June 2007

VOL.80 NO.5 June 2007 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Choosing Life or Death

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CONTENTS Choosing Life or Death: June 2007 Volume 80, Number 5 FEATURE ARTICLES

MONTHLY COLUMNS

10 Moments in Conscience: Choosing Life or Death After Hurricane Katrina Cindy Spring

4 On Your Behalf 5 Upcoming SFMS Events

11 An Open Door: Someone’s Always There to Talk at the SF Suicide Hotline Eve Meyer 13 Choosing Life After Torture: Treating Survivors Uwe Jacobs, PhD 14 Elizabeth’s Choice: Reflections on Elizabeth Edwads’s Breast Cancer Michael Lerner, PhD 16 Finding Meaning in Life and Death: AIDS Patients Face Difficult Choices Kristin Razzeca, MD

7 President’s Message Steve Follansbee, MD 9 Editorial Mike Denney, MD, PhD 35 Hospital News 38 In Memoriam

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18 Choosing Life: A Kidney Transplant Patient Reflects on her Choices Lisa Frieden

Editorial and Advertising Offices 1003 A O’Reilly

20 Choosing Life at 200 MPH: The Do’s and Don’ts of Race Car Driving Tom Madigan 22 Reflections on Choice: A Physician’s Beliefs Solidify When He Becomes Patient Steve Heilig, MPH

San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833

Email: adenz@sfms.org Web: www.sfms.org/magazine Subscriptions:

23 Reflections on Choice: A Terminally Ill Patient chooses Quality of Life Mike Denney, MD, PhD 24 Suicide and the Golden Gate Bridge: Can We Allow the Deaths to Continue?

Mel Blaustein, MD

$45 per year; $5 per issue Advertising information is available on our website, www.sfms.org/advertising, or can be sent upon request.

Printing: Sundance Press

25 Choosing to Fight, Choosing to Yield: The Spiritual Dimensions of Dying Megory Anderson 26 Physician-Hastened Death: The CMA Voices Its Opposition Anmol Mahal, MD 27 Physician-Hastened Death: The Case for Physician Aid in Dying Norman Carrigg, MD, and Stephen Jamison, PhD 29 Are We “Considering the Unthinkable”?: Publishing a Protocol for Assisted Dying Steve Heilig, MPH 30 Giving Life From Death: Organ Donation Cherry Wise, PhD 33 Supporting Patient Choice Brad Stuart, MD, Elizabeth Ciemins, PhD, MPH, and Jeff Newman, MD, PhD

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To see San Francisco Medicine Magazine online, please visit our website:

www.sfms.org/magazine Visit today to find the current issue, archives, information about upcoming themes, and subscription forms.

ON YOUR BEHALF

June 2007 Volume 80, Number 5

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artists Amanda Denz and Ashley Skabar Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro

Mark Your Calendars for the Return of SFMS Gallery Mixer!

The date is Thursday, July 12, at the Togonon Gallery (www.togonongallery. com), from 5:30 to 7:30 p.m. A great chance to meet other members in a relaxed setting with beverages, hors d’oeuvres, and live jazz.

This was a big hit last year, so be sure not to miss the fun this time! The cost is just $10.00 for SFMS members, and $15.00 for nonmembers. Nonmembers who choose to join the Medical Society at this event will have that amount deducted from their introductory dues! RSVP to Therese Porter in the Membership Department at (415) 561-0850 extension 269 or tporter@sfms. org by Friday, July 6th.

Secretary Michael Rokeach Treasurer Charles J. Wibbelsman

Reach out to New Members!

Editor Mike Denney

For several months, members of the Board, Executive Committee, and Membership Committee of SFMS have been engaged in a program to mentor new members. Upon approval by the Board or Executive Committee, each new member is assigned to a sponsor whose primary responsibility is to help the new member get better acquainted with the Society and its benefits. Sponsors are expected to connect with the new member socially (over breakfast, coffee, etc.) at least once, and to invite the member to at least one SFMS event (Annual Dinner, Legislative Day, Candidate’s Night, Mixer, etc.) during the course of the first year of membership. All members are encouraged to participate in this program. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 269 or tporter@sfms.org for more information or to volunteer.

Immediate Past President Gordon L. Fung SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate

San Francisco Medicine june 2007

SFMS Leaders Meet with Legislators In April, an SFMS delegation met with most of San Francisco’s state legislative representatives during the annual Sacramento “lobby day.” Led by Drs. George Susens, Lucy Crain, William Goodson, Eileen Aicardi, and Shannon Udovic-Constant,

our delegation met with Assemblyman Mark Leno, Senators Carole Migden and Leland Yee, and Assemblywoman Fiona Ma to discuss issues of importance to medicine and public health. It was notable that, on almost all issues discussed, our legislators had already heard from SFMS representatives and were in agreement with our positions.

This annual event is an opportunity for San Francisco physicians to be heard by our elected leaders and in most cases results in warm and frank discussions.

Joe Dunn Attends SFMS Board Meeting In May, CMA Executive Vice President Joe Dunn (pictured below) addressed the SFMS Board of Directors during its bimonthly meeting. Dunn spoke about the state of the CMA, health care reform in California, and his plans to unite physicians across the state as health care advocates. He urged every physician to get involved as an advocate at both the state and local levels.

SFMS Delegation: Open for Policy Proposals SFMS’s delegation to the California Medical Association, with a strong track record of developing and advocating policy on a wide range of medical and public health issues, welcomes substantive ideas for new policy from any SFMS member. All relevant topics considered; please contact Steve Heilig at (415) 561-0850 extension 270 or heilig@sfms.org, to discuss any potential areas of concern.

SFMS Joins Reproductive Health Coalition A number of medical associations are forming a group to improve reproductive health of California women. Specialty www.sfms.org

associations including the obstetrics and gynecology and family practice associations are joining the advocacy group Physicians for Reproductive Choice and Health for this purpose, and SFMS was asked to join as a county medical society with an active record of advocacy in this arena. Organizational meetings are underway; for information, contact Steve Heilig at (415) 561-0850 extension 270 or heilig@sfms.org/.

SFMS Distributes Funds to Worthy Groups The San Francisco Medical Society is periodically asked, via our Community Service Foundation, to help distribute funds from other sources to noteworthy charitable efforts with a health focus. The most recent round of such distributions came from a Danish Foundation, and the grantees included the Saint Anthony Free Medical Clinic, the UCSF Medical Students Homeless Clinic, Planned Parenthood Golden Gate, and the French Foundation for Medical Research and Education. The checks were presented at a recent SFMS Board of Directors meeting.

Stephen Follansbee Featured on KQED SFMS President Stephen Follansbee, MD, infectious disease and HIV specialist, was recently featured in an extensive radio report on controversies about medical marijuana. Broadcast on KQED and public radio stations statewide, the segment may still be listened to at the following address: www. californiareport.org/domains/californiareport/archive/R704192000

San Francisco’s Universal Health Access Efforts Continue At the direction of Mayor Gavin Newsom and the Board of Supervisors, San Francisco’s “Healthy San Francisco” access plan for the uninsured begins enrolling patients in July. The program was designed in concept by a task force including thenSFMS President Gordon Fung, MD, and staff member Steve Heilig. Dr. Fung continues on the implementation committee, www.sfms.org

which is chaired by San Francisco Health Director Mitch Katz, MD. A local restaurant group has sued to stop the mandate for funding the plan, which calls for contributions from businesses with more than twenty employees, but proponents feel the program will be implemented. For more information, see www.sfhp.org/HealthySanFrancisco/.

2007 SFMS Seminars!

Please contact Posi Lyon (plyon@sfms. org or (415) 561-0850 extension 260) to register for any of these seminars. Space is limited; advance registration is required.

October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training in handling phone calls and scheduling professionally and efficiently.

9:00 a.m.–12:30 p.m. (8:40 a.m. registration/ continental breakfast), $99 for SFMS/CMA members/$149 for nonmembers.

November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management.

9:00 a.m.–5:00 p.m. (8:40 a.m. registration/ continental breakfast), $250 for SFMS or CMA members/$225 for second attendee from same office/$325 for nonmembers.

Hepatitis B Free CME In an effort to increase public awareness of chronic hepatitis B, the “San Francisco Hep B Free” campaign has created a series of educational opportunities for primary care clinicians.

All events will give a general overview of hepatitis B, including fundamental epidemiology of chronic hepatitis B, screening information, and essential treatment strategies for primary care practitioners. Events are available for CME credit at the following times and locations:

July 17, 2007 Tommy Toy’s 655 Montgomery Street, San Francisco 6:30–8:00 p.m.

Guest Speaker: R. Todd Frederick, MD, from California Pacific Medical Center August 23, 2007 Absinthe 398 Hayes Street, San Francisco 6:30–8:00 p.m.

Guest Speaker: Emmet Keefe, MD, MACP, from Stanford University Medical Center To register, or to find out about other events, visit www.simplyspeakinghbv.com or www.sfhbfree.org.

July 25–October 12, 2007

Special Exhibit: The Life and Times of Edward Robeson Taylor The San Francisco History Center will host this exhibition exploring the life of Mayor Edward Robeson Taylor, an extraordinary personality and symbol of recovery for the city of San Francisco following the 1906 Earthquake and Fire.

Taylor, who was named an honorary member of SFMS in the late 1800s, was appointed to office in July 1907, to fill the vacancy brought on by the conviction and imprisonment of Mayor Eugene Schmitz.

Among his many achievements, Taylor was a physician and President of the Cooper Medical School, which became the Stanford Medical School.

The exhibition will culminate the City’s yearlong “San Francisco Rising” commemoration of the 1906 Earthquake and Fire Centennial. It is presented in conjunction with a new biography of Edward Robeson Taylor and his thirty months as mayor, which appears in installments in the April and September issues of the Argonaut, the journal of the San Francisco Museum and Historical Society.

The exhibition is free and open to the public. San Francisco Main Library, Sixth Floor, 100 Larkin Street.

june 2007 San Francisco Medicine

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president’s Message Stephen Follansbee, MD

Making Difficult Choices

T

his issue of San Francisco Medicine deals with complicated but important issues. The main principle in medicine, upon which all physicians base their professional judgment, is “Do no harm.” However, as the articles in this issue point out, the operational aspects of that principle may be complex.

On Monday, February 26, 2007, at the fourteenth annual session of the Conference on Retroviruses and Opportunistic Infections, there was an elegant discussion on the risks and benefits of breast-feeding in developing countries. The presentation was made by Dr. Hoosan Coovadia, the Victor Daitz Professor of HIV/AIDS Research, University of KwaZulu-Natal, South Africa.

He documented the relative risk of transmission of HIV through breast-feeding (approximately 8.96 events per 100 years of breastfeeding), comparing it to the mortality from diarrhea in infants who are either bottle-fed or “partially” breast-fed. Estimates worldwide of infant HIV infection per year, if all infants were breast-fed, is approximately 300,000, in contrast to the approximately 1,500,000 infants who would die from other causes if breast-feeding were avoided. So, how do physicians in the developing world offer breast-feeding advice under the tenet of “do no harm” when faced with this dilemma?

As physicians, I believe we face similar issues in our own practices. We constantly weigh benefits and risks of procedures and interventions. We advise our patients on those relative benefits and risks. I recall times when I have consulted a cardiologist about a patient with worsening symptoms of cardiac ischemia. I have asked whether further invasive or noninvasive testing would be useful, knowing that the patient had been previously found to have nonoperable coronary artery disease. I was attempting to “advocate” for the patient on the one hand, but possibly just delaying the inevitable conversation I was going to have to initiate with the patient about end-of- life care in the face of untreatable disease. I have seen patients with no reasonable chance of recovery undergo placement of “lifesaving” feeding devices without careful discussion with the family regarding the issues of quality of life and recovery, or the patient’s own predetermined wishes. Why was this done? Was it done because we see “starving a patient” narrowly as “doing harm”?

We would like to think that patient wishes are paramount and that other factors play no role. However, I sometimes think www.sfms.org

that it is easier to intervene than to have the conversations with patients about their wishes. It is hard for us to admit that we have no further interventions that will improve our patients’ health. It is hard for us to recognize that appropriate care may be end-of-life care. In my own experience, at a time when my father was dying of lung cancer, the physician in charge refused to have a discussion with him about hospice care. My father, mother, and I had been having these discussions. I was trying to play the “son” and not the physician. My parents were prepared to discuss this with my father’s physician, but he would not initiate the discussion, telling me “they were not ready.” Their natural ambivalence and hope for improvement impeded their ability to introduce the issue. The physician took the easy way out, in my opinion.

These issues become complicated and confused in the area of physician-assisted “suicide” or ending of life. There are valid and impassioned arguments on both sides. There are many arguments against physician-assisted suicide. There have been occasional news reports of doctors or nurses murdering patients. There is the feeling that, in light of this, physician-assisted suicide would only demean the profession further. There are people who feel that desire for end-of-life cannot be rational and only reflects untreated or unrecognized depression, isolation, or fear of being a burden on loved ones or society. There are those who feel that economics will dictate physician-assisted suicide. They argue that patients will choose this route because they cannot bear the burden of the continued costs of care, or the risk of pain and suffering because of lack of care. There are those who feel that physician-assisted suicide will be built into our algorithms for care, much as we construct order sheets for the treatment of community-acquired pneumonia, for example.

Can physician-assisted suicide ever be patient-focused and individualized? From my experience with patients dying from AIDS, dementia, and cancer, I believe that it can. I believe it can only be discussed in the context of a universal health care delivery system that first improves its delivery of care to those who are depressed, in pain, isolated, and poor. Hopefully we will never have to look at the elements of care, including end-of-life care, in as basic a way as those physicians who must weigh the pros and cons of advice about breast-feeding. I think this issue of San Francisco Medicine should be a springboard for further discussion.

june 2007 San Francisco Medicine

They seem happy now.

But can you identify the ones who will file a claim against you for… ...Wrongful termination? ...Sexual harassment by a fellow employee? ...Failure to Promote? ...A violation of the Americans With Disabilities Act? I can’t get up the stairs to see the doctor!

She fired me without cause!

I should have had that job!

If he doesn’t stop telling me those awful jokes...

Neither can we. But let’s look at the facts*: 1. Six out of ten employers have faced employee lawsuits within the last five years.

2. 67% of all employment cases that litigate result in a judgment for the plaintiff.

3. The median compensatory award in EPLI cases is $218,000.

managers is included as well as access to employment attorneys for advice on how to properly handle employment issues to mitigate potential future claims.

Contact Marsh Affinity Group Services at 800-842-3761 for information on the SFMS endorsed special First Time Buyer program.

4. Defense of the average EPLI case, through trial costs over $45,000.

5. The average amount paid for out-of-court settlement is $40,000.

To protect their assets, employers are transferring this risk to an EPLI policy. Now, you can too. Through the San Francisco Medical Society endorsed Employment Practices Liability Program, members may not only receive important coverage for judgments and defense costs up to $1,000,000 but will also have access to risk management tools. Web based training for you and your office

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Editorial Mike Denney, MD, PhD

The Low Road and the High Road

A

ccording to an old Celtic legend, if a Scottish person dies in a foreign land, his or her spirit will be transported back to Scotland via the “low road,” a kind of underworld passage, devoid of obstacles, for the soul to travel swiftly homeward. This legend found new expression in the year 1746 at the end of the Jacobite Rebellion, when the Scottish Highlanders, led by Bonnie Prince Charlie, attacked the British army and were defeated at the famous Battle of Culloden Moor.

Two stalwart, audacious, and courageous eighteenth-century Scottish soldiers, Donald MacDonald and a friend, captured after the battle with hundreds of others, were imprisoned at Carlisle Castle. There, some of the prisoners were arbitrarily chosen to be executed on the gallows and others were simply set free and told to travel home on the high road over the mountains to Scotland.

MacDonald, chosen to be hanged on the gallows, wrote a poem to his friend who had been chosen to be freed. Later put to music, the plaintive words were: Oh! You’ll take the high road and I’ll take the low road, And I’ll be in Scotland before ye, But me and my true love will never meet again On the bonnie, bonnie banks of Loch Lomond.

Two stalwart, audacious, and courageous twentieth-century American surgeons, Franny Moore and Michael DeBakey, had experiences that seem to recall this story of McDonald, his friend, and the song about the low road and the high road. For the better part of a century, Moore and DeBakey fought a virtual rebellion against disease. Moore, as Chair of the Department of Surgery at Peter Brent Brigham Hospital of Harvard, pioneered cancer treatments, heart operations, and organ transplants. DeBakey, as Chair of the Department of Surgery at Baylor University College of Medicine in Houston, developed coronary artery bypass surgery, endarterectomy, and arterial grafts. It was in later life, when both men faced their own choices about life and death, that they seemed to participate in the old Scottish legend.

One morning after breakfast, at the age of eighty-seven, Moore chose to travel the low road of death. Physically limited and on medications for heart failure, he went quietly into his study at home, www.sfms.org

placed the barrel of a pistol into his mouth, and killed himself with a bullet to the brain.

DeBakey, on the other hand, at age ninety-seven developed unmistakable symptoms of a dissecting thoracic aortic aneurysm.

For nearly a month he tried to continue his activities but finally agreed to go into the hospital, where he lapsed into a semicoma.

After extensive, sometimes vociferous ethical arguments among the medical staff, DeBakey was treated surgically, receiving the operation that he himself had invented years earlier. The high road of life was indeed arduous—he underwent eight grueling months of intensive post-op care and physical therapy. After all that, he became active at the hospital again, exclaiming at ninety-nine years of age that he was happy to be alive.

As in this issue of San Francisco Medicine we reflect upon Doctor Moore, Doctor DeBakey, and our theme of Choosing Life or Death, we cannot help but notice the mystery inherent in the decisions people are called upon to make—palliative chemotherapy for incurable disease, suicide in the face of seeming hopelessness, reaching for experimental cures to sustain life at all cost, adjusting to life after torture, receiving end-of-life care, and giving organs for transplant surgery—all of which require choosing a road.

It brings to mind the famous last verse of a Robert Frost poem:

I shall be telling this with a sigh Somewhere ages and ages hence: Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference.

We sometimes forget that the name of this poem is not “The Road Less Traveled—” it is “The Road Not Taken.” In earlier verses, Frost tells of how he stood for a long while looking down each road, noticing they were “really about the same,” one “just as fair” as the other. He notes how difficult it was to choose which road to travel, and he admits that “ages and ages hence” he might lament the road not taken. Thus, we are reminded that choosing life or death entails difficult, ambiguous, intuitive, sometimes impulsive, and often spiritual insights. As we ponder life-and-death decisions, we might remain aware that we are “telling this with a sigh,” always in the deep mystery of whether to travel the low road or the high road. june 2007 San Francisco Medicine

Choosing Life or Death

Moments in Conscience Choosing Life or Death in the Aftermath of Hurricane Katrina Cindy Spring The following story was compiled from news reports and analyses following Hurricane Katrina in 2005. This article was created using fictitious characters and family details.

I

t’s a hot day in late August, and the weather report says a hurricane is forming in the Gulf of Mexico that could hit your town in the next twenty-four hours. The images on the Weather Channel show a The French Quarter in New Orleans whirling circular rain cloud hundreds “How bad can this get?” By the time you of miles across. The governor and the mayor reach the hospital, the waters are bumperhave already announced that everyone deep. You abandon your car and run up the should evacuate and head upstate. stairwell to the twelfth floor ICU. Many You gather your two teenage sons and nurses and doctors are valiantly trying to put water, food, and clothing in the SUV. comfort the patients. Your dad is in and out But you can’t leave. Your eighty-one-year- of consciousness. Someone shouts that the old dad is in Memorial Hospital in the ICU, city is flooding and that they have to begin where he’s struggling to come back from a evacuating everyone. This is Monday. You serious heart attack he had three days ago. stay by your dad’s bedside.

You listen again to the weather report, and

By Tuesday, you’re sharing the sense of they’re saying this is going to be a Category dread that has come over everyone. No one 5 hurricane, which means huge and danger- is coming to rescue the thirty or so patients ous. And it’s heading straight for your part in the ICU. You get secondhand reports of the world. from people with transistor radios that the What to do? Should you try to save city is filled with desperate people who are yourself and your two sons by driving north, drowning in the floodwaters. You realize or stay and risk the fury of the hurricane to that you might not get out yourself. be near your dad? You decide you cannot A news report on the radio lets you abandon your dad. You decide that your know that someone has told the outside sons are young and strong, and you’ll ride world of the crisis in the hospital, but still out the storm. no one is coming to help. The report states: The hurricane hits and ravages the “The physicians and nurses are doing an area. All electricity and phone service go incredible job. They have to walk up to out. Your house is damaged but still offers the ICU on the twelfth floor because there shelter, so you stay inside. Now you decide are no elevators. There are patients lying you’ll make your way to the hospital to see on stretchers in dark hallways. There is no what’s happened to your dad. On your way, electricity. They have no communication you notice that water is flooding the streets. with the outside world. People are dying “A levee must have broken,” you think. from the 110-degree heat, from lack of food.

10

San Francisco Medicine june 2007

There are no working toilets.”

More reports on the radio say that the city’s largest facility, the sports arena, is filled with people who have nowhere else to go. Others gather together at intersections, hoping for rescue. Bloated bodies are floating in putrid waters all over the city.

Your father is gasping, because the ventilator he needs to help him breathe doesn’t work. The hospital’s generator and backup generator have both failed. Whenever he wakes up and asks, “What’s happening?” you tell him as best you can that help is on the way. All over the city, people are continuing to die from the storm’s destruction. At night you hear gunshots from across the street.

It’s Wednesday, and some help has arrived. Helicopters have been landing on the roof. Boats have been coming to the front door of the hospital. It’s another 110-degree day with very little fresh water available. But the few doctors on hand determine that the sickest patients, including your father, cannot be moved. They opt to transfer the patients with the best chances of survival. Orderlies have to move people on gurneys, get them through a three-foot by three-foot hole in a wall that separates the hospital from the parking structure where the helicopters are landing. They push the gurneys up ramps to the top and then carry the patients to the choppers. Some patients die before they get rescued.

As the hours go by, you get more and more frantic: Is anyone going to save your father? Will you yourself die in this horror?

In a news report, another person at the scene describes it this way: “Some of the

Continued on Page 12... www.sfms.org

Choosing Life or Death

An Open Door Someone’s Always There to Talk at the San Francisco Suicide Hotline Eve Meyer

I

t is near the end of World War II, and a family approaches the border between France and Spain. Father, mother, young son, and grandmother present their documents to a guard.

Because this coastal road is a popular escape route, he scrutinizes the papers closely. He seems to find a problem and asks the family to wait while he discusses it with his superiors.

Now the father leads the family down onto the beach. “We will not al- Eve Meyer talking with a suicide hotline volunteer low them to send us back,” he says. They nod. of the attempters are women. One out of “We will hold hands and walk into the sea.” three is under twenty.

He takes his wife’s hand, they join hands with Each death from suicide leaves an the grandmother, and they reach out for the average of six survivors—family members son. But the son tries to break from their grasp. and friends whose grief is magnified by guilt “No!” he screams, and he struggles, screaming and confusion. Each attempt also leaves as never before. six survivors. As a result, three-quarters of So intent are they on their efforts to drag this country’s population will encounter the boy into the water that they do not notice the a suicide or an attempt during their lives. guard until he is standing next to them. There Afterward, each person will wonder, “How was a mistake, says the guard. The papers are could I have prevented this?” all in order. They proceed into Spain and take In San Francisco, there are between the last boat to America. One year later, I am 100 and 120 suicides each year, or one born into this family. every three days. This means that once every three and one-half hours, someone Count to thirty-five slowly. Before you makes a suicide attempt right here—in a finish, someone, somewhere in the United city that bears a lethal suicide means at its States, will attempt to commit suicide. very entrance.

Every seventeen minutes, someone dies. Suicide is the eighth leading cause of He pushes his chair away from the comdeath in the U.S., and the second leading puter. When he turns, his smile has an edge to cause for college students. it. “Why would I want to talk about it?” he Seventeen thousand Americans are says, very evenly. “It was bad enough to have murdered every year, but thirty-two thou- to live through it when she did it.” sand kill themselves. Three-quarters of them are men. One out of every six is a child Pick up the Phone under twenty years of age. More than half Suicide-prevention crisis lines are now use handguns. listed on page two of the telephone book And for each person who dies, nearly in every major community in the United thirty others make attempts. Three quarters States. They are linked by the national www.sfms.org

number 1 (800) 273-TALK. This is how they got there: It was 1961, and a brash, handsome Englishman had just arrived in San Francisco. His name was Bernard Mayes. He was an Episcopal priest, but he came as an anchorman for the British Broadcasting Corporation on assignment to cover a story about suicide in America.

He discovered right away that Americans killed themselves far more frequently than the British. Especially in San Francisco, where the suicide rate was nearly triple the national average. And he discovered another fact he considered shocking.

Almost no one would talk to the people who were suicidal.

In Great Britain, community crisis lines had become a national tradition. They were operated by a loose federation of volunteers calling themselves “Samaritans,” with offices in virtually every town.

Mayes decided to cancel his return ticket and change the situation. He began training some of the people he had met while covering the story. When he had assembled a small cadre of followers, he purchased a red phone.

“Call Bruce” The red telephone was installed in a Tenderloin flophouse. Then the group printed matchbooks reading “Call Bruce.”

They blanketed the City’s bars with the matchbooks—and suicide lines became an American tradition.

In the first month that the line was open, the group answered nearly thirty calls, an average of one each day. Today,

Continued on Page 12... june 2007 San Francisco Medicine

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Suicide Continued from Page 11...

San Francisco Suicide Prevention answers nearly 200 calls each day.

There are now more than 500 suicideprevention lines in the United States. The British Samaritans have their American cousins. What do they know that others don’t?

Say the Secret Word You are in a beginning class at a suicide prevention center. You’re sitting on an old chair with a notebook in your lap. Who are your classmates? Maybe some of you have had direct experience with a suicide.

(Remember, nearly everybody does.) Maybe you’re considering a new professional career.

Or maybe you’re are among those wonderful souls who genuinely enjoy being involved in the community.

Whatever your reasons, you’re part of the group now, and you are opening that notebook. You are about to learn the four basic steps to being genuinely helpful to suicidal clients: Asking “I am getting the feeling that you’re in a lot of pain, that you may be suicidal.

Can you tell me what’s going on? And most important, do you have any kind of plan for how you are going to do this? Have you put any of it into action? Do you have a time frame?”

Listening “How did you feel at that time?”

Suspending judgment “And then you started drinking a lot?

What was that doing for you? How were you feeling? Is there anyone or any thing that was ever helpful?”

Contracting “Would you please promise to call me (or Suicide Prevention) when you feel that bad again? I don’t want you to feel alone like that. I care about you too much to have you be in that much pain or to lose you.”

Nothing exotic—just good listening skills and openhearted warmth.

Asking about suicide opens up a door: It offers an opportunity to think, to feel, to explain, perhaps to cry. A chance to consider a dangerous decision one more time.

Without asking, without taking that risk, nothing is prevented.

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He blinks in the sunlight and blows a steady stream of smoke over the newspaper. “A day without suicidal ideation?” he asks. “I’ve never had one. Have you?”

Breaking the Code How do you know that someone is thinking of suicide? After all, you’re not a mind reader, and it doesn’t often come up in a normal conversation or a routine history.

Most people who are suicidal leave a trail of clues that—tragically—become most obvious after it’s too late. The clues are right there all the time, though; they can be read if you know what to look for: Giving hints People who are thinking about suicide often allude to it indirectly. They may make statements that are not taken seriously but should be, such as, “When I’m not around any more …” or “I’ll be going away for a long while,” or “I wish I could never wake up.”

Putting affairs in order People who are planning a suicide often wrap up their personal, business and financial affairs quite openly. Actions such as making or changing a will, closing bank and investment accounts, and assembling financial documents are often misinterpreted as “taking hold.”

Giving away personal effects People are often so delighted with these gifts (favorite records, tapes, and books; important jewelry; furniture and art works) that they miss the ominous underlying message.

Acquiring a means of killing themselves Surprisingly, this clue is the easiest to miss—often it sets off unconscious denial.

It takes the form of buying a gun, stockpiling medication, or visiting bridges or other jumping sites.

Putting these clues together is a horrifying process. (What if you are wrong? What if you are right?) Your sole reward is the life you may save.

The Future Possibly the best news by far appeared in the October 26, 2005, issue of JAMA: In an article entitled “Suicide Prevention Strategies: A Systematic Review,” the authors, Mann et al, concluded that

the most significant factors in reducing suicide rates were physician education in depression recognition and treatment and restricting access to lethal methods in the community.

After you have read this, the door to the treatment room is, in other words, the door to life.

Eve Meyer has been Executive Director of San Francisco Suicide Prevention for more than fifteen years and is frequently a spokesperson on suicide issues. She earned a master’s degree in social work from the University of Chicago and a master’s degree in health services administration from the University of Michigan. She is married to a computer professional and has a teenage son. Photos by Ashley Skabar

Katrina Continued from Page 10... sickest patients who could be transferred were brought to the roof up eight flights of stairs, in slings made of sheets. Some patients were kept on the roof as long as twenty-four hours. We were standing there waving a sheet to get the attention of the helicopters going overhead.”

It becomes clear that the rescue efforts are not going to save everyone there. A decision is made by the staff still present on Thursday to leave the hospital, or else they will all die there. You must leave; yours sons are waiting. A staff person approaches you with a morphine syringe in hand. Leaving now means your father will die in a day or two with no one around. You are being offered a way to end his suffering now. What do you do? Let the nurse give a lethal injection or not?

Cindy Spring is cofounder of Close to Home, an ecological organization dedicated to living with wildlife in the East Bay. This article was created and presented as part of a workshop on moral conflict, given at the C.G. Jung Institute. www.sfms.org

Choosing Life or Death

Choosing Life after Torture One Physician Reflects on Years of Treating Survivors Uwe Jacobs, PhD

“M

y mirror where I could see myself was broken. Now I live without a soul. No, I don’t live, Me is dead.

I go on, trying to find the pieces, putting them back together. I just want to become whole again.”

These are the words of a survivor of torture who came to our organization for help some years ago. Similar words have been spoken by other survivors. Jean Amery, who was tortured by the Nazis and who gave us one of the most eloquent writings on torture, chose suicide. He had been writing about the choice of choosing death for many years before finally taking his own life. Amery became famous for writing that torture renders its victim forever homeless in the world. Many who have survived genocide or torture continue to live with a feeling of futility. No one who has not experienced the same horrors can feel entitled to assert anything different, nor argue that despair can be reduced to a clinical symptom.

Sister Diana Ortiz, one of the most prominent survivors of torture, describes one young girl who killed herself, after having been raped many times over, in an attempt to free herself of her memories . She further describes a young boy who, as the sole survivor of an entire family, chose to live in an act of defiance against the killers.

Ortiz has been a powerful voice on behalf of survival, of life, and faith. She exhorts us to avoid the word “victim” in describing those who experienced torture. Those who seek to, in her words, “walk with survivors” take guidance from her and other survivors of torture and try not to miss their steps.

Dr. Judith Wilson, a psychologist who works with Survivors International (SI), tells about the roller coaster of providing psychotherapy for clients who have been www.sfms.org

tortured. She described a pattern that was unique but in some respects all too familiar: the seeming abandonment of all hope by

“Jean Amery, who was tortured by the Nazis and who gave us one of the most eloquent writings on torture, chose suicide.

He became famous for writing that torture renders its victim forever homeless in the world.” the survivor and the subsequent emerging of the will to survive and choose to live. It struck me some years ago that this theme was often present among our clients and that it seemed crucial to be willing and able to dwell within a pit of hopelessness from time to time in order to emerge again on the other side.

I began to work with a survivor of torture for the first time about twelve years ago. I was worried about not knowing the proper way of doing therapy with a torture survivor, although I had read a great deal about it. The hardest thing, however, was not the lack of special technical skills but the feeling of helplessness in the face of the patient’s sense that she had been irreparably damaged. The years of physical torture, rape, and other sexual abuse she had endured in an African jail left her feeling that she was now worthless and nothing but a burden.

She felt like a burden because of her profound unhappiness and despair, and she felt worthless in part because she was certain that no man would ever want to marry her

now. There was simply no hope for her.

The only thing I had to go on was the fact that she came back to see me more than once. So I deduced that hope for a better future had to be within her. I reasoned that she was quelling life-affirming choices in order to feel less pained by her memories and other difficult feelings. This clinical stance felt presumptuous, but I simply did not feel as though I had any other way to view the situation. It seemed at times that she was taking my encouragement to take more risks and that she was making progress.

It did help a great deal that she was granted political asylum, and that I had testified on her behalf in immigration court. Some time later, however, she disappeared, and I was left to feel that perhaps not much or nothing at all had been gained for her beyond the immigration relief. I talked with colleagues about this experience as a warning that one must be prepared for very painful failures in this work, and one must not overestimate the clinical process when legal issues are paramount.

However, I heard several years later, through a chance meeting, that she had moved, gotten married, and that she would still talk about how much therapy had helped her. This brave survivor had indeed chosen life after torture, and the ultimate lesson was that I had used my own pessimism to ward off my doubt and uncertainty. Experienced clinicians know that this dynamic is ubiquitous: giving in to the process of life is to risk rejection by others and a storm of emotions within oneself. Torture intimidates us with its enormity and asserts that there can be no hope afterward, that the fight will always be lost because the pain of torture is too great to be contained.

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Choosing Life or Death

Elizabeth’s Choice Reflections on Elizabeth Edwards’s Breast Cancer Michael Lerner, PhD

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n M a r c h John and Elizabeth Edwards announced that Elizabeth’s breast cancer has returned. The cancer is in her rib. It may, the doctors said, be elsewhere as well. The earlier treatments had not eradicated it. The cancer can be treated, the doctors said, but there is no cure. Standing with Elizabeth beside him, John Edwards said they had decided together that he would continue his race for the presidency.

My thoughts were with Elizabeth. For the past twenty-two years, I have worked closely with hundreds of mothers like Elizabeth Edwards who are facing metastatic breast cancer while their children are still young. I thought about what Elizabeth and John went through in making their decision.

I thought about the conversations they had before they told their staff and stepped into the sunlight to make their private grief public before a media-drenched world.

I imagine that Elizabeth had decided to live as well as she can for as long as she can. Who knows? She may have a decade of life ahead if she is fortunate. Perhaps there will be new treatments available. There is reason for hope.

I imagine that Elizabeth also decided that if she has less time, making John the President would be the greatest gift she could give to the man she loves. I imagine she wants to go out fighting for the things she believes in while also taking care of her family.

The one thing Elizabeth Edwards’s new diagnosis—and their shared decision to stay in the race—makes almost certain is that breast cancer will be front and center in the presidential campaign. The predictable course of media coverage will be stories about her courage, about new treatments, 14

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Elizabeth Edwards

about the need for more research, and about living with recurrent breast cancer as a chronic disease.

What interests me is the possibility that a new story might be told. It is a story about the need to prevent breast cancer. It is a story that a number of us across America have been telling for some time.

It is not an easy story to reduce to a sound bite. But here are the basics: There is an epidemic of breast cancer. The causes of the epidemic are clearly environmental. We do not know which environmental factors contribute, or how much.

More important, we may never know which environmental factors contribute, or how much, to the breast cancer epidemic.

Breast cancer is a disease that is amplified in industrial civilizations by an infinitely complex interaction of many factors. Diet, exercise, and chemical exposures make some contribution. There are many other possible contributors.

If it were “just” a breast cancer epidemic that is amplified by industrial civilization, maybe we would throw up our hands and say, “This is a tragedy, but it is too hard to

deal with all the complexities to try to do something.” But the breast cancer epidemic is not the only epidemic. And it is not separable from the other epidemics of our time.

How many of our children struggle for breath? How many cannot read, or write, or pay attention to what is happening around them? How many are autistic? How many have birth defects that you can see? How many have birth defects that you cannot see at birth—defects of the heart, the immune system, or the mind? How many have childhood cancers?

How many young girls have premature puberty? How many of them develop endometriosis?

How many young couples struggle with infertility? And, as we get older, how many of us, like Elizabeth Edwards, develop cancers in the prime of life? How many develop allergies, chemical sensitivities, or autoimmune diseases? How many develop early-onset Parkinson’s disease, or ALS, or early-onset Alzheimer’s? And how many are subtly altered in ways that do not manifest as frank disease, but that shift the experience of what it is like to be human?

It may be too much to ask Elizabeth and John Edwards to talk about breast cancer prevention. It seems indecent to intrude on their private and public tragedy, and to tell Elizabeth Edwards what her message about breast cancer should be. We cannot decently ask Elizabeth Edwards to make the link between preventing breast cancer and preventing many of the epidemic diseases of our time.

But it may be that some of the rest of us can say a word or two on the subject.

Because after more than twenty years of working with hundreds of young mothers with metastatic breast cancer, there is only www.sfms.org

one thing I am sure of.

I know Elizabeth Edwards is strong enough to face life and death with metastatic breast cancer. But I also know, deep in her heart, that Elizabeth Edwards absolutely does not want her daughter to face the same disease. She does not want her daughter, when she has young children, to face what she is facing now. She has lost one child already. She has no need, whether she is alive or dead, to lose another.

That thought may lead Elizabeth Edwards where many of the courageous women with breast cancer I have known have been ineluctably led. They know how difficult it has proven to find a cure for breast cancer.

Billions of dollars and decades of research have not found one. They know what living with breast cancer is like: the surgeries, the chemotherapies, and the radiation.

They know about living from one checkup to the next, with the ever-present fear of recurrence. And when recurrence comes, they know what it means for them and the ones they love.

Above all, the mothers with metastatic breast cancer know what it means to think about having their young children lose their mother. That is the hardest thing of all.

That is what Elizabeth Edwards is facing.

Many of these courageous women have come to understand that the only sensible thing to do is to make the kind of investment in breast cancer prevention that we have made in breast cancer research. And they understand that this investment in prevention should be not only an investment in a research agenda, but an investment in public policies that protect public health.

These courageous women have come to understand that the breast cancer epidemic is essentially inseparable from the other epidemics of environmentally related disease in our time. And so they have decided to fight for a world where every major contributor to breast cancer and other chronic diseases is minimized.

That means a return to some basic public health values. It means clean air, clean water, and safe foods. It means schools where children eat nutritious meals and exercise vigorously every day. It means eating the foods our grandparents and their parents for thousands of generations before them ate. www.sfms.org

It means reducing the terrible gap between rich and poor, which is the largest single contributor to the burden of all disease in this country and every other country. It means health care for all. And it means a systematic and thorough approach to reducing our burden of thousands of toxic chemicals that were not in our grandparents’ bodies and should not be in ours.

From a public health perspective, politics aside, John Edwards is talking about the real issues. He talks of universal health care.

He talks of narrowing the gap between rich and poor, the yawning gap that is the single greatest cause of ill health. It is also the single thing we could most readily change with a simple vote in Congress and the stroke of a pen. He talks of the need to spend at home the billions we are now spending to fight in the Middle East. Right now, Edwards happens to be the candidate who is really talking about public health.

Will Elizabeth Edwards’s new cancer diagnosis lead her to do the kind of thinking so many thousands of women across the country have done? Will it lead her to think about breast cancer prevention? Will she do the research and come to understand how complicated breast cancer prevention is? Will she go deep enough to recognize breast cancer as an ecological disease that is part of the whole fabric of ecological diseases we face today? Will she see the need to do what the Europeans are doing, and what people are doing in states across the country—to work for clean air, clean water, and safe foods, and to systematically reduce the thousands of untested toxic chemicals building up in our bodies? And if she makes the connection, will she discuss it with John Edwards? And if he agrees, will Elizabeth and John Edwards be the ones who finally bring breast cancer prevention into the American mainstream?

I don’t know the answers. I only know that if Elizabeth doesn’t do it, we need to continue to do it. We need to tell the simple truth that breast cancer prevention is part and parcel of preventing most of the major diseases of our time. It is only complicated if we get caught up in the game of trying to figure out which specific stresses are responsible for what proportion of what disease. It is simple if we just say we need to make our

country safe for our children, and for all of us, again. We know how to do that. That is our choice, and Elizabeth’s choice.

Michael Lerner, PhD, is cofounder of the Collaborative on Health and the Environment and President of Commonweal.

Torture Continued from Page 13...

In many ways, therefore, the clinician working with a survivor of atrocity is forced to exercise an uncomfortable sort of hubris.

We are to hold out hope without knowing from experience what we are up against. A survivor from Bosnia reminded me of this every single time she saw me by repeating, “You cannot imagine this if you haven’t been through it.” She was another woman of incredible strength who was coping by locating all hope and life in her children, often repeating that there was no hope for her but only for them. Having seen neighbor turn against neighbor in sadistic cruelty, she felt that her faith in humanity had suffered too great a blow to ever be recovered. And like many other survivors of genocide, she had to be a living memorial to those who did not survive. Hence we find that survivor guilt is frequently the most powerful impediment to making choices in favor of life. Life in this sense means desire and the fulfillment of desire.

Clinicians of all professional stripes must remember that it is an act of courage for the survivor to choose life and healing.

Such acts of courage may be required in something as seemingly simple as taking medicine as prescribed. The most trying clinical problem for healers is the patient’s refusal to accept what would help, because it leaves us without the satisfaction of having helped. In such instances, it bears keeping in mind that hanging on to despair and illness could be a simple act of decency. Who is to say when it is time to leave the dead and try to live again?

Ewe Jacobs, a psychologist, is Director of Survivors International, an organization dedicated to helping victims of torture worldwide.

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Choosing Life or Death

Finding Meaning in Life and Death Patients with and Practicioners Treating AIDS Often Face Difficult Choices Kristin Razzeca, MD

D

eath has been a prominent occurrence in my HIV practice, and I have gained useful insights into caring for patients as they start the dying process. Some choose to live fully and purposefully in the face of death, while others choose death because the physical and/or emotional pain in their lives can no longer be endured.

As physicians, our medical training teaches us to evaluate, diagnose, and treat.

We can mistakenly equate the patient with the illness and neglect the whole person.

Our role is to help guide patients to a healthier life. Traditionally, our training has not focused on helping a patient die well.

We do not receive instructions on helping them accept the inevitability of death, or on providing support and comfort to them as they begin the dying process. But I believe it is our responsibility, as physicians, to extend care, comfort, and support when death becomes imminent.

Being with a patient during this process can be extremely difficult and emotional, evoking feelings that our care was not sufficient or aggressive enough. Ultimately, however, being with the dying patient can be one of the most rewarding aspects of being a physician. Patients place their trust in you. This privilege carries a responsibility not to abandon them as they near death.

Their dying can become a learning process for both patient and physician.

One of my earliest experiences with patient death was with “Randy,” a young man. He had been infected with HIV at the age of seventeen. Randy was hospitalized with wasting syndrome and profuse diarrhea caused by cryptosporidia. He was not responding to any antivirals. His prognosis was poor. I noticed that Randy didn’t have any 16

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visitors, and I asked him about his family, from whom he had been estranged for years.

He wanted me to call and inform them that

“Traditionally, our training has not focused on helping a patient die well. But I believe it is our responsibility, as physicians, to extend care, comfort, and support when death becomes imminent.” he was hospitalized and not expected to live.

He was certain that now his parents would forgive him for being gay and HIV-infected.

He wanted to apologize to them for the embarrassment he had caused them. He knew they would want to be with him as he died, and that once again he would be accepted and loved. I made the call but was told by his father, “We no longer have a son.” Randy died shortly afterward; his nurse and I were at his bedside, but not his parents. His devastating disappointment made me realize that I should have addressed this painful matter earlier and worked with him to accept that his parents would not be available to him. I and others could then have encouraged him to seek support elsewhere and face death without that intense disappointment.

My patients with children have demonstrated a different facet of dying: an amazing ability to live life fully despite their imminent deaths. All of them demonstrated courage and determination to live so they could continue their roles as parents. “Caroline” first came into my practice when her

son was six years old and her CD4 count was 26. Despite her impaired immune system, her goal was to see her son graduate from high school. During the next twelve years, she survived many major illnesses secondary to her HIV infection, and she proudly gave me a picture of her son in cap and gown, standing with his arm around her, on his graduation day. She looked frail, but satisfied that her goal was accomplished. She died four months later.

My patient “Susan” was a mother with two teenage sons. Her husband had died three years earlier. She presented to the clinic one day complaining of newonset headaches. Her examination showed multiple cranial nerve palsies. Her scans showed a right frontal lobe mass, a pelvic mass, and nodules in the liver. Biopsy of the liver nodules confirmed a diagnosis of Burkitt’s lymphoma. She underwent intrathecal and systemic chemotherapy, followed by cranial radiation. She suffered multiple complications, including a left hemiplegia.

During the two years she lived following her diagnosis, her course was further complicated by numerous infections and prolonged hospitalizations.

Her older son remained devoted to her. Her younger son became sullen and angry, began having difficulty in school, and was arrested once for shoplifting. He refused to visit his mother in the hospital.

She attempted to write letters to him, but writing was difficult for her. She was extremely upset, knowing she was dying and feeling she had so much she needed to try to teach her sons. I brought her a small tape recorder that she used to record messages for them. She recorded more than forty tapes, methodically labeling them all. She died less than two days after completing www.sfms.org

her project. Nine months later, her sons came to the clinic with a tiger lily to plant in our memorial garden. Her older son felt this particular plant symbolized the beauty and delicacy of their mother, coupled with her strong determination. As her younger son planted the flower, he whispered, “I heard you, Mom, and I’m still listening.”

I could picture Susan’s beautiful, radiant smile once again.

Many people facing death have an intense desire to leave a legacy or show gratitude for the people who helped them through their illness. A patient of mine said he wanted to thank the people who had helped him over the years through the county’s HIV services. “Richard” was diabetic and infected with HIV. He suffered a severe peripheral neuropathy from the diabetes and some of the antiviral medications.

He developed a non-Hodgkins lymphoma, but chemotherapy greatly exacerbated his underlying neuropathy. We tried numerous agents to try to minimize the neuropathy, but it was refractory to treatment. Essentially, Richard became wheelchair-bound.

When his lymphoma recurred, he elected not to undergo additional treatment. After discussing this carefully with him, I initiated hospice care. Despite this, Richard decided to participate in the AIDS walk that year, wanting to be part of the team from the clinic. He had been able to obtain several sponsors and was looking forward to the walk. He and his partner arrived at the walk and joined the team from the clinic.

We assumed we would take turns pushing his wheelchair. Instead, Richard started the walk with the aid of a walker, and partway through he began relying on his partner and a close friend to support him on either side. He completed the entire walk, raising $3,500 for local HIV/AIDS services. He was very proud of this incredible accomplishment and died peacefully two weeks later, feeling satisfied that he had been able to “give back” to the community that had helped him over the years.

Many of my patients have taken active roles to help educate younger people.

“Isaac” had been a heroin addict. He had had a difficult childhood and fell into a life of drugs early. He was coinfected with HIV and hepatitis C (HCV) by the time he www.sfms.org

was twenty years old. His HCV progressed rapidly, and he did not respond to the available treatment. He died with hepatic failure.

However, he had spent the majority of his time for the previous five years mentoring young African-American men in a weekly support group.

He didn’t try to gloss over his addiction and the difficulty he’d had in rehab. He presented his story honestly and hoped that he would be able to help change the course of even one young person’s life. Before his death, he was honored by Santa Clara County with a community service award. He was in the hospital at the time and unable to attend the awards ceremony, so arrangements were made for the mayor of San Jose to present the award to him at the hospital. Isaac was surprised when the mayor, followed by San Jose Mercury News reporters, arrived in his hospital room.

Most rewarding for him was that every member of his group was also present to see him receive the honor. Isaac died peacefully, feeling assured that he had made a positive intervention in the lives of several of these young people.

Other deaths were definitely less positive or peaceful. One young man, “Tom,” tried to deal with the guilt and shame he felt after telling his family that he was gay and HIV-positive. Outwardly they seemed to accept this, but he felt they were very disappointed in him. He was in psychotherapy, working through his feelings about this, but then a relationship with a partner ended and he spiraled down. He started isolating himself. He began drinking one night and had unprotected sex, resulting in syphilis and herpes infections. I treated him and emphasized the need for safer sex, and I encouraged him to increase the frequency of his therapy sessions. For months he felt significant guilt for the unsafe, anonymous encounter he had had. He continued with therapy, and I stressed the importance of socializing with his friends rather than remaining isolated. He came in for his regular

visits, and finally he appeared to be happier and more relaxed. He informed me that he had made some decisions about how he was living his life, and that he felt much better. I was shocked to receive a call from the police the next day, saying they had found him dead. He had left behind a suicide note stating that he was too ashamed to continue living. I realized then that patients will often try to please their physicians by appearing to improve, or will “improve” briefly after having decided to commit suicide. Feelings of guilt and loneliness coupled with isolation are warning signals of intense emotional pain. I’m not sure any other interventions would have helped Tom. However, I now realize more fully how negative an impact guilt and shame can have on patients. I am more aggressive in helping them establish support systems and pursue competent psychotherapy.

Every person who dies has his or her own story. As an HIV physician, I am provided unique opportunities to learn more about how people die and to help them die peacefully. I’ve witnessed patients living fully as death approaches because of their love for their children. I’ve seen the determination and the desire of people to leave something of themselves behind, either through mentoring young people or helping their community. I’ve seen the need for dying patients to accomplish final goals, continuing to live until these goals have been achieved and only then being able to let go of the struggle. I’ve realized the importance for the dying patient of feeling loved, accepted, and supported.

I watched my own beautiful, older sister struggle with cancer for three years. She was determined to provide a more complete foundation on which her two teenage daughters could build their lives after she was gone. Her death was devastating for her husband and two daughters, as well as for our parents and remaining family. Seven

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Choosing Life or Death

Choosing Life A Kidney Transplant Patient Reflects on the Choices that Gave Her Life Again Lisa Frieden

C

hoosing life was not the way I spent my life before I got sick. I was a hard-core athlete who could push the limits of any sport I tried. I didn’t worry about self-preservation, because I came from an incredibly healthy family and I trusted that my body would always support my wildest adventures. Maybe that’s why I was so unprepared when the unthinkable happened.

In the fall I turned thirty-three, I started feeling tired. I looked pale. Because I’d always been so strong and athletic, I explained away my symptoms. I was tired because I’d tweaked my back lifting something heavy, and I must have gotten out of shape. I was losing my tan because winter was coming. It was my first fall in Berkeley, a much colder place than southern California, where I was from. That must explain why I felt cold all the time … or so I told myself.

So many excuses. So many reasons to explain away symptoms that, taken by themselves, seemed innocuous.

By the second month of these vague symptoms, I began feeling depressed. A mental problem seemed believable; it never occurred to me that my body might be failing. I started taking Saint-John’s-wort.

Soon after, I noticed my pee looked foamy. I explained it away as a side effect of the herb.

But I kept feeling worse. I finally decided to see my internist, who, I hoped, could prescribe some antidepressants to make me feel better.

I told her I felt tired, cold, weak, and pale. She agreed I might be depressed and almost agreed to prescribe antidepressants, until I mentioned the foamy pee. She gave me a thoughtful look and then said we should draw my labs before doing anything else. That was Friday. Monday morning, at 18

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9:15 a.m., she called me at my office and told me to go to the hospital. The lab results showed my kidneys were failing.

I suppose other people might have

“My story illustrates how murky the waters can sometimes be around the issue of illness and self-preservation. How can you choose to take your life into your own hands if you don’t know you’re dying?” rushed to the doctor at the first sign of anything wrong, but I come from a family where no one ever gets seriously ill. Endstage renal disease (ESRD) did not exist in my paradigm.

My story illustrates how murky the waters can sometimes be around the issue of illness and self-preservation. How can you choose to take your life into your own hands if you don’t know you’re dying? In retrospect, seeking professional help was my first step toward self-preservation.

Life-or-Death Choices At the hospital, I underwent a kidney biopsy. The results revealed my kidneys were only functioning at 4 percent. By the next afternoon, I sported a shiny new permacatheter and had undergone my first hemodialysis session.

It never occurred to me to question the medical counsel I received, which was why my hospital roommate’s dismissive comments about dialysis so surprised me. She

told me it was a waste of time.

“But what alternative is there?” I asked.

“Put your faith in God. The power of prayer is all you need,” she said.

That evening, her husband came to visit. He’d brought bags of McDonald’s.

I smelled it as I ate my renal-friendly, incredibly bland, unappetizing hospital meal.

That afternoon I’d met with the renal nutritionist, who had begun my education in eating responsibly. McD’s was a big no-no.

I couldn’t fathom my roommate’s behavior.

The next day, I asked the nephrologist about her. She shrugged. The patient had refused dialysis and had already been in the hospital several weeks with ESRD. She’d probably die there. I don’t know what private choices that patient made, but I know that self-preservation for me meant listening to the professionals, taking their advice, and sometimes making difficult sacrifices to ensure that I stayed alive.

During my four months on hemodialysis, I made life-or-death choices every day, starting with what I ate. Foods with too much potassium or sodium can kill a dialysis patient, and phosphorus-containing foods can leach calcium from the bones at a crippling rate. I had to forego all my favorite foods: milk, chocolate, cheese, nuts.

Hemodialysis entailed three four-hour sessions a week, on Tuesdays, Thursdays, and Saturdays, but because the clinic was only open from 6:00 a.m. to 6:00 p.m., I had to negotiate the time away from work with my boss. I was working full-time at a high-powered, high-stress job. Losing eight hours each week for dialysis took a big toll on me, not to mention that it meant a costly loss of billable client time. I was a mess after each dialysis session, so I had to work doubly www.sfms.org

hard on the nondialysis days to catch up as best I could.

Listening to the overworked dialysis staff complain, and witnessing how other patients and I were treated, I grew increasingly afraid for my life. How could I ensure the staff properly cleaned and prepped the equipment? How could I ensure that I wouldn’t contract some horrible bloodborne disease or die from heart failure? I’d watch my blood flow out of my body through tubes to a machine where it would cycle, and then I’d feel that weirdly cool flow of blood back into my body. The experience terrified me, because others held my life in their hands.

Then I realized that peritoneal dialysis works as well as hemodialysis. I could do it myself, in the comfort of my own home.

After four months of hemodialysis, I underwent surgery to switch methods.

For the next year, I kept myself alive by giving myself peritoneal dialysis every day. I’d hook up my peritoneal catheter to a machine in our bedroom and dialyze for ten hours each night. I’d also take thirty minutes in the afternoon to dialyze, but fortunately I could still work at the computer during these moments, so I didn’t lose any work time. While my previous life as an athlete was history, peritoneal dialysis did allow me to take back some control over my life.

Going on with Life When I was first hospitalized, my family had been tested as potential kidney donors.

I was lucky. My sister, my mother, and my husband Kurt all qualified, but it took six months for the anti-GBM antibodies to disappear, and then another six months of zero-antibody test results before the transplant doctors felt safe conducting the surgery.

Surprisingly, Kurt’s antigens matched mine more closely than my blood relatives’.

“There was a one in 10,000 probability of this,” the doctor said, adding, “It is a true gift.” Kurt thus made the best candidate, and he chose to donate his kidney. When asked why, he told friends and family, “I’m simply being selfish. I want my wife back.”

And he’d explain that, by giving me his kidney, he hoped to regain the physically fit and active wife he’d married. www.sfms.org

The transplant was a success. After a week in the hospital, we returned to a life much more like the one we’d lived before

The Frieden Family

ESRD. I once again could bike, hike, and run. We joked that my newly acquired taste for dried apricots and my now-spotty memory, both Kurt characteristics, must be consequences of my having his kidney.

But there are also differences.

Self-preservation now constitutes a central part of my life. I take my immunosuppressant medication every day to ensure that I keep Kurt’s kidney. Unfortunately, this act of self-preservation comes with trade-offs: These drugs have side effects, including high blood pressure and high cholesterol, and I’ve already had two skin cancers. So I take further action by taking hypertensives and a statin, and I avoid sun exposure as best I can.

There has been another big difference.

Choosing life now means wanting my life filled with other lives. Before I got sick, we’d talked about getting a pet, but we’d never bothered. Now we have a dog and two cats.

Before I got sick, we’d kept putting off having kids. Now I wanted a child.

My transplant doctors advised against it for fear of the graft’s health, but I’ve learned a few things about taking all medical advice at face value. I went online, researched, and communicated with doctors from other clin-

ics who had more experience in transplant pregnancies. Despite two miscarriages, I gave it one last try, and in 2004, four years after the transplant, Kurt and I brought a miraculous baby girl, Lila, into the world.

She’s now two and a real trouper.

We’ve just spent a week on the road camping, including a two-day backpacking trip into the spectacular Utah wilds. I’m writing this article while sitting in a delightful rental house in Moab, as Lila and our dog nap and Kurt bikes Moab’s famous Slickrock trail.

I’ll be forty-two this year, and we just celebrated our seventh-year transplant anniversary. The aches and pains I feel these days come from encroaching middle age as much as anything, and I welcome them heartily. I hope to live long enough to see kidney cloning become a reality, but in the meantime, I count each day as a blessing.

Life is good.

AIDS Continued from Page 17... years later, I can see her legacy living on in both of my nieces, who exhibit many of her strengths and admirable traits. I know how proud she would be to see the results of her final three years as their mother.

To be a physician is a special privilege with many responsibilities. Working with dying patients is emotionally challenging, but it is also instructive and humbling. I have learned that death can be a peaceful, meaningful process when patients have accepted it and have completed what they believed to be important.

This article is dedicated to my sister, Pamela, and to all my patients who have taught me the meaning of living and dying well.

Dr. Kristin J. Razzeca is an immunologist and HIV specialist who has combined basic science research on T-cell receptors at Stanford University School of Medicine with a clinical HIV practice at Camino Medical Group.

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Choosing Life or Death

Choosing Life at 200 MPH The Do’s and Don’ts of Race Car Driving Tom Madigan

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ne evening in the mid-1960s at the Long Beach drag racing strip, I was behind the wheel of a roaring nitromethane-fueled dragster, preparing to make a run that would rocket me down the quarter-of-a-mile course at a speed of 200 miles per hour. I looked up into the grandstands, and it occurred to me that I was doing something that all those spectators were unable to do. Instead, they would enjoy the thrill vicariously, without danger.

That was fine with me. I would take them along for the ride. It was a great feeling of enjoying life to the fullest.

Since its introduction more than 100 years ago, the automobile has played a twofold role in the development of modern civilization. On one hand, it is the basis for transportation and commerce, the utility vehicle for human beings. But it is also a mechanical instrument probing the limits of technology and providing a platform for daring deeds and great adventure. Motor racing is a by-product of this second dimension and has probably been in existence since the building of the second automobile.

From this ritual of mechanical competition grew a thunderstorm of misconception, folklore, and legend. To the outsider, noncompetitor, and uninitiated, automobile racing was a foolish endeavor based on audacious behavior and brazen acts performed by daredevils with a death wish. The characterization of race drivers choosing death over life was magnified as the automobile reached the age of forty years. No longer were cars built by tinkering mechanics in dirt-floor garages. Industrial icons had been born.

Such names as Ford, Ferrari, Porsche, and Mercedes-Benz became powerful images of a country’s wealth. Motor racing sometimes took on a status of nationalism. Race car 20

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drivers became soldiers of industry. But as racing machines grew more powerful and drivers pushed the limits of reason, death became a constant passenger.

After World War II, automobile rac-

“I used to have a ritual before each run. I would take a moment and think, ‘This could be the last few moments I have on earth. But I choose to do this because I want to overcome the obstacles present, and I love what I do.’” ing expanded rapidly in the United States.

Races were conducted on public roads, dirt ovals used for horses, the expansive dry lakes of the California desert, and the barren salt flats of Utah. In Europe, racing spurred the spirit of rebuilding and living fully again after the horrors of war. Race car drivers such as Nuvolari, Ascari, and Fangio had entire nations chanting their names. And racing remained a brutal game of playing with death.

Superstition fueled the fire with stories such as that of champion Alberto Ascari and his fear of numbers. Ascari died in a crash in 1955, at the same age and on the same day of the month as his father. Bill Vukovich was killed within days of Ascari’s crash.

The caldron of myth and profligacy boiled over that same year when, at the 24 Hours of Le Mans race in France, a car skidded out of control and flew into the crowd, killing more than 100 people. Voices were raised

against the sport, calling for a stop to the mindless waste of life.

Of course, automobile racing did not stop. However, change was on the horizon.

Racing turned its back on such daredevils as men with royal titles who raced for the chance to be brave and dashing. Also exiled from racing over the years were the playboy sportsmen, who considered daring death a prelude to enjoying the adulation of beautiful women. Racing did not want a duplication of the drama played out by the audacious, untrained Marquis de Portago, who, in 1957, at the age of twenty-nine, kissed his girlfriend, the American actress Linda Christian, jumped into his Ferrari at the Mille Miglia, a thousand-mile race in Italy, and sped off without a seat belt, only to ignominiously crash and die.

Today’s race drives are protected by state-of-the-art safety equipment in driving machines so technologically engineered that the chances of a fatal crash are greatly diminished. The reality is that modern race car drivers are not embracing death each time they slide behind the wheel of an exotic machine. Over the years racers may have been foolish, unprepared, victims of technology outpacing safety, or just guilty of using bad judgment, but nowadays the idea of choosing to die in a race car would be unacceptable to drivers.

Race drivers have strong wills, a powerful need for competition and overcoming challenges, and an excessive urge for ego stimulation. They feel a desire for selfgratification and a willingness to take risks unacceptable to the average person. But today, driving a racing car at high speed is the culmination of careful training, experience, and incredible courage. The outsider can never understand the feeling of speed www.sfms.org

When put to the test, racing car drivers do not choose death, but rather will always choose the ultimate joys of life.

Tom Madigan is a West Coast auto writer with forty years experience in the race car business. He is the author of several books on the subject.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members:

nor the intensity of will required to push limits to the breaking point. The act of running at the limit is reserved for a rare few.

This very uniqueness is the reason racing draws throngs of spectators. People simply can’t resist the thrill of witnessing fate being tempted. As one racer said, “If your ego needs to be fed enough, then the danger goes out the window.”

To discover how race car drivers feel about the dangers and the choices surrounding the world of speed, I talked to a crosssection of racing drivers to get a real-world perspective on the issue. To each driver I posed this question: Life or death—is it ever a conscience choice?

Former World Champion National Hot Rod Association driver and a close friend Kelly Brown said, “I used to have a ritual before each run. I would take a moment and think, ‘This could be the last few moments I have on earth. But I choose to do this because I want to overcome the obstacles present, and I love what I do.’”

Three-time class winner at the 24 Hours of Le Mans race Jim Busby said, “Dangers are not in the front of your mind.

You love what you are doing and you always feel that nothing will happen. Your mind rejects the bad things that might happen.

Racers must fall into a zone, you must move beyond conscious thought, your body must react on autopilot. If you think, you are slow. www.sfms.org

You are trained and experienced; fear is not an option. The only time the shock of fear hits is when someone as good as you, in as good equipment as yours, dies.”

Harry Hibler, a friend for more than forty years and another ex-Top Fuel driver, earned the nickname “Hand Grenade Harry” because of his many spectacular 200mph crashes. In answer to my question, he remarked, “I always thought of the car as my friend, and it would never hurt me.”

Craig Breedlove, holder of the Land Speed record five different times at speeds over 600 mph, offered his feelings. He told me, “Although the level of danger increases at speed increases, I always felt that my desire to achieve something that had never been done before made me willing to take the risk. On my record runs, I was scared speechless and had butterflies as big as pigeons, but I never had the belief that I would die.”

Racing automobiles is an occupation for a chosen few. Drivers understand the risks involved, but a powerful need for competition, self-satisfaction, and great rewards motivates their actions. Drivers are much safer now than at any time in the history of auto racing, and statistics show that very few drivers die as a result of racing. Race drivers are different than the average person, but outside the car they are as human as any of their fellow souls.

Ryan Chungwai Chang, MD Lily Huang, MD Rebecca Gail Piltch, MD Paul J. Turek, MD Fiona Wilmot, MD interested in sponsoring a new member?

SFMS has embarked on a NewMember Sponsorship program. Upon approval by the Board or Executive Committee, each new member is assigned a sponsor, an established SFMS member whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (such as the Annual Dinner, Legislative Day, Candidate’s Night, or a Mixer) during the course of their first year of membership. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information or to volunteer.

june 2007 San Francisco Medicine

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Choosing Life or Death

Reflections on Choice A Physician’s Beliefs Solidify When He Becomes the Patient Steve Heilig, MPH

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ne of San Francisco’s most respected and beloved physicians, William Atchley, MD, came to UCSF in 1952, following medical school at Harvard and an internship at Columbia. He practiced as an internist for more than forty years, serving as the first head of the cancer research ward at UCSF, professor and chief of the UCSF medical staff, and chair of the ethics committees at both UCSF and SFMS, where he was elected an Honorary Member in recognition of his devoted and distinguished clinical, teaching, and advocacy contributions. A valued mentor to many, he retired more than a decade ago and is now living with prostate cancer at home in Marin, receiving home hospice care.

This month SFM had a chance to talk with him about the experience of transitioning from doctor to patient.

SFM: Let’s start with a bit of clinical data.

Have you recently set some sort of record with your personal lab results?

Atchley: My PSA is 3025 ng/ml. Some of your readers might think that’s a misprint, but it’s true. The National Cancer Institute considers a count higher than 20 to be “significantly elevated.” So it makes me chuckle to think how worried I was when it hit something like 50.

SFM: You recently went on hospice care, after years of treatment for cancer. That’s often a difficult transition for people, both patients and physicians.

Atchley: Yes, it’s the transition from “cure” to “care,” as the palliative mantra goes.

I was consumed by pain. Prostate cancer often goes to the bones, and I could not 22

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sit, stand, walk, or think. I was a wreck, on large amounts of morphine—but when the hospice people came in, they changed the medication schedule and approach, and I have been pain-free, completely, for a month. It’s remarkable.

SFM: So you’re a convert to choosing hospice.

Atchley: Yes, but I was an easy and early convert, as I was closely associated with people who first got hospice going in Marin decades ago. This just makes it personal.

The whole arena is so much more open now. Long ago, my father, also a physician, overheard me using the word “cancer” with a patient and was stunned I would even mention it. It used to be all hidden. Now it’s more like I have a chronic illness with side effects under better control, so I can still have a comfortable life at home. And people do talk about it, and rightly so. I think of all the people I’ve known who died but could have been saved by more open discussion and aggressive screening, and I tell people not to take “maybe” as a diagnosis.

SFM: On the issue of pain, one concern has long been that pain meds are too tightly regulated, so that physicians are afraid to use appropriate amounts.

Atchley: Yes, we really need to continue to loosen up there. Those publicized cases of abuse, such as celebrities like Anna Nicole Smith, get way too much attention and ruin the context for other doctors who often should be prescribing a lot more medication. I have enough methadone in my drawer to get rich selling it out on the street, but my caregivers know I won’t

Atchley’s SFMS membership application Received May 1955

abuse it. Dame Cicely Saunders, a founder of modern hospice approaches, was one of the first to demonstrate that if you assure patients they’ll get all they need, they tend to use less, not more.

SFM: And how about the controversial issue of physician-assisted dying?

Atchley: I think that option should always be there for the really sick person. It must be regulated and reviewed, but to take away that last vital choice, especially for patients with a horrible disease like ALS, is just cruel.

So I favor controlled legalization, like in Oregon and Holland. It can be done safely.

SFM: Has facing death changed you?

Atchley: A big thing is just being able to talk about it, and now we do. In fact, it’s hard not to. My wife Annalise and I have become essentially one person, we’re into it so deeply, on both practical and emotional levels. Just keeping track of the meds is a major job. It’s very remarkable how close we’ve become; our love has just burgeoned.

I’m a very lucky man. And so in choosing not to squeeze every last drop of blood out of the patient—me, in this case—and in no longer trying to “cure” me, and to not see death as a failure but rather as part of the cycle of life, you might say I’ve in fact chosen life.

For more information, visit www. hospicebythebay.org or call (415) 526-5550. www.sfms.org

Choosing Life or Death

Reflections on Choice Patient with Terminal Cancer Chooses Quality of Life over Chemotherapy Mike Denney, MD, PhD

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n the autumn of 2005, Beverly Hawks, then a seventy-two-year-old mother of two, grandmother of three, and longtime active member of her community in Chelsea, Michigan, was diagnosed with carcinoma of the parotid with spread to many adjacent lymph nodes. She was treated at the University of Michigan Medical Center with radical neck surgery and irradiation.

Six months later she noticed a new lump, which proved to be a recurrence. She then started chemotherapy.

Recently, SFM had the opportunity to talk with Beverly on two occasions by telephone about the choices she made during her medical treatment.

Beverly: Yes, and there wasn’t a lot of choice to be made there. I was hemorrhaging inside and it had to be fixed.

SFM: And then later you had cancer of the breast?

Beverly: Yes, that was in 1984. I was given a choice between a radical mastectomy and simple mastectomy plus irradiation. I chose the radical surgery, thinking at that time that it was the best chance for a cure. And that certainly seemed to be correct for me.

I had a breast reconstruction in 1986 and remained in remission over the years.

SFM: Now, to your current illness . . .

SFM: As I mentioned, Beverly, this issue of the magazine is about choosing life or death. Should I use your real name when we print this interview?

Beverly: Well, I must say that illness seems like a rather weak term for what I have, doesn’t it?

Beverly: Yes, Mike, of course. You know me well enough to know that I’m proud of who I am.

SFM: Yes, indeed, it does. When were you first diagnosed with cancer of the parotid?

SFM: We’ve known one another for maybe forty-five years . . .

Beverly: In 2005. I noticed a lump high on the left side of my neck. I was having some dental problems, so I thought that was it.

But the lump persisted, so a biopsy was done, and it showed a malignancy. At first they weren’t sure where it was from, but I had a radical neck operation, which showed that the tumor was from the parotid gland with spread to many of the lymph nodes. So I agreed to have postoperative irradiation treatments.

Beverly: Forty-seven years.

SFM: As we discussed the other day, I’d like to ask you about— Beverly: Look, I’m terminally ill. Relax and ask me anything you want.

SFM: OK, Beverly. So, first maybe let’s just look at your past medical history. You had an ectopic pregnancy many years ago?

www.sfms.org

SFM: Was that a difficult decision?

Beverly: No. It was a straightforward decision to undergo radical treatment for a very

serious problem, and I’m glad I made it.

SFM: As it turned out, that treatment wasn’t successful.

Beverly: In early 2006, I noticed a lump underneath the redness and scarring in my neck. A biopsy showed that the cancer had returned. The doctors did some additional removal of tissue and tried some additional irradiation. But I could tell that it was desperate, and that they didn’t really think the chances of cure were very good. That’s when they suggested some chemotherapy.

I mean, it wasn’t as though there was any cure, and I knew that the chemo wasn’t really proven, but the doctors said that it was all they had to offer. So I accepted it for a while. But it made me so sick that I couldn’t stand it. I vomited all the time, sometimes had to receive intravenous fluids, and I was just miserable. I also got a blood infection called clostridium difficile and had to be hospitalized.

Then, one day as I sat in the waiting room at the clinic preparing for my third chemotherapy infusion, I suddenly realized what was going on. I knew I didn’t have long to live, and I didn’t want to live it in misery. It wasn’t worth it. In that moment, I decided to stop the chemo. I went home.

I talked with my children. I called hospice, because I knew that way I could stay at home and be taken care of by my children.

SFM: That must have been a difficult choice.

Beverly: Actually, it was very easy. Once I fully grasped what was going on and what my choices were, it was absolutely clear as

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Choosing Life or Death

Suicide and the Golden Gate Bridge Can We Allow the Deaths to Continue?

Mel Blaustein, MD “The Golden Gate Bridge is to suicide what Niagara Falls is to honeymooners.”

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his is the quote Renee Milligan found on her daughter’s computer in the days after her body was recovered. At age 14, Marissa Imrie was the youngest bridge suicide. She left this note for her mother: “Please forgive me. Don’t shut yourselves off from the world. Everyone is better off without this fat, disgusting, boring girl.

Move on.”

Her mother, her family, her friends— none of them can move on when affected by this tragedy.

Marissa was one of more than 1,300 Golden Gate Bridge suicides—the actual numbers are even higher, but the count includes only bodies found. Our majestic bridge is the number-one suicide site in the world. Twenty-five deaths per year—about two deaths per month. And a local problem: 87 percent of suicides are Bay Area residents.

Only 5 percent come from out of state.

The Golden Gate Bridge is a suicide magnet, an alluring, romantic last stop. The most photographed man-made structure in the world, one of the wonders of the modern world—plus a parking lot, bus access, and a four-foot rail. It’s a natural destination for those wanting a quick exit: four seconds to the water, covering 200-plus feet at 75 miles per hour.

Suicidal individuals consider their options—gun, rope, car, pills, jumping. The JAMA 2005 International Conference consensus article on suicide prevention strategies indicated that educating doctors to recognize depression and restricting access to lethal means are the two most effective suicide deterrents. Barriers at the 24

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Eiffel Tower and Empire State Building have virtually eliminated suicide at these structures. Toronto, home of the Bloor Street Viaduct, which was second to our bridge with 380 suicides, erected a barrier in 2003; suicides were eliminated and the barrier dubbed the “Luminous Veil” when it won the 1999 Canadian Architects Award of Excellence.

Suicidality is an acute, impulsive state of a person in crisis. Suicide is not an act of free will but that of a desperate person in psychic pain seeking escape from intolerable feelings. Suicidal individuals may be depressed (most often), anxious, abusing alcohol or drugs, psychotic, physically ill, or at a point where they just can’t go on. They may be any of us at some time. These states are treatable and preventable. Fourteenyear-old Marissa was on her school’s track team and was hardly a “fat, disgusting girl.”

She never got to see a doctor.

Suicidal individuals are ambivalent.

Kevin Hines, who jumped from the bridge in 2000 and survived, reflects how he would have turned back had one person asked why he was crying. His lone interrogator was a German tourist who asked him to take her picture.

A suicide barrier will save lives and spare families and friends. We know from scientific studies that individuals prevented from jumping off the bridge will not go elsewhere. Richard Seiden’s 1978 study of

515 potential jumpers taken by CHP from the bridge found that 95 percent were still alive 25 years later.

I see no good arguments that oppose the erection of a suicide barrier. As civilized, moral people, we cannot possibly allow these deaths to occur when we have the means to intervene. Survivor Kevin Hines lectures to students about suicide and saves many lives.

Survivor Ken Baldwin, a school teacher in Angels Camp, California, describes graphically how he changed his mind while falling toward the water: “The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing….

It was incredible how quickly I decided that I wanted to live once I realized everything I was going to lose—my wife, my daughter, the rest of my family.”

Currently, the nineteen-member Bridge Board is undertaking a $2 million engineering and environmental impact study into the advisability of building a barrier on the Golden Gate Bridge. This effort is spearheaded by the Psychiatric Foundation of Northern California, family members of those who jumped, and other advocates. This is the eighth effort to build a barrier since 1937. It looks promising, but persistence will be necessary. In 2006 there were thirty-four bridge suicides, and in the first quarter of 2007, seventeen more fatalities added to the count. As people of conscience, can we allow this to go on?

Dr. Mel Blaustein is the Medical Director for the Department of Psychiatry at St. Francis Memorial Hospital in San Francisco and President of the Psychiatric Foundation of Northern California (PFNC). Dr. Blaustein created PFNC’S special Task Force on the Golden Gate Bridge in 2004. www.sfms.org

Choosing Life or Death

Choosing to Fight, Choosing to Yield Reflections on the Spiritual Dimensions of Dying Megory Anderson

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n the absolute surety of having to face our own death, there are choices. Although some of us will go quickly and unexpectedly, for the rest of us there is often a bittersweet choice of going softly or with a fight. Some people choose both paths: fight, then yield.

I am reminded of a Buddhist monk who once told me that he spent his whole life preparing for his death, and that he expected that when it was his time to go, he would just close his eyes and his soul would leave his body. I don’t doubt for one moment that he will die that way. And I think he is thrilled in anticipation of the experience.

Do I think that when it is my time to die, I will close my eyes and take myself into the land of death? I doubt it. Most likely, I will be in some sort of institutional setting, being cared for by health care professionals whose sole task is to keep me alive.

Our culture has created a wonderful expectation for us: We aren’t going to die. We will be immortal, forever setting a standard of youth, vigor, and demanded excellence in care for our bodies and life choices. Our medical system tends to reassure us that all conditions can be either fixed or reversed by magic pills or machines. Is there ever a time when death is not the enemy?

When I sit with the dying, I see how differently death comes to people. And since I try to bring the spiritual to the act of dying, I see how beliefs really do affect how a person moves toward the mystery of death and afterlife. For example, I have experienced watching a Mormon facing death, who knew for absolute certainty that she would soon be with her family in Spirit World, where she would be welcomed back; she was there before she was born and she was returning there at death. She looked www.sfms.org

forward to a joyful reunion in the midst of a sad parting.

Most of us don’t get to plan out our death to our liking, but I have always been struck by people who work hard at preparing themselves spiritually for what happens after

“The choices lie in how we die, rather than if we must die.” this life is finished. In each case, there is a wonderful sureness that something new, yet familiar, awaits them in death.

The choices then lie in how we die, rather than if we must die. Recently I have seen two examples of how people chose to die. Both are heart-wrenching for me—these people were and are part of my life.

In April, I was awakened early in the morning by a friend pounding on my front door. “Megory,” she said. “Something terrible has happened. Steve is dead. They found his body. He jumped off the Golden Gate Bridge.”

I was stunned. My friend was a brilliant scientist, researcher, and musician. He was only fifty-three and had many things to live for. Yet he chose to die as a relief for his depression and sorrows. Judaism teaches that absolute atonement comes at the moment of death. All the things Steve agonized over, all his worries and fears, were put right. It’s done and over with. The problem is that those of us who are left behind now carry burdens, such as all the “if-only” thoughts and the inability to understand why he took this tragic step. But I do believe that his choice was one that came out of the depths of his heart.

As I sat vigil with his body and then

with his ashes, I thought of Tony, a longtime friend who is also facing death. He found out on Christmas Eve that he has Stage IV esophageal cancer. Radiation has made it easier for him to swallow, and he is actually feeling quite good. Every time we speak on the phone, he tells me about how he is getting ready. He is cataloguing his paintings and all of his writings. He asked if I could come for a visit; he wants his friends and family with him to enjoy the time they have left together. I hear joy in his voice, and that makes me feel joy with him. The tears are there—I hate that he is dying. It is going to be very hard when I go to Michigan to see him and say goodbye. But I watch him in these days of preparation, and I am deeply touched. His choice is to go into death with incredibly majesty.

Is death the enemy? Perhaps. Is Tony “giving in” when he should be fighting? I don’t believe so. Embracing what is before you with dignity is a very different metaphor than shrinking when defeat inevitably comes.

Steve’s suicide was bold. Some may say that he did not have a right to make that choice for himself. But it was a bold walk into death.

Tony’s gradual dying is also a bold choice. It is a positive way of coping with this hard reality, one that lets each witness feel good about life and its natural ending.

Steve was not particularly religious, and neither is Tony. But each has shown me a core spirituality that I am learning from as I’ve watched their choices.

Can we ever choose death for a spiritual reason? I think we do it all the time.

Megory Anderson is Founder and Executive Director of the San Francisco-based Sacred Dying Foundation. june 2007 San Francisco Medicine

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Choosing Life or Death

Physician-Hastened Death The CMA Voices Its Opposition Anmol Mahal, MD

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bill before the California legislature, Assembly Bill 374, wants doctors to help patients kill themselves. Its authors call it the Compassionate Choices Act, but it is physician-assisted suicide, and there is nothing compassionate about this legislation or about assisting patients in achieving death.

Patients may be terribly frightened when they learn they are facing disability or a serious, possibly fatal or incurable disease. Some may want to give up during their initial phase of treatment or diagnosis, when many patients face depression and go through their own grieving process. But, as doctors, we often are inspired by the courage our patients show in successfully surmounting obstacles and leading full lives, sometimes for years after an initial diagnosis.

This is a critically important time for families to bond and even reunite as they try to come to terms with a loved one’s decline and eventual death. It is not uncommon during this time for family, loved ones, and friends to assume roles, take on responsibilities, and work out plans in a unique process that leads to peaceful closure. Premature use of life-ending drugs would deprive them of this opportunity and could lead to tragic consequences.

As a physician, I find physician-assisted suicide completely incompatible with my role as a healer, and it poses various societal risks. This isn’t a new idea in California: An initiative legalizing euthanasia appeared on the state ballot in 1992, and although it polled well, it failed to gain a majority of votes. Last year a similar legislative effort, by the same principal authors, failed in committee. The California Medical Association, which represents 35,000 California physicians, has restated its opposition to 26

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the practice of physician-assisted suicide five times since the 1980s. These votes are taken at the Annual House of Delegates, where nearly 500 physician leaders meet each year to deliberate and make policy.

“Doctors could be forced to make the highly subjective decision that the patient’s life is no longer worth living— surely a breach of medical ethics.”

The American Medical Association takes a similar stance on this issue.

Still, I believe much of the support for this bill comes from a misunderstanding of end-of-life care. Virtually all pain can be controlled through appropriate medication, comfort care, and other measures, possibly in a hospice setting (when patients and their families have decided to end treatment aimed at curing the underlying condition).

We at the CMA have battled on behalf of patients to make pain control and hospice care available to chronically ill patients, and it is paid for by most private and government health insurance plans.

We consistently support our patients’ need for pain and symptom relief, aware of the so-called dual, or double, effect: Treatment has risks and could inadvertently hasten death. But we let our patient’s body make that decision. We don’t decide it for them.

I fear that legalizing physician-assisted suicide will lead to other abuses in our already fragile health care system. The “right”

to a lethal dose of drugs could become an expectation, then a duty, pressed forward by concerns about scarce resources and a belief by the dying that they are a burden to others. It is very difficult for a doctor, in this situation, to truly be certain that the dying patient is not reacting to the belief that he or she is a burden to loved ones. Doctors then could be forced to make the highly subjective decision that the patient’s life is no longer worth living—surely a breach of medical ethics.

We, as doctors, have another burden that we face every day. Although, given all of the advances in medical science, we can determine diagnoses with a much higher degree of accuracy than in the past, there is no such certainty with prognosis. As much as we often hate to admit this, some things are out of our control. Death and its timing is one of them. That’s the way it should be.

As a physician and a healer, I am personally extremely uncomfortable deciding my patients’ timing of death.

Anmol Mahal, MD, is President of the California Medical Association.

Would you like to participate in the debate on physician-hastened death?

Please visit the San Francisco Medicine Magazine online discussion forum at www.sfmedicine.blogspot.com, or click on the link on our home page, www.sfms.org, to comment on the articles that appear in this issue.

www.sfms.org

Choosing Life or Death

Physician-Hastened Death The Case for Physician Aid in Dying Norman Carrigg, MD, and Stephen Jamison, PhD

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ue to ongoing legislative efforts, arguments surrounding physician aid in dying (PAD) are firmly before the public. Proposed legislation defines PAD as providing a mentally competent, terminally ill patient with medication, upon the patient’s request and with strict guidelines, that the patient may use to end his or her life. Some of the safeguards include evaluation by attending and consulting physicians, multiple requests, hospice enrollment or psychological assessment, and two waiting periods.

Arguments against legalization include prohibitions against killing by physicians, lack of fit between PAD and the doctrine of double effect, and the distinction between aiding and passively allowing a patient to die. We will argue that distinctions between PAD and other practices are fallacious, and its illegal status is more dangerous than its legislated regulation.

Prohibitions based on nonmaleficence, or doing no harm, are wrong here and must be balanced against (1) beneficence, or the duty to alleviate suffering; and (2) support for autonomy and control by a dying patient over the timing and manner of death. Killing takes life against the will and without the consent of one who wants to continue living. By contrast, one requesting PAD does so voluntarily and is already dying. Further, the physician is a participant in only part of an action that must be completed by the patient. PAD is not a direct action causing death. Instead, it allows the patient to die at a time of his or her choosing, either by the underlying disease or by the medication that has been provided for palliation. As such, PAD falls firmly under the doctrine of double effect.

Intention is central to the doctrine of www.sfms.org

double effect, and Oregon research shows no correlation between prescribing and intending to cause death. It can be argued that the physician’s intention in PAD is not always, mostly, or even frequently to cause death.

“A 2005 survey found that 57 percent of physicians surveyed believe that ‘it is ethical to assist an individual who has made a rational choice to die due to unbearable suffering.’”

There are many other reasons, such as: relieving pain, suffering, and anxiety; honoring the patient’s desire for autonomous choice; providing the patient a prescription as insurance against a worst-case scenario; reducing risk of violent suicide; and, extending the dialogue with the patient to address palliative needs.

Before dismissing this range of possible intentions, know that palliative sedation has been reported to be used in 15 to 30 percent of dying patients, or 2 to 50 percent of hospice patients, with indications for sedation ranging from 14 percent for delirium or agitation and 35 percent for dyspnea to 40 percent for anxiety/psychological distress (i.e., emotional distress). It is likely that physicians in Oregon as well as those providing for palliative sedation act out of similar intentions. Any deaths resulting from either are justified under double effect if the intention is not to cause death. Certainly this applies to PAD, which is not an action directly causing death. Indeed, it can

be argued that it is less directly causal than palliative sedation or withdrawing treatment. And in terms of the latter, research investigating end-of-life decisions in six European countries found that physicians reported they had the explicit intention of hastening the end of life in 45 percent of instances where treatments were withheld or withdrawn.

Looking further as to causation, data from Oregon indicate that 10 percent of dying patients seriously consider PAD, 1 percent request it, and one in six requests are granted, but only one in ten requests results in a patient’s death. Many patients change their minds, and up to a third who receive prescriptions never use them. Are there similar opportunities for patients to change their minds following palliative sedation or withdrawal of treatment? It might be suggested that there is a higher correlation between palliative sedation and death than between PAD and death.

There are various potential benefits from providing a legal framework for PAD. Oregon data show increased willingness by physicians to refer their patients to hospice, earlier referrals to hospice and higher rates of enrollment than elsewhere, and more aggressive pain management. A risk assessment perspective shows other potential benefits: Violent suicides among hospice patients in Oregon, for example, have been “almost nonexistent” since passage of the law. Also, research has found that the rate of aid in dying is four times higher in study sites outside of Oregon, where the practice is illegal. Legalization with strict safeguards could channel these patients into palliative care and hospice.

Finally, it should be pointed out that a

Continued on Page 32... june 2007 San Francisco Medicine

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Choosing Life or Death

Are We “Considering the Unthinkable”?

Publishing a Protocol for Assisted Dying Steve Heilig, MPH

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he work of SFMS rarely makes the front page of The New York Times, although that has happened more than once. A decade ago, when a pending United States Supreme Court could have legalized “physician-assisted dying” in California and other states, a network of hospital ethics committee representatives meeting at SFMS developed procedural guidelines to be used if legalization occurred. After extensive review by dozens of participants, the guidelines were published in the Western Journal of Medicine in June 1997, eliciting much media and professional attention, including the Times story titled “Considering the Unthinkable: Protocol for Assisted Suicide.”

The Supreme Court did not decide in favor of legalization then, leaving that question to individual states, and the debate about the issue has continued. Legislation is again proposed this year, and thus we reprint the guidelines here.

The full version, with more background and procedural information and more draft forms, plus references, is available on request from Steve Heilig at heilig@sfms.org.

Physician-Hastened Death: Advisory Guidelines for the San Francisco Bay Area Developed by the Bay Area Network of Ethics Committees’ ad hoc working group on appropriate care of the terminally ill in cases of requests for physician-hastened death. Members of the BANEC Working Group: Robert Brody, MD, San Francisco General Hospital; Steve Heilig, MPH, San Francisco Medical Society; Fred Marcus, MD, Redwood Medical Group, Redwood City; Lonny Shavelson, MD, Alta Bates Medical Center, Berkeley; and Patricia Carson Sussman, MS, Visiting Nurse Association and Hospice of Northern California.

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Principles and Procedural Guidelines This document is a blueprint for potential policy, to be used as deemed appropriate by individuals or organizations.

I. The ultimate responsibility for the care of the patient, pertaining to end-of-life decisions and treatments, resides with the patient’s physician. The actual informed decisions, however, are to be made by the patient.

II. The primary care physician is qualified to provide appropriate care, with or without consultation, for the great majority of patients who are dying.

III. The care of patients experiencing “difficult deaths,” those undergoing (in their judgment) intolerable or prolonged suffering as they die, or those who are making complex and irreversible decisions about end-of-life care (including the decision to hasten death), may fall out of the range of skills of many primary care physicians.

Hospice programs have extremely effective teams that provide medical care and help patients with their decisions about end-of-life treatments. Certain physicians in the medical community are also recognized to have special expertise in palliative, end-of-life care. For those patients who face difficult deaths, or those who are making complex and irreversible decisions about terminal care (including a request for physician aid in hastening death), the BANEC Guidelines urge referral to a hospice program and/or consultation with a physician experienced in palliative care (including, but not limited to, pain control).

Many patients, given appropriate and skilled end-of-life care, will withdraw their requests for a hastened death.

IV. At times, in spite of skilled physi-

cal, psychological, spiritual, and social care, an adult patient who is mentally competent and terminally ill will desire a physician’s aid in hastening death.

V. These guidelines urge that, before a physician aids a patient in hastening his or her death, specific steps occur (with specific documentation in the patient’s hospital chart and/or outpatient medical records).

(NOTE: No physician, nurse, physicianassistant, pharmacist, or other health care worker is required to participate in the act of hastening a patient’s death, nor in the patient’s evaluation for such an act.) Chart documentation should include: A) The primary care physician’s ascertainment of: 1. The terminal diagnosis (a reasonable certainty of death within six months provided the disease runs its expected course, ascertained by review of the medical records and pertinent history and physical examination).

2. An assessment to confirm that, in the best judgment of the physician, the patient is mentally competent and not suffering from a depression that impairs decision-making capability. (It is highly recommended that physicians who are not experienced with such evaluations seek appropriate aid, with their patient’s consent, from other practicioners in the medical, psychological, or social services community.)

3. Knowledge that high-quality palliative care, by hospice and/or a physician recognized to have expertise in palliative care, has been made accessible to the patient.

4. Knowledge that, to the best of the physician’s knowledge, the patient’s choice to hasten death has been freely www.sfms.org

made, independent of financial, family, health care worker, health insurance, or other coercion.

B) A second opinion to confirm the four points noted above by the primary care physician. These guidelines strongly recommend that the second opinion be obtained from a physician recognized to have expertise in palliative end-of-life care.

C) Documentation of the patient’s evaluation by a hospice program and/or physician with palliative care expertise (this can coincide with the second opinion noted above). Documentation should also be made of the palliative-care recommendations resulting from this evaluation, and the ways in which they have or have not been followed.

Alternately, documentation should be made that the patient declines an evaluation for improved palliative care. These guidelines recommend that these patients sign a form to indicate an understanding that they have waived a medical evaluation that could offer care with significant potential for improving their quality of life as they die.

D) The patient has been counseled that a decision to hasten death should, if at all possible, be discussed in detail with family members, loved ones, and others who are likely to be significantly affected by this decision.

The patient has also been counseled that the hospital and hospice medical ethics committees are available and willing to discuss his/her care, and the decision to hasten death, with the patient and/or family.

E) A witnessed consent form should be signed by the patient, to include full disclosure of the illness, the procedure to aid the patient in hastening death and the associated risks, and a statement that other medical options exist (including hospice care) that might provide further comfort without hastening death.

The witnessing procedure should be in accordance with that now established for the signing of a Durable Power of Attorney for Health Care Decisions, i.e., “(1) Two qualified adult witnesses who are personally known to the patient (or to whom the patient provides evidence of his/her identity), and who are present when the patient www.sfms.org

signs and acknowledges the signature; or (2) acknowledged before a notary public in California. If the witness is other than a notary public, the law provides that none of the following be used: (1) a health care provider or an employee of a health care provider, (2) an operator or an employee of a community care facility or residential care facility for the elderly. Additionally, at least one of the witnesses cannot be related to the patient by blood, marriage, or adoption, or be named in the patient’s will. For patients in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman.”

For patients and/or witnesses who are not able to understand the consent form in English, the forms will be provided in a language they can understand, or the signatures should be accompanied by that of a competent translator.

F) A second witnessed signature by the patient must be obtained no sooner than forty-eight (48) hours after the first signature.

G) Before aiding the patient in hastening death, there should be chart documentation of verbal counseling that the patient has the right, at any time, to change his or her mind and to return to care that includes the involvement of a hospice team or another physician experienced in palliative care.

H) Chart documentation that the physical process of hastening death was initiated and completed by the patient. These guidelines emphasize that the physician may aid the patient in the process of hastening death (e.g., by provision of oral or injectable medication, or the starting and maintaining of intravenous access), but it should be the patient’s own physical effort that initiates and completes the process.

I) These guidelines emphasize that, although it is the patient who undertakes the proximate action that leads to the hastened death, a physician or the physician’s designee responsible for the care of the patient should remain immediately and continuously available to the patient and family until death has occurred.

J) The cause of death on the death certificate should be listed as the underlying disease.

K) Reporting: These guidelines urge that a system similar to that of the California Tumor Registry (including the confidentiality of information) be established to which all cases of physician aid in the hastening of a patient’s death be reported. This registry would be able to request, for review, the full medical records of the patient, including details of the hastened death. The registry should track complete demographic information and issue an annual report detailing its findings. This report should be accessible to the public.

It is also recommended that existing hospital, hospice, and community clinic peer-review organizations include cases of aid in hastening deaths in their mandate of review.

Please see the checklist on page 37 for more guidelines for physician-hastened death.

Would you like to participate in the debate on physician-hastened death?

Please visit our online discussion forum at: www.sfmedicine.blogspot.com Or by clicking on the link on our home page: www.sfms.org.

june 2007 San Francisco Medicine

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Choosing Life or Death

Giving Life from Death Organ Donation Turns One Family’s Tragedy into Another Family’s Salvation Cherry Wise, PhD

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he month of April brought a very important day for all of us associated with the California Transplant Donor Network (CTDN): our annual Donor Family Gathering. This year we hosted more than 900 donor family members and friends, and 150 recipients of organs and tissues.

Together we all celebrated the astonishing altruism of the human heart. We applauded the recipients, who lined up on the stage to try to find words to express their appreciation for the gift of life they received. We joined the cheers of the donor families, as photographs of their loved ones were projected onto a full-sized cinema screen. We marveled as donor families and recipients met for the first time and became instant family. And we returned home humbled by the knowledge that, as nine-year-old Sean said in the support group I had facilitated that morning, “Everything can change in just a second.”

But that was not all that he said. Sean added, “And then we have to put that in the back of our heads and live our lives the best we can for the people who are not with us anymore.” With the wisdom of childhood, Sean had precisely described the paradoxical challenge that faces the families of potential donors, and the staff who work with them: to find strength and purpose in tragic circumstances—to choose life out of death.

The Challenge In the 1980s, Organ Procurement Organizations (OPOs) were established.

Born of their local transplant centers, they assumed responsibility for presenting the option of donation to families, and for providing medical management of donors.

While hospital personnel were often grateful to have that charge removed, they were also 30

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apprehensive about an outside organization approaching their patients and making such a request when the family was already emotionally overwhelmed. Our coordinators

“Sean had precisely described the paradoxical challenge that faces the families of potential donors, and the staff who work with them: to find strength and purpose in tragic circumstances—to choose life out of death.” would often be told, “We don’t think you should talk to this family; they have already been through enough.” We understood and respected the hospital’s impulse to be protective, and yet we had heard so many families express their appreciation for the opportunity to choose donation. Over and over they would tell us, “Donation was the one good thing that came from our tragedy; it gave us the strength to go on.” And we could never forget that seventeen people on the waiting list were dying every day, hoping for an organ that never became available.

That tension, between the protection and care for the grieving family and the desperate needs of recipients, is inevitable—and indeed it was helpful in guiding us toward a protocol that would both respect the rights and the vulnerability of the bereaved and make sure that as many recipients as possible would receive the lifesaving gift they were waiting for.

The Philosophy of the Family Team The Family Service Team at CTDN is an ethnically diverse group that includes grief counselors, social workers, and a psychologist, all of whom are committed to dynamic process improvement through monthly case reviews and in-services. The first document developed by the team was a set of guiding principles that clearly articulates high standards of care for the donor family.

• Excellent family care and excellent processes with optimal outcomes go hand in hand; these are not competing values or strategies.

• For the family, their loss and grief— not the donation—are primary, and all our interventions are guided by this fundamental awareness.

• We are not taking something from families; we are giving information to families about an important decision to consider the possibility of saving lives through donation.

• As an organization, we are confident in our belief that donation can be of inestimable long-term value to bereaved families, offering them some meaning in their loss.

• Because we serve an extremely diverse community, we acknowledge that any assumption that donation is the right thing to do is culturally influenced; and that different, deeply held convictions may influence decision-making by families from other cultures, leading them to say no.

• Donation is an extraordinary act of altruism at a time of intense tragedy.

When we empower families in every possible way, consent becomes their own decision, and the healing potential of the decision to donate is maximized. www.sfms.org

Values in Action In order to turn these lofty ideals into action, we turned our attention to research and literature in the fields of grief studies and crisis intervention. In addition, we analyzed the practice of those colleagues who were recognized as providing superior family care.

A convergence of ideas and practice soon emerged. CTDN coordinators meet families who are in shock and in the grip of the acute phase of grief. Family members may manifest that grief in idiosyncratic ways that range from stoicism through unmediated despair to somaticization. What they have in common is disruption of their typical coping mechanisms and severe impairment of their cognitive functioning; in fact, some experts estimate that functioning is typically reduced to about the fifth-grade level.

Clearly this is not an appropriate time to offer information about donation; rather, this is a time to identify the family’s needs and offer emotional and practical support.

Maslow’s Hierarchy of Needs As we began to explore how best to provide this support, we noticed that our practices bore a striking similarity to Maslow’s postulated Hierarchy of Needs.

First, the family’s safety and survival needs must be attended to, then their social supports identified, and their spiritual beliefs and practices supported, all in a context of utmost respect. Then, finally, the family is provided with the information about donation so that they can make their decision.

Whether that answer is yes or no, the decision will be momentous for many families, and making it would meet Maslow’s definition of a self-actualizing experience.

Crisis Intervention A continued exploration of interventions that could strengthen these families led us to review Crisis Intervention theory.

While not all family members will benefit from a uniform approach, long-term recovery from traumatogenic events can often be enhanced by reducing the individual’s sense of helplessness in the face of the crisis. The fundamental goal of Crisis Intervention is to help individuals regain their prior level of functioning, through empowerment of the family by offering choices, information, www.sfms.org

And, as we find that three out of four families choose the option of donation in the midst of their own tragedies, we continue to be amazed by the generosity of the human spirit.

Californians Donate Life

and respect.

We have incorporated the following principles of crisis intervention into our practice: prompt support, stabilization of psychological and cognitive functioning (through emotional and practical support), facilitation of understanding (through timely and sensitive explanations and sharing of information), focus on decision making and problem solving (through respectful support of the family’s consideration of the option of donation), and the encouragement of self-reliance (through eliciting the family’s wishes and ideas about how best to move forward).

Core Elements of Family Support and the Donation Discussion These many considerations have resulted in a sequence of care that emphasizes collaboration between the hospital and CTDN to provide optimal support to the family at every stage: gathering and sharing information; brain death discussion and beginning of family support; coping with loss; donation discussion; and aftercare.

Our goal is that every family should make an informed decision about donation (whether that decision is a yes or a no), so we offer the information about donation after we have helped family members begin to regain their prior level of functioning.

We are careful to offer the information in a noncoercive way, so that if a family decides against donation, they will not be burdened by feelings of guilt or feel judged by us.

In the past, families have often found it difficult to make the decision about donation when they were not sure about the wishes of their deceased family members.

As of May1, 2007, 1.3 million Californians have signed up on the state organ and tissue donor registry, and this is a source of great relief and comfort for their families when tragedy strikes. Occasionally, however, families are shocked and distressed when they find out about that decision.

In these situations, we turn our support to discussion of the challenge the family is experiencing in accepting the decision the individual family member made. We take whatever time is needed to gently review their understanding and acceptance of brain death; to help the family access social and spiritual support; and to offer information about donation, paying special attention to dispelling possible misconceptions. We sympathize that it must be very difficult to be asked to support a decision they themselves would not have made. In almost all cases, after these interventions, the families are able to comfortably accept their loved one’s choice.

It truly is a miracle that a family’s decision to think of the needs of others in the midst of personal tragedy can result in life for seven or even eight organ recipients and countless tissue recipients. At the Donor Family Gathering, I met a twice-bereaved mother who told me, “When I lost my daughter ten years ago, it was terrible...

There was no comfort. But when my son died last year, I accepted the option of donation. Nothing can bring him back, but knowing that he was a donor keeps me in touch with life. It makes all the difference.”

We are honored to be part of the amazing circle of life that is the world of donation and transplantation.

Cherry Wise, PhD, works for the Family Services Team (California Transplant Donor Network). june 2007 San Francisco Medicine

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Reflections Continued from Page 23... to what I should do. I have looked after my last will and testament, put all my affairs in order, and I know that I’m in good graces with God. SFM: So you didn’t have any more treatment?

Beverly: Well, I began having severe pain in my neck and arm. The doctors said it was a nerve being invaded, so I went in for an epidural. It was really awful. There were lots of individual, caring people looking after me, but the system itself didn’t seem to work. Waiting and waiting for things. The venipuncturist carrying out standing orders to start an IV when I already had a port.

Doctors coming in without knowing my case, yet supposedly offering advice. And, even then, the epidural didn’t seem to help the pain much. If I had it to do over again, I wouldn’t go in for the epidural.

SFM: Beverly, it may be a difficult question, but are you content now with your choices?

Beverly: Yes. I chose quality of life. I no longer have to spend my precious time

putting up with unnecessary frustrations or suffering.

SFM: I’d like to ask you two more questions. The first is, what advice would you offer to others who face choices about serious illnesses?

Beverly: I think that everyone has to make their own decisions, but you have to first find out all the information you can possibly find out, and then know that the best choice isn’t always to follow medical advice to do something.

SFM: And what about hospice? Is that the great help people say it is?

Beverly: With hospice, I can be supported yet still live my final days the way I want to, at home and with my family visiting. It has worked out beautifully.

SFM: So, Beverly, do you have anything else to say to me, your old friend?

Beverly: I love you, and I wish you well.

Note: One week following this interview, Beverly Hawks died peacefully at home with all her family present.

Physician-Hastened Death Continued from Page 27... majority of physicians support this choice. A 2005 survey found that 57 percent of physicians surveyed believe that “it is ethical to assist an individual who has made a rational choice to die due to unbearable suffering.”

Perhaps it’s time for the California Medical Association to take a lesson from CAPG, the California Association of Physician Groups, which explained its support for Assembly Bill 374, the Compassionate Choices Act, as follows: “While our primary duty as physicians is to care for and heal patients, it is CAPG’s position that patient care is ultimately about the patient, and that physicians should empathize with terminally ill or dying patients asking to be relieved of intolerable suffering when their disease can not be healed nor their intractable pain alleviated.”

Dr. Norman Carrigg is a retired oncologist who was in private practice in Marin County for more than forty years. Stephen Jamison, PhD, is the California Coordinator of Compassion and Choices and author of several books, including Final Acts of Love: Families, Friends, and Assisted Dying (Putnam, 1996).

Would you like to participate in the debate on physician-hastened death?

Please visit the San Francisco Medicine Magazine online discussion forum at www.sfmedicine.blogspot.com, or click on the link on our home page, www.sfms.org, to comment on the articles that appear in this issue.

Free CME Course on Domestic Violence www.respondtodv.org Physicians are more likely to recognize, validate, assess, and respond to suspected domestic violence in their patients after participating in an Internet course on the subject, according to new study results reported at the National Conference on Health and Domestic Violence in San Francisco, CA. The “Respond to Domestic Violence” course is a free program provided to physicians and health care providers through support from Blue Shield of California Foundation (www.blueshieldcafoundation. org). California physicians may earn up to 16 CME credits at no charge.

79 percent of physicians who took this course said that they will make practice changes in how they handle suspected IPV, indicating there is an “excellent” or “good” likelihood that they will change practice behavior. For more information and to take the course, visit www. respondtodv.org.

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www.sfms.org

Choosing Life or Death

Supporting Patient Choice Advanced Illness Management Brad Stuart, MD, Elizabeth Ciemins, PhD, MPH, and Jeff Newman, MD, MPH

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he end of life comes hard for many patients, but there are alternatives to death in the hospital. Since the 1970s, home hospice has set the standard for end-of-life care in the U.S. Hospice, paid for by Medicare, sends nurses, social workers, clergy, and volunteers to patients’ homes to provide pain relief and family support. However, over the past ten years, median survival in hospice has dropped from nearly a month to less than two weeks. Half of the patients in our Sutter Health hospice program in San Francisco die within eleven days of enrollment. One quarter survive fewer than seven days, and ten percent die in less than twenty-four hours.

For many people wrestling with latestage illness, hospice is hard to accept.

Physicians must certify a life expectancy of six months or less, and patients must sign away their right to Medicare payment of disease-modifying treatment. Medicare will not cover treatment that combines hospice care with life-prolonging measures such as chemotherapy or dialysis.

For African-Americans, hospice is a particularly difficult choice. The California Health Care Foundation reports that in 2004, 76 percent of hospice patients were white, while only 6 percent were AfricanAmerican. In surveys, African-Americans say that they may not want to forego acute treatment, and they may view hospice as “second-rate care,” or as an attempt to deny needed services.

To overcome these barriers, we started a program in the East Bay called Advanced Illness Management (AIM) to provide home-based palliative care blended seamlessly into home care. In 2005 we extended it to San Francisco and strengthened program evaluation. www.sfms.org

AIM uses nurses and social workers from both home care and hospice to support patients and their primary care physicians with a unique mix of disease-modifying care and symptom management, along with education about disease process, prognosis, and treatment options, including hospice.

Any diagnosis is eligible as long as illness is advanced. AIM eases the transition from curative toward comfort-focused care, and the transition happens at the patient’s and family’s own pace.

Our evaluation reveals that participation in AIM is associated with more than doubling of hospice referral, compared to otherwise similar patients receiving home care. Among African-Americans, the association is even stronger. Unpublished data from the AIM program in San Francisco show that hospice length of stay for patients transferred from AIM is extended by up to 25 percent.

Not only are pain and other symptoms treated sooner, but important decisions also get made before sudden declines lead to 911 calls. Ninety-five percent of hospice patients never return to the hospital.

Like many other hospitals and systems, Sutter Heath is also developing and expanding inpatient palliative care services, including multidisciplinary consultation and dedicated units. At the Pacific, Davies, and St. Luke’s campuses of CPMC, we have observed increased and more timely consultations, improved symptom control, decreased hospitalization stays, increased transfers to lower levels of care, fewer procedures, and increased pharmacy and therapy utilization—all leading to reduced costs and charges.

Electronic heath records will improve patient-centeredness related to palliative

as well as other aspects of care. Advanced directives developed by patients with the support of their families and primary care physicians will be readily available to clinicians in emergency departments and hospitals for timely decisions. Advanced methods of symptom control and terminal disease management initiated in the inpatient setting will be better communicated to ambulatory and home-based care, further improving patient and family satisfaction and reducing unnecessary and expensive hospitalizations.

Brad Stuart, MD, is Senior Medical Director, Sutter VNA and Hospice. Elizabeth Ciemins, PhD, MPH, is Senior Health Services Researcher, Sutter Health Institute for Research & Education (SHIRE). And Jeff Newman, MD, MPH, is the Director of SHIRE and an Adjunct Professor for the Institute for Health and Aging at UCSF. To see a list of references used for this article, please visit our website, www.sfms. org/archives.

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hospital news Chinese

Joseph Woo, MD

The Chinese Community Health Care Association (CCHCA) celebrates its twentyfifth year of service this year. CCHCA is the physician independent-practice association that serves as the principal medical group for the Chinese Community Health Plan and other plans affiliated with Chinese Hospital. CCHCA is unique in that it is a not-for-profit, tax-exempt IPA whose assets are to be used for public and community needs as outlined in its bylaws. Its ongoing mission is to provide quality care at affordable prices in a culturally sensitive manner to the Chinese community of San Francisco and the Bay Area.

This birthday was celebrated at a gala held at the Olympic City Club. In attendance were CCHCA Executive Director and SF Health Commissioner Edward Chow; IPA President Eric Leung; and founding physician Rolland C. Lowe, who received special recognition for his dedication to the community. Congratulations and thanks to the scores of other physicians who make the IPA successful and an entity we are proud of.

In addition to providing support to the Chinese Hospital Association, the IPA supports community health programs including the Chinese Community Health Resource Center and the Neighborhood Disaster Response Plan.

CCHCA has contributed more than $3 million to community programs and is an active member of the NICOS Chinese Health Coalition and the Federation of Chinese American and Chinese Canadian Medical Societies.

www.sfms.org

CPMC

Damian Augustyn, MD

Drs. Brian Andrews, Charles Cobbs, Bruce McCormack, Peter Weber, Thomas McClure, and Christopher Cody are among the 100 physicians and chiropractors nationwide who have committed to be evaluated under the Back Pain Recognition Program (BPRP), a new program developed by the National Committee for Quality Assurance (NCQA) that recognizes health care providers who deliver top-quality care to patients with low back pain.

The latest addition to CPMC’s Kanbar Center is a Stereotaxis lab, a $2.4 million piece of equipment that will make CPMC one of only three West Coast hospitals using this technology (joining USCF and Seattle’s Swedish Hospital).

The Stereotaxis system is a magnetic navigation system used during complex electrophysiology and coronary intervention procedures. It allows the physician to remotely control precise computerized interventional procedures with greater efficacy than conventional mapping techniques.

The procedures performed could vary from implanting a cardiac resynchronization device for the management of heart failure to performing a complex ablation for the treatment of various heart rhythm problems.

The California Pacific’s Center for Diabetes Services’ Diabetes Self-Management Education Program has been awarded continued recognition from the American Diabetes Association (ADA). Our high-quality education services were originally recognized by the ADA in January 2001. The ADA Education Recognition effort is a voluntary process that assures that approved education programs have met the National Standards for Diabetes Self-Management Education Programs. Programs that achieve recognition status are staffed with knowledgeable health professionals who can provide participants with state-of-the-art information about diabetes management.

Saint Francis

Guido Gores, MD

At Saint Francis Memorial Hospital, part of choosing life means choosing to approach the end of life with comfort and dignity. To fill that need, the hospital has developed a Palliative Care Services Program. Headed by Medical Director Patricia Galamba, MD, the Palliative Care Program aims to provide sensitive care, with a focus on promoting quality of life, to patients and families living with a terminal illness.

From diagnosis to the end of life, the Palliative Care Team—which consists of physicians, nurses, chaplains, social workers, and other clinicians—works with patients and their loved ones to help them understand their prognoses.

Through advanced care planning, the patient and family are assisted in determining what interventions and medical care they prefer, including completion of advance directives.

In addition, patients and families are educated about the disease process and options for care after hospitalization. We are pleased to be able to bring these services to patients and their families in their time of need.

On a more upbeat note, we are pleased to announce the hiring of our new Vice President of Medical Affairs, Robert L. Vautrain, MD, MS. Dr. Vautrain will join us starting June 5 and will oversee medical affairs at both Saint Francis and our sister CHW hospital, St. Mary’s.

He comes from Springfield, Illinois, where he served as Chief Medical Officer of the Memorial Health System starting in 1997. Since 1982, Dr. Vautrain has been a Clinical Associate Professor at the Southern Illinois School of Medicine.

From 1981 to 1997, Dr. Vautrain was in private practice in internal medicine. We welcome him to Saint Francis and the San Francisco medical community and look forward to working with him for the benefit of our patients.

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hospital news St. Luke’s

Jerome Franz, MD

In addition to his role as Chief Medical Executive for the hospital, William Miller has taken on the assignment of Chief Medical Officer for the Health Care Center, which used to be our neighborhood clinic. The HCC is undergoing a major restructuring under the guidance of its new CEO, Eric Pousard. Multiple care sites will be merged for efficiency. However, the restructuring will center around Health First, an innovative program of family medicine for our underserved population that employs a team of community health workers and nurse practitioners supervised by physicians. The growing Women’s Center, which delivered 1,200 babies in 2006, will continue to provide high-quality care for our community, although we will be losing the popular Homestyle Midwifery program as it moves into private practice.

We want to thank Susan Bailey, who has resigned as Chair of the Surgery Department, for her work over the past four years. At its April 18 meeting, the department elected Lora Burke to be the new Chair. Lora is a breast and general surgeon, a key figure at our Breast Health Center, and highly respected by her peers. The medical director for surgical services continues to be Samer Michaels, Chair of Anesthesiology, who is also the person working most closely with administration on the reorganization of the hospital as we aim to reduce our financial losses over the next two-and-a-half years.

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St. Mary’s

Richard Podolin, MD

Physicians and health care professionals at St. Mary’s Medical Center affirm life and regard dying as a natural process that is a profoundly personal experience for the individual and his or her loved ones. Decisions about end-of-life issues can be difficult for patients and their families.

Discussing these issues requires an acknowledgment that life must end and that loss is inevitable.

Health care providers can facilitate these discussions by providing honest and clear information about the medical condition of each patient; by providing an opening and a safe emotional space for patients, and sometimes families, to have these conversations; and by listening carefully and with compassion to the hopes, fears, and expectations of their patients.

An advance directive is one effective tool to document choices regarding end-of-life care. An advance directive appoints the patient’s choice of an agent for that time when he would no longer be able to speak for himself. It can also document decisions about types of treatments, such as a decision to forgo attempts for resuscitation, or to avoid using such machines as ventilators when the chance of recovery is small.

Through conversations with their physicians, and by completing advance directives now, patients can make their preferences known and spare their families from having to grapple with these difficult questions. Current events, such as the Terri Schiavo case, can serve as an opening topic for a discussion with patients about their own wishes.

At St. Mary’s, the Palliative Care Consult Service, which includes physicians, nurses, and chaplains, is an active partner with the primary physicians, helping to begin difficult conversations and complete advance directives. We at St. Mary’s strive to acknowledge death as part of life and we honor the need for each person to have an opportunity to express his or her wishes and values.

UCSF

Ronald Miller, MD

The Islet and Cellular Transplantation Center at UCSF Medical Center is now offering a new and innovative procedure for treating chronic pancreatitis, an inflammation of the pancreas that leads to scarring and destruction of the organ. Called pancreatectomy and islet autotransplantation, the procedure helps to alleviate the pain caused by chronic pancreatitis while preserving the patient’s ability to secrete insulin. UCSF is the only facility in the West offering this treatment. Islet autotransplantation requires the removal of the pancreas. Once removed, the patient’s own islets—cells within in the pancreas that form clusters and produce insulin—are isolated and extracted from the organ. The cells are then put back into the patient via an infusion into the liver. “Once in the liver, the islets resume making insulin,” said Hobart Harris, MD, MPH, a professor and Chief of the Division of General Surgery as well as Vice Chair of the Department of Surgery at UCSF. “By transplanting the islets into the liver, we reduce a patient’s risk of developing surgically-induced diabetes.” Islet autotransplantation has a 100 percent survival rate at UCSF. “Islet autotransplantation has dramatically increased the quality of life for our patients,” added transplant surgeon Andrew Posselt, MD, PhD, codirector of UCSF’s Pancreas and Pancreatic Islet Transplant Program. “More than half of our patients require no insulin therapy post-procedure.”

UCSF’s Islet and Cellular Transplantation Center is a leader in treating diseases of the pancreas. In addition to islet autotransplantation, UCSF performs two other procedures designed to provide selected patients with a healthy supply of insulin-producing beta cells, including solid organ pancreas transplantation and pancreatic islet allotransplantation. For more information or to refer a patient, please contact the UCSF Center at (415) 353-8893. www.sfms.org

Physician-Assisted Suicide Guidelines Continued from Page 29...

Veterans

Diana Nicoll, MD, PhD, MPA

PHYSICIAN CHECKLIST IN ASSISTED-DEATH CASES (To be completed before the hastening of a patient’s death) Patient’s name: ____________________________ Physician’s name: __________________________

Date:_________

Prior to assisting in the death of a patient, please confirm the following:

Most of the men and women who return from combat in Iraq and Afghanistan are resilient and will suffer no long-lasting trauma from their service, but a significant minority is at high risk for risk-taking behavior and suicide, says Charles Marmar, MD, Associate Chief of Staff of Mental Health at SFVAMC. Dr. Marmar explains that in combat, deep bonding develops between members of a fighting unit, who share an ethos of “no comrade left behind.” Sense of self becomes porous; “I” becomes “we.” The death of a unit member is thus perceived as a partial death of the self, leading to despair, survivor guilt, and a sense of responsibility for the unit member’s death.

After return to civilian life, unresolved grief, guilt, and depression can become a terrible burden among vulnerable individuals, leading to risk-taking and suicidal thoughts and behaviors.

Untreated post-traumatic stress disorder can complicate the picture by intensifying despair, impulsivity, alcohol and drug use, and suicidal thoughts. Traumatic brain injury, which has been termed the “signature wound” of the conflict in Iraq, increases the risk of depression and impulsivity.

Fortunately, the V.A. and the Department of Defense are working together to screen at-risk military personnel and to provide state-of-the-art treatment. Depression and grief are treated with antidepressant medications. Guilt and exaggerated sense of responsibility are addressed through cognitive behavioral therapy. Traumatic brain injury is treated with neurocognitive rehabilitation and supportive care.

Group therapy is also an important component of post-combat trauma treatment. The original trauma occurred in a group setting, and a combat support group functions as a surrogate combat unit. Group members offer care, understanding, forgiveness, and a sense of shared experience. www.sfms.org

1.____ The patient is an adult resident of California.

2.____ As the patient’s physician, I am well aware of the patient’s medical history, condition, diagnosis, and prognosis.

3.____ The patient’s condition is terminal, with death reasonably expected to occur within six months of this date.

4.____ A second physician has confirmed this terminal diagnosis.

5.____ The patient is mentally competent and able to exercise rational thought processes in making decisions regarding his or her health care.

6.____ High-quality palliative care, by hospice and/or physicians qualified to provide such care, has been offered to the patient, with full understanding that such care might result in an improved quality of life during the patient’s remaining days.

7.____ If such care has been refused by patient, such refusal has been documented by a signed consent form.

8.____ To the best of the physician’s knowledge, the patient’s choice to die has been freely made, independent of financial, family, health insurance, or other sources of coercion.

9.____ The patient has been offered consultation with an ethics committee.

10.___ The patient has been offered counseling by a psychiatrist, therapist, social service worker, member of the clergy, or other.

11.___ The patient has been counseled to discuss his or her decision with any family members, loved ones, or others who will be affected by this decision.

12.___ The patient has made the required two signed, witnessed requests, at least forty-eight (48) hours apart, for a hastened death.

13.___ The patient has been offered appropriate means of ending his or her life, with full disclosure of the process and the pros and cons of each, and has made an informed choice of which intervention will be used.

14.___ At the time of the procedure, the patient is still competent; has made a third, final request, with witness(es) present; and has been advised that the procedure may be halted at any time upon the patient’s request, with a return to optimal palliative care as an option.

15.___ A health care professional (physician or nurse) with expertise in this area has been identified who will remain immediately and continuously available to assure that distressing symptoms are minimized via appropriate palliative means.

Following death, the usual confirmation and reporting requirements are in effect, with the addition of the reporting form for physician-assisted death.

Narrative Section (optional): Please use an additional form to add any comments deemed appropriate regarding the patient’s case. ______________________________ ___________ Physician’s signature Date

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In Memoriam Ronald Bangasser, MD Ronald P. Bangasser, MD, who served as CMA president in 2003– 2004, died on May 3 in Redlands after his struggles with cancer. He was 57. Dr. Bangasser had practiced medicine since 1975. He had been active in state and national medical societies for nearly thirty years, serving as speaker and vice speaker of the CMA House of Delegates and as president of the San Bernardino County Medical Society. He served on the CMA Board of Trustees for eight years before taking office as president. He also served energetically in multiple AMA leadership roles.

Dr. Bangasser was a family practitioner with Beaver Medical Group in Redlands, serving as both Medical Director and Director of External Affairs. He specialized in the management of chronic complicated wounds and in 1986 founded the nationally recognized Paul F. Bangasser Wound Care Center (dedicated to his father in 2005) at Redlands Community Hospital.

Often a national spokesperson on influenza issues and a vigorous advocate for immunizations, he was a member of the Board of Directors of the Integrated Healthcare Association and Chairman of the California Adult Immunization Coalition, and he served for four years as a speaker for the Centers for Disease Control/AMA National Flu Vaccine Summit.

Dr. Bangasser received his medical degree from Chicago Medical School and interned at San Bernardino County Medical Center. He trained in hyperbaric oxygen research at St. Luke’s Presbyterian Hospital in Milwaukee, Wisconsin, and at the Navy Diving Medical Officers’ Training School. He also was an avid scuba diver and instructor.

For twenty-eight years, Dr. Bangasser was a key figure in the San Bernardino County Medical Society, CMA, and AMA, serving as president of SBCMS before taking on that role for the CMA. He served as Chair of the California Delegation to the AMA, Chair of CMA’s Finance Committee, and Vice Chair of CMA’s Hospital Medical Staff Section. He was an AMA delegate and a member of the AMA Council on Medical Services.

Dr. Bangasser served as president of the California Foundation for Medical Care and the San Bernardino County Foundation for Medical Care. He served on the boards of the Inland Empire Foundation for Medical Care and the Pacific Foundation for Medical Care, dedicating many years to the foundation movement in California.

Dr. Bangasser served on the board of directors of Blue Shield of California, was vice chair of the Blue Shield Foundation, and served on the National Council for Quality Assurance’s Committee on Performance Measurement and the NCQA’s Practicing Physicians’ Advisory Committee. He also served on the Quality Forum, District IX, Centers for Medicare and Medicaid Services.

Dr. Bangasser was past chair of the Institute for International Research and the Network Professional and Technical Advisory Committee for the Joint Commission on Accreditation of Healthcare Organizations.

He served on the task force on provider solvency for the Department of Corporations.

In 1995, the SBCMS honored Dr. Bangasser with the prestigious Nicholas P. Krikes, MD, Award for Outstanding Contribution to SBCMS for his years of dedicated service. In 2002 he received the AMA Pride in the 38

San Francisco Medicine june 2007

Professions Award and the CMA Young Physician’s Joseph Boyle Young at Heart Award. Other awards include the Riverside County Medical Association’s Outstanding Contribution to Organized Medicine Award; the James C. MacLaggan, MD, Political Action Award; and the Medical Board of California’s Physician Humanitarian Award.

For twenty-two years, Ron served as the team physician for San Bernardino Valley College; he gave 12,000 sport physicals and attended 110 football games. In 1999, the college presented him with its Distinguished Service Award. Ron also served as the team physician for the San Bernardino Stampede Professional Baseball Team.

As a scuba diver (expert and instructor), Ron Bangasser taught many colleagues, friends, patients, and citizens the joy of scuba diving. He served as an instructor for the San Bernardino County Sheriff’s Department team responsible for retrieving boats, planes, people, and bodies.

Ron worked diligently for the local United Way, at one point serving as Chairman of the Professional Division of the United Way fund-raising campaign. He was successful in obtaining record contributions from physicians in the area.

He promoted the involvement of medical students and residents in organized medicine. He annually sponsored students from Loma Linda University School of Medicine to attend CMA’s Legislative Leadership Day. Dr. Bangasser is survived by his wife, Susan; two daughters, Debbie Waxler and Sandi Bangasser; and his mother, Florence Bangasser. Donations in his honor can be made to the Ronald P. Bangasser, MD, Medical Student Scholarship Fund, c/o the Physicians Memorial Gift & Benevolence Fund (PMGBF), 3993 Jurupa Ave., Riverside, CA 92506.

Richard Cazen, MD Dr. Richard Alan Cazen, one of San Francisco’s most preeminent gastroenterologists and HIV specialists, passed away peacefully on Thursday, April 26, in his birthplace of Pittsburgh, Pennsylvania. Dr. Cazen had been diagnosed with an aggressive brain tumor in September of 2005 and, by sheer will, outlived his prognosis by almost a year.

Beginning practice in 1981 at the emergence of the AIDS epidemic, Richard became a pioneer and activist in the treatment and protocol of this very new and raging disease. As a gastroenterologist, he maintained one of the only subspecialty practices in San Francisco, concentrating not only on the disease itself but on the gastrointestinal symptoms from AIDS and side effects from HIV-related drug interactions and toxicities. He was fearless in his opinions, working side by side with pharmaceutical researchers, striving to perfect dosages of existing drugs as well as implementation of new drugs on the horizon, many of which are now the standard of care for today’s more refined treatment. He had a provocative and strong character, and those who worked with him or were treated by him will never forget him. Both directly and indirectly, Dr. Richard Cazen saved countless lives.

Richard Alan Cazen was born in Pittsburgh on August 20, 1948. He graduated from the University of Pennsylvania with honors and went on to study medicine at Yale. After graduating medical school, he went on

Continued on Opposing Page... www.sfms.org

SFMS Gallery Mixer, July 12, 2007 On Thursday, July 12, SFMS will once again collaborate with the Togonon Gallery in presenting a Gallery Mixer for its members and guests; featuring a wonderful mix of fascinating art, beverages, appetizers, convivial fellowship, and live jazz. For more information about the return of this popular member event, see the On Your Behalf section or contact Therese Porter in the Membership Department (tporter@sfms.org or (415) 561-0850 extension 268).

About the Gallery The Togonon Gallery works with both emerging and established artists from the West Coast, with a focus on diverse backgrounds and heritages. Many of its established artists have been active in the major art movements of the twentieth and twenty-first centuries, including Abstract Expression, Minimalism, and the Bay

In Memoriam Continued... to complete his residency in internal medicine and continued his fellowship in gastroenterology at the prestigious University of California in San Francisco. He lived and practiced medicine for the remainder of his life in San Francisco, maintaining active staff privileges at California Pacific Medical Center.

Dr. Cazen was a man of many passions. A loyal San Francisco Giants fan, he maintained season tickets, attending almost all home games.

Fine clothing and cuisine also took precedence in his life, and he will be sorely missed by the restaurateurs and fancy boutique owners not only in San Francisco but globally. He was a devoted patron of the theater, often flying to New York City or London to attend the opening of a new play or musical. Elaine Stritch was among his favorite actresses, and he had the honor of meeting her while attending Yale. This remained one of his fondest memories.

Dr. Cazen is survived by his sister, Judy Haffner (Harold), of Pittsburgh Pennsylvania; his two nephews, Mark (Shelly) and Barry (Danielle); one great nephew, Alex; two great nieces, Ilyssa and Lauren; and countless friends, colleagues, and, above all, his patients. Donations should be made to the Dream Foundation, 1528 Chapala St., Suite 304, Santa Barbara, CA 93101 or www.dreamfoundation.org.

www.sfms.org

Area Figurative and Realist Traditions.

Its mission is to fuel artistic dialogue around the work of established and emerging artists who identify their creative process through their connection to the West Coast.

The Gallery aims to support dialogue on culture, ethnicity, and art in the exploration of diversity on many levels; reflect the community; and encourage the viewing of art within a context of place and time rather than simply because it is a trend.

Togonon Gallery is a dynamic exhibition space where both the artists and the public can discover the distinctive qualities inherent in West Coast art.

The Gallery is located in a 3,000-square-foot space at 77 Geary, in the heart of downtown San Francisco.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Ashley Skabar for more information, (415) 5610850 extension 240 or askabar@sfms.org.

Classified Ad • Medical Transcription Experienced, reliable. All Specialties. Workers’ Comp reports. Correspondence, chart notes. Toll-free dictation line/internet dictation/tapes. C. Sivesind (925) 829-3741

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Northern California Physician Opportunities Sutter Health offers a wide variety of practice styles, geographies, and life styles.

With facilities in Northern California from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, you have boundless career opportunities to fit your goals.

We have open opportunities in a variety of specialties. Contact us for more information.

Sutter Health Physician Recruitment 866-448-7070 916-454-6645 fax docjobs@sutterhealth.org www.sutterhealth.org

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