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SPIEGEL Interview with Dr. Michael de Ridder 'What Is So Bad About Dying?'

Michael de Ridder, the head of the emergency ward at a Berlin hospital and author of a new book on dying, discusses how modern medical advances are making death more complicated for patients with little hope of living. His book makes a plea for doctors to allow people to die with greater dignity.

SPIEGEL: Mr. de Ridder, as an emergency physician, you fight to save lives every day. Which makes it interesting that you, all people, are now calling for a new definition of death in an era of high-tech medicine. Isn't that a contradiction?

De Ridder: In my field in particular, I see how the limits of life are constantly expanding, without regard for the well-being or will of the patient. In some emergency rooms, half of all admissions now come from nursing homes. If someone who is chronically ill has a heart attack or gets pneumonia there, the most sensible thing to do is to make sure that they don't suffer, and to refrain from doing anything else. But this is all too rare. Instead, old people, who are dying, are torn out of their familiar surroundings, rushed off to hospital in an ambulance, resuscitated and given artificial respiration. If they're unlucky, they die in the elevator. These are horrible, undignified situations.

SPIEGEL: Why does it happen like this?

De Ridder: Dying a simple death is no longer an option in our society, even in places where one might expect to. Hardly anyone dies without an infusion or artificial feeding. For a long time, dying has not been natural.

SPIEGEL: What do you consider "natural death"?

De Ridder: I'm reminded of a woman in her late 80s who was still very vigorous. Her daughter brought her to our emergency room with massive intestinal bleeding. A colonoscopy showed that it was caused by a tumor. The bleeding could only have been stopped with an operation. She didn't want it. She said that she had lived a full life and now preferred to die rather than embark on an indefinite path of suffering. The daughter agreed, and the woman died that same day. It was a totally plausible decision that no one could object to, particularly as bleeding to death is a gentle way of dying. But the doctors felt snubbed. There were bitter discussions over whether this should even have been allowed to happen.

SPIEGEL: But don't doctors see themselves as guardians of human life?

De Ridder: The mandate to heal is primary, of course. But the mandate to allow someone to die well is equally important in terms of ethics. In reality, however, the chain of resuscitation and treatment often takes on a life of its own. The person who is supposed to benefit from it, with his or her individual ideas about living and dying, is no longer relevant. Here's a classic example: A doctor arrives here with an old man from a nursing home. After having a stroke two years ago, the man stopped eating, could no longer communicate and seemed to have lost all interest in life. He had now contracted a serious case of pneumonia, and the people at the nursing home didn't want the responsibility. Just as the doctor was transferring him into the emergency room, he went into cardiac arrest. Her automatic response was: intubation, oxygen, ICU! I said to her: "Slow down. This man is dying, and now we are going to allow it to happen."

SPIEGEL: In the past, doctors had no other choice. It was said that pneumonia was the old people's friend.

De Ridder: And rightly so. Because it allows the patient to slip away quickly and, for the most part, without suffering.

SPIEGEL: Today's technical advances force these sorts of ethical decisions on doctors. Are they prepared for this?

De Ridder: Poorly. Often they do not have the internal systems in place to deal with this. Because of that, their first concern is to be on the right side of the law. They think: I did everything possible, so nothing can happen to me. This can have grotesque results. I remember a very emaciated old man with septicemia. Presumably it was a perforated intestinal tumor or something like that. Whatever the case, it was a hopeless situation. While the doctors were waiting with him in front of the X-ray machine, he went into cardiac arrest. They agreed not to resuscitate the man or do anything else. A completely responsible decision. But the file says something different: "Resuscitation discontinued after 25 minutes." The doctors wanted to cover themselves because they felt the hand of the state prosecutor on their shoulders.

SPIEGEL: An understandable fear?

De Ridder: No, it's a perversion of medical thinking. If I resuscitate someone like that, I am failing in my mandate. And in the face of such undesirable developments, we must ask ourselves: What is so bad about dying? It happens anyway, and it is never particularly nice. With palliative medicine, we now have the ability to make death happen the way people want it to: Peacefully. But all too often we work against that principle and turn death into a horrible experience for many.

SPIEGEL: To avoid this, more and more people have living wills, in which they specify exactly what they don't want.

De Ridder: And those who don't have living wills are automatically treated with everything that is technically possible? What a perverse world, in which people have to walk around with notes in their wallets that say: "Please, no tubes!" because doctors pursue the technological imperative instead of first considering the welfare of the patient or the medical signs.

SPIEGEL: So what do you propose?

De Ridder: We need a concept for the treatment of hopeless cases. We can delay the time of death almost indefinitely with dialysis, artificial respiration and feeding tubes. But at what point does this no longer serve the welfare of the patient? As an intensive-care doctor, there have been times when I've treated patients and said to myself afterwards: That wasn't a good decision. I too have experienced the long-term consequences of medical aid that doesn't make sense.

SPIEGEL: Do you have something specific in mind?

De Ridder: The many patients who have been resuscitated only to remain alive in a vegetative state, for example. Medicine puts 3,000 to 5,000 people a year in this awful state, in which they will remain suspended, unless they happen to have a living will. It was different in the past. In the 1960s, just about every other patient left the hospital in reasonably good health after resuscitation. The others died, partially because at the time you couldn't just keep feeding the unconscious. Today about one in 20 patients survives resuscitation. Take away those who leave the hospitals requiring long-term intensive care and the success rate drops.

'Expensive Human Rights Violations'

SPIEGEL: Why is that?

De Ridder: In the past, doctors were acting under much stricter conditions. They would only treat patients who, for example, had a heart attack with atrial fibrillation but who were otherwise healthy. I happen to be one of those patients. Without highly advanced medical procedures, I would not be sitting here today. Nevertheless, I still support the conditions that doctors worked under then. Because since then, the use of medical technology has been expanded to include even the chronically ill and those who have already reached the limits of their lives. In an extreme case, a patient with an end-stage tumor is shocked back into life.

SPIEGEL: What criteria should a doctor use to decide which lives are worth preserving?

De Ridder: It isn't about morals. It's about empiricism. You could say, for example: If a treatment was not successful the first 100 times, it should not be used for the 101st time. With the example of resuscitation: No brain can survive without oxygen for more than eight to 10 minutes. If I know that this time limit has been exceeded -- the patient has enlarged pupils and is almost clinically dead -- then my efforts are pointless. Unless of course, I think it's a good thing to produce patients in a vegetative state, at a 99-percent success rate. But doctors are fighting such concepts with all their might. They say: But you never know! There are 100 extraordinary circumstances that may mean that it is possible to help one out of 100 patients to continue to live a meaningful life, they say.

SPIEGEL: So should that person, that one out of 100, simply be abandoned?

De Ridder: Let me answer that with a question: Should I be allowed to put 99 people into a terrible situation, just because what I do benefits one person? How ethical is behavior where 99 decisions cause suffering: Are these (decisions) not as important? The guiding principle for any physician is not to harm the patient. Additionally resuscitating someone who has metastasizing cancer and failing kidneys, after cardiac arrest, is completely pointless. This isn't any requirement for dialysis any longer either. Doing this, I am just prolonging the patient's suffering. And in fact, our ICUs are filled with people who are being treated without good medical reason, people who don't belong there.

SPIEGEL: Does this also affect other areas of intensive care?

De Ridder: Yes, for example, artificial feeding through a percutaneous endoscopic gastrostomy (PEG) tube inserted into the abdominal wall. The PEG tube was invented to feed accident victims or people with a temporarily impaired ability to swallow. It was never intended as a long-term measure. But today about 100,000 people in Germany are living off these tubes. That is even though many studies have shown that a PEG tube neither prolongs life nor improves its quality during the end phase. On the contrary, in fact. And this is particularly applicable to patients with advanced dementia. These are expensive human rights violations that are happening at the end of life -- and doctors are responsible for them.

SPIEGEL:Some patients want their doctors to help them end their life with dignity because they can no longer tolerate their suffering.

De Ridder: I am convinced that there are situations in which it isn't just ethically justified, but in which I, as a doctor, have a duty to do this. Situations in which I am called upon to relieve the suffering of someone who is severely ill, and in a hopeless situation -- and to conduct this in the manner in which the patient wants. In this sense, I see assisted suicide as a kind of palliative measure, albeit a very extreme one.

SPIEGEL: What kinds of situations are you thinking of?

De Ridder: I experienced one case, up close. A patient had a tumor in his neck, and it began to bleed. He was in his last few weeks. He said: I don't want to burden my family, or myself, in this condition. A completely plausible concern. And his doctor helped him. That is ethical behavior, as far as I'm concerned.

SPIEGEL: Would you help?

De Ridder: Yes, if their decision were permanent and it was reached without external pressure, and if there is no evidence of psychiatric illness. You have to know the patient very well for this. Over the past year and a half, I have come to know a young woman, a brilliant scientist, who, since an accident two years ago, has been paralyzed from the head down and is completely without feeling. She wanted the artificial respiration shut off but she was refused, as that is clearly illegal. She was literally reproached for being the only patient in the ward who didn't want to live.

SPIEGEL: How is the young woman doing now?

De Ridder: She is breathing on her own again. But she says that she can't touch anyone anymore, she can't do her work anymore, she can't even lift a pebble. She doesn't want to live like this. Mind you, it's a life that wouldn't even exist without advanced medical procedures and it's also one that she can no longer end on her own. In that situation, I can't exactly order that the woman should be turned so-and-so-many times a day, that she should be fed and that she should lie there for another 40 years, just because we have the technological know-how and we want to satisfy our ethical standards.

SPIEGEL: So what do you intend to do?

De Ridder: If she stands by her decision, then I will help her. And I will face the consequential controversy.

SPIEGEL: You could run up against medical rules of conduct.

De Ridder: Yes, official medical ethics forbid something that is permissible under criminal law and constitutional law. But should they? We have to clarify this. A large number of my colleagues support what I say -- this is confirmed regularly by opinion polls. For years, the German Medical Association (Editor's note: the national umbrella organization for German regional medical associations which helps in establishing health policy) has had a de-facto ban on thinking or speaking about this issue. But as doctors we need an open debate on physician-assisted suicide and the problems that arise around the administration of palliative care.

SPIEGEL: Mr. de Ridder, we thank you for this interview.

Interview conducted by Beate Lakotta
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