What’s Really Involved in Physician-Assisted Death?

November 3, 2017

The following article appeared in U.S. News & World Report on November 3, 2017:

Only in a handful of states, and only according to stringent guidelines, people with advanced terminal illness have the right to choose to take lethal medications prescribed and dispensed for the purpose of ending their life peacefully and on their terms. The process, known as “death with dignity,” “medical aid in dying” and “physician-assisted death” remains a hot-button topic.

Here’s a brief look at where physician-assisted death currently stands in the U.S. and what the process involves. In addition, proponents and opponents weighed in to U.S. News by email to offer a range of perspectives.

Medical aid in dying is currently legal in six states – California, Colorado, Montana, Oregon, Vermont and Washington – and the District of Columbia, according to the website of the Death With Dignity National Center. While most of these states have specific “Death With Dignity” or similar laws, Montana is the exception. The state’s Supreme Court has ruled that the practice is covered under already-existing legislation on the rights of terminally ill patients.

Oregon, which enacted its Death With Dignity law 20 years ago, has the most well-established program. In 2016, the state reported 204 prescription requests with 133 resulting deaths. (A significant proportion of recipients in all states where it’s legal don’t follow through on their prescriptions.)

Overall, medically assisted death is relatively rare, according to a study in the July 5, 2016, issue of the Journal of the American Medical Association. The study, which evaluated reports from the U.S., Canada and Europe, found that more than 70 percent of patients who made the choice had cancer.

Typically, older, white and well-educated patients were involved, researchers found. Many of the U.S. patients were in hospice or palliative care. Nowhere was there evidence that vulnerable patients were involved at higher rates than the general population, the JAMA study concluded.

“In the United States, the concern that minorities, the disabled, the poor, or other socioeconomically marginalized groups might be pressured to accept PAS [physician-assisted suicide] does not seem to be borne out,” researchers wrote. (The term “physician-assisted suicide” is opposed by several medical and public health associations as a way to describe the medical practice of aid in dying.)

Pain was not the main reason patients made the request. Rather, loss of autonomy and dignity, inability to enjoy life and regular activities and other types of mental distress were the dominant motivations, the study found.

The vast majority of patients requesting physician assistance in dying are enrolled in hospice, points out Susan Enguidanos, an associate professor of gerontology at the Davis School of Gerontology at the University of Southern California. Therefore, their pain at the end of life is likely being managed.

“As a palliative care researcher, respecting patient preferences is a major aim of my [work],” Enguidanos says. “Thus, for patients living in states with legal physician-assisted suicide and who meet the program criteria, I support their right to access to this program.”

If anything, Enguidanos says her greatest concern is that access may not be equitable among terminally ill patients: “Like many other health-related services, costs of care and access to resources may prohibit some individuals from accessing physician-assisted suicide.”

Others expressed much different concerns. “Physician-assisted suicide asks physicians to breach the central principles of ‘first, do no harm’ and act in the patient’s best interests,” says Dr. Jack Ende, president of the American College of Physicians. Preventing or easing suffering, and meeting unaddressed needs of patients and families, should be the medical focus, he adds.

“Medical ethics and law strongly support a patient’s right to refuse treatment, including life-saving treatment,” Ende says. “We need care that emphasizes the last phase of life, including facilitating a natural dying process in the home setting for those patients and their families who prefer to be there and whose care can be managed there.”

The potential for discrimination exists, according to Diane Coleman, president and CEO of Not Dead Yet, a grassroots disability rights group. “If society really wanted to meet the needs of people with serious illnesses, it would invest in quality palliative care and in-home support services,” she says.

Vulnerable people like the elderly could suffer from legalization, Coleman suggests: “Nothing in assisted suicide laws prevents a seriously ill person from being pressured to request lethal drugs by insurance denials or delays, or by family.”

Dr. William Toffler, national director of the Physicians for Compassionate Care Education Foundation, agrees that medically assisting a patient to die is “fundamentally incompatible” with the role of physicians as healers. “Many patients experience subtle if not overt pressure to accept assisted suicide and fear ‘being a burden,'” he adds.

Kim Callinan, chief program officer for Compassion & Choices, says the nonprofit group supports medical aid in dying modeled after the Oregon Death With Dignity Act. “That gives only medically capable, terminally ill adults with six months or less the option to request prescription medication that they must be able to self-ingest to die peacefully in their sleep, if they decide their suffering becomes unbearable at life’s end,” she says.

Carefully restricted access “would reduce the potential for abuse and error while helping persons who will die do so in a manner that they choose,” says Arthur Caplan, a professor of bioethics and director of the division of medical ethics at New York University Langone Medical Center. “This limit is also consistent with the ‘do no harm’ ethos that is critical to medicine: Helping the dying die well is not the same as helping someone who is not dying.”

But one brain cancer survivor sees it differently. “Three-and-a-half years ago, my doctors told me that I only had a few months to live,” says J.J. Hanson, president of Patients Rights Action Fund. “Although I was determined to do all I could to survive, I struggled with suicidal ideations at times. If I had access to assisted suicide, I may have taken the lethal pills in an impulsive moment instead of discussing my feelings with my doctors and family.”

“You can’t unmake that choice,” continues Hanson, who has spoken out against proposed legalization in New York state. However, where medically assisted death is legal in the U.S., the process is structured in a way that discourages impulsive decision-making.

The District of Columbia officially began its Death With Dignity program in June 2016. Patients who fill all the qualifications, including documenting their D.C residency, must make two explicit oral requests for the lethal-medication prescription at least 15 days apart, as well as a written request in the interim. Two witnesses, who cannot include the treating physician, are required for the written request.

The patient cannot be suffering from impaired judgment due to depression or another psychiatric or psychological condition, and can change his or her mind at any time. Physicians participate on a voluntary basis. On more than one occasion, the physician who prescribes these medications and the pharmacist who dispenses them must notify the D.C. Department of Health, which regulates and oversees the Death With Dignity process.

End-of-life medication can be taken in a health care or hospice facility, at home or any other permitted location, but not in a public place. If the patient does choose to take the medication, the cause of death listed on the death certificate will be the underlying medical condition.

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