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."