Laughing When It’s No Laughing Matter

Tarris Rosell, PhD, DMin, and David Casarett, MD

At our 2015 annual Flanigan Lecture events, I had expected more controversy and less humor. The topics were CPR and medical marijuana, and ethics issues pertaining to both.

Off the lecture circuit and in clinical or personal situations, Flanigan lecturer Dr. David Casarett encounters plenty of controversy, and not much to joke about. He is a palliative care and hospice physician. His patients are either suffering or dying, or both. Families are traumatized or grieving. Serious business. In healthcare facilities, controversy erupts daily around treatment decisions and transitions of care, and about what should be done when a patient stops breathing.

Serious Cases, Controversial Outcomes

Some seriously controversial occurrences were impetus for both of Dr. Casarett’s recent book projects.

• A 2 year old, Michelle Funk, drowns in a cold creek, and after 3 hours of protracted CPR attempts, she (miraculously?) comes back to life—with brain cells intact and working.

Does this mean that we should default to CPR for everyone who stops breathing or loses a heartbeat, and that rescuers should almost never stop, on the chance that the victim could be another Michelle Funk?

• A 42 year old with end-stage cancer and associated pain gets some relief from getting stoned, and moves to Colorado hoping for ready access to “medical marijuana.”

Does this mean that permissive marijuana laws such as those in Colorado, and increasingly elsewhere, are right and good, to be emulated everywhere?

Controversy.

Humorous Paths to Thoughtful Conversation

Casarett finds humor in the midst of ongoing debates regarding what ought to be done with “the recently dead” or those who find pain relief from a reefer. Book titles—Shocked and Stoned—reflect  a not entirely serious treatment of controversial topics. His next book is on assisted suicide. We brainstormed one-word titles to fit a trilogy. Nothing very funny, or appropriate, came to mind. And that is a challenge one faces when addressing serious topics with humor. Joking around with the suffering of others could be experienced as insensitive and inappropriate.

In person, David Casarett is just the opposite. He comes across as witty but thoughtful, even shy. I expect his patients and colleagues love him, and he them. He also has a penchant for finding issues in palliative and hospice care that pique our curiosity—and tickle the funny bone.

It is hard not to smile at some early attempts to resuscitate newly dead bodies. Casarett writes and speaks about a method once used that involved blowing tobacco smoke up the rectum. Really.

Although medical marijuana is supposedly about getting relief from symptoms and not about getting high, just mention Colorado these days and “stoned” jokes start to fly. Casarett provokes this response, or perhaps anticipates it, by the title of his book on the subject.

Suffering and dying are no laughing matters, and we surely do not all agree on what ought to be done about default CPR standards or legalizing marijuana for medicinal use. Behind each controversy are the incredibly sad stories of persons who died and others who suffer the pain and discomfort of incurable diseases. Our wish to avoid these experiences, or conflict, may lead to avoidance altogether. Scholar-practitioners like David Casarett enable us to engage the serious and controversial with tasteful good humor. Everyone likes a good joke. When the laughter dies, thoughtful conversation might begin—as it did for Flanigan Lecture participants on August 12th.



By Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics

The "Slow Code" Debate

Half-hearted medical care for hopeless cases

Robert Cribb

Toronto Star

November 25, 2012

Dr. John Lantos, director of the Children’s Mercy Bioethics Center in Kansas City and co-author of a journal article titled “Should the ‘slow code’ be resuscitated?” says the clandestine practice is happening far more than medical professionals openly concede.

“People say, ‘We’d never do a slow code. But they also say they stop resuscitation after three or five minutes. “I think it’s appropriate to do that. I just think it’s politically incorrect to admit the real rationale. They’re stopping because CPR is futile and inhumane.”

Link to Podcast: Resuscitate the Slow Code? John Lantos, MD, The Bioethics Channel, November 9, 2012

CPR Rates among Elderly and Minorities

Rosemary Flanigan
Distinguished Fellow
Center for Practical Bioethics

October 16, 2009

A July 2, 2009 article in the New England Journal of Medicine suggests NO improvement in elderly survival following CPR from ’92-’05; in-hospital deaths preceded by CPR increased, and the proportion of survivors discharged home after undergoing CPR decreased.

And the article associates higher rates of CPR but lower rates of survival after CPR to race. That is most interesting, I think. Justice denied over the centuries is most apparent today in the lack of trust in the healthcare system shown by blacks—shown here in their expectations of CPR as has been shown elsewhere in their low rate of advance directive planning. Talk about complexity!

The journal article ends: “This study provides information useful to older patients and their clinicians in their decision about whether to choose to be resuscitated, since the proportion of elderly patients who choose resuscitation is directly related to the probability of survival that is presented to these patients. Our findings also provide a stimulus to understand the association between race and survival, with the goals of not only eliminating racial disparities in the quality of medical care but also understanding factors associated with the incidence of CPR and the rate of survival after CPR for patients of all races.”

What if an ethics committee invited some emergency room professionals to a short meeting in which this article is discussed? What if the committee invited some GPs to the same meeting?

Facts don’t always change moral assumptions, but sometimes they do.

Ethics Committees and Blood Transfusions II

Rosemary Flanigan
April 7, 2009

Thanks to all of you who ruminated on the suggestion that ethics committees review orders for over 7 units of blood!! Those would have to be very special ethics committees and supported by a very special medical staff!!

John Carney said 2/3 of patients who didn’t want CPR, for example, “want other measures of life-sustaining treatments.”

So the question is, “How does the hospital respond in such cases?” And I would answer, “However the patient decides”—on the POLST or TPOPP forms where they list the “other measures” they want. Of course, this demands an institutional commitment and a medical staff commitment.

BUT it certainly calls for a literate, thoughtful patient-body!!!! And isn’t that what so many of us have been about these many years?

And not just us—but our surrogates as well.