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Wednesday, March 26, 2014

JL on Tim Bowers

The best part of writing this blog are the comments I receive. I am often taken to task and beyond but once in a while I get a comment that reaffirms my writing is important. To this end below is a comment I received from JL that warmed my soul. Bowers has been on my mind as I prepare for my talk on Friday. As I reread the material published to date I grow increasingly disturbed by what took place. JL's long comment highlights why Bowers case is important and needs to be discussed in detail.

JL wrote:

          It’s a crisp fall day in an Indiana farm town.  A young hunter sits in a tree stand some sixteen feet in the air awaiting his prize buck.  His view is tranquil as he enjoys a brisk breeze.  As time passes, images of his expectant wife drift through his mind.  Business is good, his family is growing, and life is as it should be…….simple, secure, and peacefully predictable.   Eventually, as the day progresses, the sun begins to set.  He gathers up his gear and begins his descent, maneuvering down the tree stand as he’s done so many times before.  However, on this particular day, the young man’s life deviates far away from everything familiar.   On his downward climb, he abruptly finds himself flailing through chilly air.   With brutal force, his sixteen foot fall comes to a crushing halt as his body smashes into the cold November ground.  He is stunned, breathless, and confused.  Disoriented and fearful, he tries to reach for his cell phone only to find his desires met by motionless arms.  Trepidation and panic overcome his paralyzed body.  He lay silently and lifelessly for hours.  His flustered mind races as his body begins to fight the trauma it has endured.  The damage to his spine slows his heart rate, lowers his blood pressure, and robs him of his ability to shiver in attempts to warm his body.   Breathing becomes ever so difficult as he struggles to willfully fill his lungs.  The man lays awkwardly positioned on frigid ground, his body broken, and his mind lost in disbelief.  After enduring several horrifying hours alone, help arrives.  Met by a fury of doctors, nurses and terrified family members, he works hard to process his surroundings through a curtain of confusion.  Bright lights, unnerving voices, and white coats rush around him making the graveness of the situation overwhelmingly real.  Quickly, a tangled mass of tubing surrounds and infiltrates his body.  A large hose is thrust down his throat with imposing force.  He bites down in logical opposition to such a barbaric act.  He is so exhausted, so utterly and soulfully exhausted.  His mind and body is overcome by fatigue, bewilderment, and trauma.  He begins to drift off……..finally, finally, it appears he can rest.  At long last, his body finds peace as he enters a medically induced state of sedation.   The process of healing can now begin as his broken body finds reprieve. But, no! Suddenly, the young man finds himself awake again.  His mind is foggy as he tries to fight through the heavy haze of sedation.  He struggles to gain his bearings and make sense of his overwhelming circumstance.  Weeping family members overcome with anguish hover over him.  They talk of his life in a wheelchair and his inability to breathe independently.  He is told of the baby he will never hold, and the hugs he will never give.  Grief saturates the man’s body to its very core.  He is exhausted, hopeless and besieged with uncertainty.  And so it is, at this intensely susceptible moment within hours of injury, that medical professionals present the young man with an option to die.  Hence, with his family in support, and a nod of his head, an emotionally and physically battered man surrenders his gift of life and succumbs to death.                                                                                               
With this turn of events, the family of Timothy Bowers, a 32 year-old husband and father-to-be, grieve his loss and try to move forward.  Meanwhile, the hospital and health care team involved in his case tout their prompt and unwavering endorsement of patient autonomy.  News spreads of the proceedings and support grows for the “courageous” deer hunter that selflessly chose to die and the medical staff that boldly gave him a choice.  And I, as a physical therapist and patient advocate, sit in horror and disbelief over the flagrant miscarriage of events.  
Does one truly believe that Tim Bowers was of sound mind and in complete understanding of his condition at the time he was given an option to die?  Could any human being demonstrate logical reasoning and exercise keen judgment after suffering such emotional and physical trauma?  Of course not.  Tim Bower’s was a shattered and confused young man just as any of us would be after enduring such a nightmarish ordeal.  Furthermore, there is no way Mr. Bowers could have fully understood his plight in light of the fact that medical doctors cannot even detail prognosis at such an early stage.  Traumatic spinal cord injuries are exceedingly unpredictable which make adequate assessment especially in the first hours following injury arduous at best.                                                                                                                                         
All of this raises the next question: why was Tim Bowers’ case handled with such blatant haste?  Has human life lost its value?  After all, Mr. Bowers was not in a vegetative state.  He did not suffer a brain injury.  He could have expressed his wishes at any time in the days or weeks to follow.  Why not slow down, wait a few days, let the patient rest, get his bearings, and reassess options after the situation gains stability?   In fact, it is widely known among the medical community that a progressive loss of function will occur during the initial 24 hour period following spinal trauma.  After this time, edema in the region of injury begins to subside as some areas may even reestablish circulation.  After a 72 hour period, the American Spinal Injury Association guide is followed as initial sensory and motor function is assessed and documented.  In addition, radiology can attain new images that may offer more information to doctors and patient regarding functional outcome.  Also, with additional time, the rehabilitation department can be consulted whereas individuals can gain a better understanding of daily life given persistent paralysis.  In accordance, psychiatric services can assess the individual’s mental state and aid in his or her understanding of the situation.  In lieu of all this, it is clear, that given even just a few days, Tim Bowers could have been equipped with crucial pragmatic knowledge to apply to his life and death decision.                                                                 
Put simply, Timothy Bowers was neither courageous nor cowardice in his accordance with death.   Instead, he was a broken young man inundated with emotional and physical exhaustion brought on by the horrific events of his nightmarish day.  He was, no doubt, plagued by sedation-induced brain fog, total confusion, and immeasurable grief at the time he was approached with an option to die.  Tim Bowers was the beneficiary of the perfect storm:  a family, so adamant they knew his wishes from past conversations based on the hypothetical, they chose to wake him from his medically induced resting state; and doctors, so exceedingly eager to give the illusion of patient autonomy, they lost all medical judgment.  The health care system failed Mr. Bowers and his family.  Physicians put Tim Bowers in a position to end his life despite understanding the distressing physiological aspects of acute spinal trauma and the adverse cognitive effects of sedation.  To appreciate just how senseless this was consider the fact that doctors routinely advise patients to avoid driving a motor vehicle due to impaired judgment, thinking and motors skills following medical sedation alone.  However, doctors allowed Tim Bowers to “decide” if he wanted to live or die. This practice was not only careless, but by many standards, it was criminal.                     
Advocating and granting patient autonomy within our healthcare system is vitally important.  All of us, as human beings, should possess the right to determine the course of our medical treatment.  However, the concept of patient autonomy only works in the best interest of the individual when he or she is of sound mind and well informed.  Tim Bowers, the young father-to-be, was neither.  The actions of the hospital and physicians involved in his case were, at the very least, impulsive, irrational and reprehensible. They effectively committed a fatal injustice by disguising such careless practice as championing patient autonomy.   This type of deception has no place in a compassionate and ethical health care system.

Monday, March 24, 2014

Tim Bowers and Lethal Language

This Friday I am giving a talk about the death of Tim Bowers. Bowers died within 24 hours of a devastating cervical spinal cord injury. Bowers death was highly unusual and controversial. The day after his injury at the family's request Bowers was taken out of heavy sedation and told of his condition. In emotionally laden language Bowers was told he would be a vent dependent quad. Bowers pregnant wife told him he would never be able to hold their child. In all likelihood Bowers would live in a nursing home totally dependent on others. Given this prognosis, Bowers chose to die and the vent that kept him alive was removed. He died shortly afterwards. 

Bioethicists such as Art Caplan, praised the family and physicians involved. A prefect case of a patient asserting his autonomy. I read this statement and shake my head in wonder. What if Bowers had been severely burned? Would he have been given the same "choice"? I think not. What disturbs me is the unquestioned assumption that life as a vent dependent quad lacks any value. When I think of Bowers I am taken back in time to the first year I was paralyzed. There were no high level quads. One night I asked why were there no upper level quads. I was told to think about it. Puzzled I could not come up with a logical answer. Think about it I was told. Would you want to live as a C-3 quad instead of being a T-3 para. Of course not. Nature I was told was allowed to take its course. The logic apparently was any injury above C-8 was not worth living. At C-8 the thinking was one could still transfer independently with a sliding board. Any injury above C-8 created a life of physical dependence that was not worth living. Not much has changed in 30 years. A C-8 SCI has been replaced by being vent dependent. The lethal logic circa 1978 has not changed. Being paralyzed leads to diminished quality of life. Expectations, typical life experiences, are believed to be impossible to obtain or achieve. This belief is deeply ingrained in the American psyche. Lethal thoughts can and do lead to lethal actions. 

If readers happen to be in the Syracuse are information about my talk is below. 

Consortium for Culture and Medicine Seminar 
 Friday, March 28, 2014 
4 to 5 pm 
Room 1507/1508 Setnor Academic Building 
766 Irving Ave 
“Does Lethal Language lead to Lethal Treatment? End-of-Life Issues”

William J. Peace, PhD
Renee Crown Honors Program, Syracuse University 
We will discuss the decision-making strategies that take place
immediately after devastating injuries, focusing in particular on
decisions to remove patients from life-sustaining treatment. Of
particular interest are patient autonomy, the notion of dignity,
terminal sedation, and VSED (voluntary suspension of eating and
drinking).  The story of Timothy Bowers, the hunter who was taken off
life-sustaining treatment twenty-four hours after experiencing a
devastating spinal cord injury, will serve as a test case. 
Free and open to the public