer quote] is a misstatement. It would be true if the article had said, "Even a normal, healthy person would feel little discomfort after the first few days of hunger." A normal, healthy person would need fluids to avoid feeling persistent thirst.


(Not to mention profound fatigue, postural hypotension, renal failure, delirium, and other not-very-pleasant sensations.) My response to him was:

I'm glad it's a misstatement. However, the article does say: "Schiavo, who could begin her eighth day without nutrition or water who this afternoon, will die of dehydration, not starvation, the doctors said. It will cause her kidneys to fail. Toxins will build up in her blood, eventually causing her heart to stop beating. Dehydrated patients gradually weaken, drift into a coma, and appear to die painlessly, Marik said. "It's a very painless and very compassionate way of dying," he said. Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors said", the article seemingly being very precise about the matter of hydration.

I wonder how such a statement got into print. With the Schiavo case being a hotly-contested issue and a cause of hot emotions across the political spectrum internationally, it seems major newspapers need to take significantly more care in what they publish.

Certainly a major correction by the newspaper is in order. Will it happen?

-- SS

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Update, Sun. March 27: Dr. Marik also responded and said the statement was in error. However, instead of correcting the article, the Philadelphia Inquirer republished it almost verbatim in the Sunday, Mar. 27 edition under the title "Dehydration death seen as peaceful." The bizarre statement that "Even a normal, healthy person would feel little discomfort after the first few days of thirst, the doctors said" is repeated.

I'd sent an email about the error with a link to this blog post directly to the Inquirer reporters just after writing the post yesterday, about 10:30 AM EST. Apparently reporters are delayed in reading their email, don't work on weekends, or perhaps stick by their quotation.

What's amazing is that print newspapers still wonder why people are turning to the Blogosphere for information and away from old media. In the blogosphere, feedback and corrections to errors are rapid.

-- SS

5 comments:

MichelleB said...

If it's such a peaceful way to die, why'd this guy get arrested?

http://www.timesargus.com/apps/pbcs.dll/article?AID=/20050324/NEWS/503240325/1003/NEWS02

Roy M. Poses MD said...

I have also communicated with Dr. Paul Marik, who responded thus:"What I said was 'She would become dehyrated and progress into acute renal failure. She would drift slowly into a deeper coma and ultimately her heart will stop due to electrolyte and metabolic abnormalities.' I
said that this would 'be a painless death.' She asked me about a healthy person and I repled 'A healthy alert fully cognitive person
would become thirsty and seek out fluids.'"
It's amazing how every aspect of this case brings out conflict and grief.
I agree with InformaticsMD that the newspaper stories on the case have often over-simplified complex medical concepts, and may have gotten some things plain wrong.
On the other hand, on this blog we are very dependent on local news media for reporting about some aspects of health care that rarely seem to make it to the polite medical journals. So I feel I must show proper appreciation of the news media as well.
Newspaper reporters usually work very hard under trying conditions. They have rarely been trained in health care. So they mostly try their best to get things right, and usually succeed. But sometimes they get it wrong, at times because subconscious biases lead them astray. And in such an emotionally charged and complex case, getting it wrong does have consequences.
Maybe as the blogsphere matures, the "main stream media" (MSM) will figure out how to use it to increase the accuracy of their product.

APeticola said...

Thanks, Scott, for raising this issue. Although I absolutely think death is the best choice here, I think this "letting someone die" is far more brutal than actively killing someone quickly, and I'm appalled at both alternatives on the table, and amazed that no one seems to be questioning these as the choices.
I'm personally very skeptical about any kind of "good death" (or "peaceful death"), believing only in the "least worst" death. Although I'm certain someone with a minimally functional brain does not suffer some aspects of a fully functional person, I'm also very skeptical of the idea that all pain and sensation reside in the brain. That's a convenient idea, not only here but for organ transplants, etc. I remember when the medical profession questioned whether neonates suffered pain and thought it was better not to relieve it.
I also question whether if the only legal way is to let her die, whether she should not be receiving anesthesia, or at least medication for anxiety and pain. It's very troubling. Though not to me more troubling than her previous state. Both seem horrible.
Although it's also a difficult choice, active euthanasia is the best, i.e. "least worst," possibility here to me, and it's amazing that no one is talking about legislation to permit that. Instead, we yak about how painless dehydration is.

Anonymous said...

Regardarding Roy Poses' comment on the MSM, the Philadelphia Inquirer has a track record for not using anything - reader feedback, blog commentary, etc. - to improve their product.

Anonymous said...

Looking at the pictures and listening to the testimony of the people that actually loved Terry, the Philadelphia Inquirer could only have gotten this information wrong, because they support the passive euthanasia of another human being. There was nothing peaceful or easy about her demise; only someone who already thought it justified would try to paint it that way. Bad journalism as well as bad ethics.