The death of the French nurse Vincent Lambert this Thursday after 10 years in a vegetative state and a long judicial battle that divided his family has once again put the focus on the debate on dignified death and euthanasia. In Spain, the family of María Teresa Blanco, with a neurodegenerative disease, also beat with the medical team to keep it alive, despite the fact that clinicians consider it a "therapeutic frenzy". The lack of a document of anticipated wills in both cases, has put in the hands of their respective families and doctors, the end of these patients.
"What should prevail are reasonable decisions," ditched Dr. Josep Planas (Barcelona, 1953), oncologist and head of the Palliative Care Unit at the Hospital del Mar in Barcelona. The doctor has dealt with all types of cases since he founded the service 27 years ago and demands common sense in the decisions, using the "rules of the game" of bioethics and encouraging documents of anticipated wills when there is a diagnosis with unfavorable prognosis.
Question. What is therapeutic fierceness?
Answer. We start from the base of an incurable patient, where all the therapeutic possibilities have been exhausted and we intend to continue with a more or less aggressive treatment. Fierceness does not lead either to prolong life or to give quality of life.
P. Where is the limit of the fierceness?
R. Saying where the limit is is a very individual issue. Hospitals usually have a committee of futility, which is the one that assesses whether it really is worthwhile to have a patient in the ICU and try to do thousands of procedures that are not going to improve the patient. This committee, which is very similar to bioethics, is the one that defines and advises the care teams where to continue or where to stop. This committee is an advisor – the person in charge is the service that takes that patient – but he usually listens to it.
P. Does pain and suffering mark the decision making?
R. Suffering and pain are not synonymous. You can suffer without having pain. Nowadays, in the palliative units, treating pain is possible. Suffering, on the other hand, is enormously complex. The unconscious person does not know if he suffers, probably not. I would not go for the subject of suffering, but for asking ourselves if all the effort we are making, of treatments, if they are useful or not and what objectives they have. And if the objective is not clear, we must stop and think when we stop it. Stopping a treatment is not euthanasia.
P. Is the power of the clinicians in these cases very limited?
R. There are some rules of the game that bioethics gives you. Bioethics does not solve problems, but gives some guidelines. And the first guideline is that the decision of the individual is above that of their environment, except that their decision may cause some harm to the environment.
"Stop a treatment is not euthanasia," says the oncologist
P. And if the patient can not decide?
R. I recommend the history of life: what do we think when we are healthy? That's why it's important for society to talk about these things. The life story has to be a trustworthy person. I would never make a document of wills if I do not know what disease I am going to have. That's why I insist on talking about this close to the diagnosis of chronic incurable diseases. Most people can anticipate, more or less, where the shots will go. And the rest, we can not foresee, that's why it's important to know what people think about this.
P. Bet on the obligation to sign a document of advance directives?
R. I do not like the concept of obligatory nature. But what the professionals involved in patients with a disease that will potentially cause very serious problems and bioethical decisions sometimes do not and should do, is to advise patients with a certain vehemence so that they think that if this disease is going to go wrong , what do they want, both in the sense of doing things and of limiting. When the situation is predictable, like the sick woman in Madrid, it would be necessary to foment, perhaps not to force, that the person is responsible for his future, of what may happen to him, even if it is a serious decision. It is not necessary to do it to the crazy thing, nor in the first visit, but to consider it seriously and when this person is able to decide. Another thing is when an acute process occurs, such as the case of the French patient, such as an accident or a stroke, where it is not possible to foresee the consequences. Here comes the mess. If one does not have the capacity to decide, there comes the problem of the relatives. And the second problem is if not all the relatives go in the same direction.
P. In a case where no document has been signed, what is the most important, the clinical decision or that of the family?
R. What should prevail are reasonable decisions. What you should know is how a healthy person thinks about an illness. It would also be convenient to have a reference person so that, when we can not decide, this person who knows us, knows how to interpret our will. And if it were not familiar, better, to avoid conflicts of interest. That he was a friend, a person of extreme confidence, that he knew how to interpret. What should be achieved is, before an exhaustive information on the part of the medical team, that the relatives, with an order, could decide reasonably and always taking into account how this person is, what beliefs he had, how he thought.
"The decision of the individual is above that of their environment", maintains the doctor
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