Can We Really Prepare for Enabling "Death with Dignity"?

Can We Really Prepare for Enabling "Death with Dignity"?

Guest Commentary

Jan 13, 2016

Lynne P. Taylor, MD, FAAN
Speaker, "Perspectives on Physician Aid in Dying," 2016 Gastrointestinal Cancer Symposium
Friday, January 22, 6:00 PM-7:00 PM

As a neuro-oncologist practicing in Washington State, I have encountered patients who have requested death with dignity—the right to autonomy in determining the time of death, freedom from pain, and the release from a life of limited choices because of disability or fatigue.

I considered this request only in the abstract for many years until voters in the state of Washington passed an initiative in 2009 making death with dignity—also known as physician aid in dying—legal. Now that California Governor Jerry Brown has signed their End of Life Option Act, more than 14% of the U.S. population will soon be able to request physician aid in dying. The law allows physicians to prescribe a lethal dose of secobarbital so that a patient with a terminal illness can self-administer the drug.  

As the Gastrointestinal Cancers Symposium is in California this year, Program Committee Chair Dr. George Fisher thought it would be important to have a point/counterpoint on this topic, which will take place on Friday, January 22, at 6:00 PM–7:00 PM. All attendees are welcome to join this discussion.

States have requirements in place to ensure that all appropriate palliative care needs of the patient are addressed before a physician acts on this request. The patient must have a terminal diagnosis defined as death that is likely to occur in 6 months. The attending physician must document two verbal requests for death with dignity from the patient separated by a mandatory 15-day waiting period before accepting the written request.

The physician must then inform the patient of their right to rescind the request and honor an additional 2-day waiting period before the prescription can be written. A second consulting physician must also agree with the diagnosis and provide counseling or a psychiatric evaluation of the patient. The law also requires the bereaved families, physicians, and pharmacists to report on the demographics of the patient population and the outcome of the requests.

Of the 176 patients prescribed lethal doses of medication in Washington State in 2014, 76% had terminal cancer. A total of 126 patients died after ingesting the medication.  Approximately 15% did not take the medication, although we don’t know the reasons why. Two experienced complications such as vomiting, but none awakened from their drug-induced coma before they died.1

Recently, one of my patients with colon cancer and brain metastases made a formal request for physician aid in dying. Despite our best efforts, she was unwavering in her decision. I realized that I have had no formal training for how best to prescribe a lethal dose of medication to allow someone to end their own life, as it is obviously not a part of our medical school training. Despite my fears, however, my patient fell asleep quickly after taking only three-fourths of the dose and died 1 hour later very peacefully with her family at her side.

These initiatives raise tough questions for us all as caregivers. Is physician aid in dying a legitimate part of palliative care or a failure to provide adequate palliative care? I find that it is easy to oppose physician aid in dying as a general concept, but I sometimes find it very hard to reject when faced with the individual issues of a particular patient.

Whether or not physician aid in dying is an option, we can better prepare for these end-of-life care decisions by seeking out more advanced training and education in palliative care management. We all wish for a good death for our patients and, ultimately, for ourselves. I expect the debate about what that is and how to get there will go on for some time.

Dr. Taylor is a neuro-oncologist and palliative care specialist at Virginia Mason Medical Center in Washington State.

Reference

1. Washington State Department of Health. Death With Dignity Data. Accessed Nov. 12, 2015.

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