Touched and troubled by Amy
CMAJ 1997;156:1118
In response to: R.W. Dunn; W.D. Gutowski
Re: "Learning from Amy: a remarkable patient provokes anguished debate about rationality, autonomy and the right to die" (CMAJ 1997;156:229-31)
Dr. Gutowski is troubled with Amy's story, and that was exactly the purpose of publishing it. He is appreciating some of the feelings we experienced at the time. Amy was a singular woman. She presented us with substantial challenges that evoked considerable soul-searching.
It is fair to suggest that the patient really had a deep longing for assistance and that her first suicide attempt was a cry for help. However, careful examination of the details makes this appear unlikely. She was repeatedly offered aggressive medical treatment, palliative care and psychiatric help, all of which she unequivocally refused.
Gutowski refers to my "superficial" knowledge of the patient. As hospital department chief, I participated in many of the deliberations. I reviewed the records and spent hours interviewing those who cared for her, including the family physician who had established a good relationship with her. Almost all of the principals mentioned in the story reviewed the manuscript, checked it for accuracy and offered supplemental material. I can therefore assure Gutowski that my understanding of the details is not superficial. I also suggest that a family physician with a continuing relationship with a patient can have as deep an understanding of patients and their social context as a consultant psychiatrist can gain from even several sessions.
Gutowski implies that Amy's death was somehow facilitated by her physicians and that her care was managed in a cavalier fashion. The article makes clear the extent of advice, assistance and support offered to her. Although it may be desirable to "ally ourselves with life" when possible, we do not have the right to overrule the wishes of competent people, even if we feel they have made a bad decision. Although it is appropriate for a professional caregiver to suspect that a wish to die is not rational and must therefore be based on a mental illness, it remains our belief that this was not the case with Amy.
The details around Amy's last days were reviewed by our hospital's ethics committee at the time, and it felt the decision to release her was reasonable. More recently, her case was formally discussed during an interdisciplinary rounds. Her caregivers, the ethics committee, 2 medical bioethicists and a representative from the coroner's office were present. We reviewed details not covered in the article or available at the time of her death, including a "psychological autopsy" from the medical examiner. There was again no suggestion that her treatment was wanting. Although we continue to debate the issues and wonder "what if," I am convinced that Amy received compassionate and appropriate care to the fullest extent possible.
Stewart Cameron, MD
Chief
Department of Family Medicine
Queen Elizabeth II Health Sciences Centre
Assistant Professor of Family Medicine
Dalhousie University
Halifax, NS
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