endpage
Dr. No
by Barbara Iozzia
 |
Dr. Jack Kevorkian grabs headlines every time he helps a terminally
ill patient who wants to die. But doctors opposed to physician-assisted
suicide, like Thomas Cavalieri, DO, have gotten little attention until
very recently. The New York Times Magazine profiled several in its July 21 cover story, and Cavalieri is beginning to get a wider audience, too. A devout Catholic who has spent the past 15 years developing and overseeing the geriatrics program at UMDNJ-School of Osteopathic Medicine, Cavalieri is concerned about the impact physician-assisted suicide would have on clinical care. "If it is allowed, physician-assisted suicide will probably inhibit palliative care - the frail elderly might feel pressured, or patients will opt for it because of a fear of being a burden to others," he observes. |
"In the Netherlands, where euthanasia is legal, there have been
cases where physicians have used it based on their own decisions as to
whether a person has an acceptable quality of life. That is unethical to
me."
Cavalieri's research projects have examined physicians' and the public's
attitudes toward physician-assisted suicide - when a doctor supplies the
fatal medication or device but the patient commits the act - and voluntary
active euthanasia, whereby a patient asks a physician to administer the
life-ending treatment.
In 1994, he surveyed 76 internists and family practitioners from southern
New Jersey on these two practices. Participants were chosen randomly from
membership lists of the New Jersey Medical Society and the New Jersey Society
of Osteopathic Physicians.
"We found that physicians were equally divided concerning physician-assisted
suicide for the terminally ill," he explains. "They considered
the ability of the patient to make his or her own decisions regarding care
the most important factor.
"Eighty-five percent were against physician-assisted suicide in situations
where the patient is unable to make the request. Ninety-six percent said
they should not be compelled to participate if they are morally against
it."
In a survey completed in 1995, in which 104 residents of Camden County
were interviewed as to their views on euthanasia, he found that although
58.7 percent supported it, there were concerns about the potential for
abuse and the possibility of diminished medical care. Those under age 50
were more likely to support it than people over that age.
"The majority of those surveyed for the second study viewed voluntary
active euthanasia as an act of compassion toward the dying," he says.
He believes many people are warming up to it because they think they may
be victimized by the medical profession. They have images of being kept
alive as "vegetables" tethered to ventilators, or they fear uncontrollable
pain.
"We need to educate people about advance directives in the privacy
of our offices when they come to us as patients," he says. Cavalieri
plans to study why this interaction does not take place routinely and what
physicians can do to encourage patients to prepare living wills. "Patients
are less likely to opt for drastic measures if they feel they have control
over their health care or have made plans to have those decisions made
by someone they have chosen."
Cavalieri's interest in geriatrics was sparked by his relationship with
his maternal grandmother.
As a teenager, Carmela Panaro left Italy with her family, joining the millions
of other immigrants who disembarked at Ellis Island seeking a better life.
They settled in South Philadelphia, where she met her future husband, Thomas
DiBruno, who saved her life after she had slipped into a swirling water
drain and was in danger of being swept away. They had four children, one
of whom, Mary, is Cavalieri's mother. Cavalieri was named for his grandfather,
who died before he was born.
Young Tom and his family frequently visited Carmela, whom he says helped
build his self-esteem and stressed the importance of an education.
"She was very strong and determined," he recalls.
"My ability to see wisdom in older persons and to appreciate the contributions
they have made is directly linked to my admiration for my grandmother."
Carmela often spent time with her daughter's family, even after they moved
from South Philadelphia to nearby Glendora in Camden County when Cavalieri
was 5. During the last year of her life she lived with them, until she
died from pancreatic cancer when Tom was 13.
A positive relationship with an older person is a common reason for choosing
to go into geriatrics, says Cavalieri. "I see it all the time with
my students. The role of a grandparent can be profound."
As a college student, he spent summers working as an emergency room technician
at Kennedy Memorial Hospital in Stratford. This experience cemented his
decision to become a physician.
After graduating from the College of Osteopathic Medicine and Surgery in
Des Moines in 1976, Cavalieri came back to Kennedy for a one-year internship,
where he met his wife, Donna, a nurse. They now have four children. He completed an internal medicine residency at Thomas Jefferson Medical Center
in Philadelphia and joined SOM's division of general internal medicine.
The following year he was asked to develop a program that would combine
clinical care, teaching and research in geriatrics.
"In the early 1980s, geriatrics was just being recognized as a specialty
in the United States - there were only a few medical schools offering courses
in it," he recalls. "I always enjoyed caring for the elderly
so it seemed like a natural progression for me to take the challenge."
His first priority was faculty development, and he set about educating
himself, taking courses at Harvard, the Philadelphia Geriatrics Center
(then an affiliate of the Medical College of Pennsylvania) and Mount Sinai
Medical School in New York City. In 1986 he passed the first gerontology
boards, given jointly by the American Board of Internal Medicine and the
American Board of Family Medicine.
He introduced a three-hour lecture series into the curriculum. This was
expanded over the years so that today's students take a mandatory 20-hour
didactic course in their second year and do a one-month clinical rotation
in their third year. During the rotation they see patients in: the hospital;
the Center for Aging, SOM's clinical and academic teaching facility; patients'
homes; and in eight affiliated nursing homes, including the only one in
the state that has a 40-bed unit dedicated to the care of patients with
Alzheimer's disease.
"One of our primary goals all along was to attract medical students
to geriatric medicine," Cavalieri says. "While this nation is
bemoaning a physician surplus, we're experiencing a paucity. Future projections
for the growing 'old old' population - those over age 85 - say our medical
schools will not be able to produce enough geriatricians to meet this need.
By the year 2030 we will have more than 1 million Americans over the age
of 100."
Cavalieri's list of SOM accomplishments is long: the Center for Aging and
its programs for geriatric assessment, dementia evaluation, urinary incontinence,
falls assessment and elder abuse; the New Jersey Geriatric Education Center,
which he heads; and visits to the homebound. But, he is proudest of the
school's two-year geriatric fellowship, one of only nine in the country
that is federally funded. Since it was established in 1989, the program
has trained 25 physicians and dentists who have gone on to hold clinical
and academic leadership positions.
Now six months into his position as chair of SOM's Department of Medicine,
Cavalieri says his mission is to continue to be an advocate for the health
care needs of the elderly and to ensure that the teaching of geriatrics,
both academic and clinical, is interwoven into other medical disciplines.
He says some of the greatest rewards of his work have been to see the enthusiasm
students and younger physicians have for geriatrics. When asked to express
his outlook on his field, he readily quotes President Kennedy: "As
a nation we have been successful in adding years to life. Now we must add
life to years."
