When patients look to you to help themselves die

Derrick J. Sorweide, DO, watched his mother die of cancer. She suffered emotional distress while under hospice care. Though medications numbed her physical pain, she felt helpless as she lay there, frustrated that she had no control over the end of her life, he says.

“She told me several times that she wanted to end it all,” Dr. Sorweide remembers. But she lived in a state that has no “Death With Dignity” law. Death with Dignity laws allow physicians, in certain circumstances, to write a lethal prescription for a patient at least 18 years of age who has six months or less to live.

So Dr. Sorweide witnessed her slow, heart-rending progression toward death. During her last five days of life, she was in a coma. Those days were the toughest for him as he braced himself for the inevitable.

These vivid memories helped shape Dr. Sorweide’s views on what most people term “physician-assisted suicide.” He is grateful that he now practices in Oregon, which in 1997 became the first state to enact a Death With Dignity law.

“I’m a fan of the Oregon law,” says Dr. Sorweide, noting that just having the option of obtaining a lethal prescription restores a modicum of control to dying patients. “It’s not a route we take for the vast majority of terminally ill patients. It’s a last resort. Every other solution you can possibly think of needs to be exhausted first. But it’s one tool that we have.”

Dr. Sorweide says that during his career as a family physician, he has written lethal prescriptions for three patients who met the state’s criteria, two of whom died before the prescriptions were filled, and has discussed the Death With Dignity option with 20 to 30 patients.

He also teaches students about Oregon’s Death With Dignity law. “I tell them that I don’t care what their opinion is on the law. If they’re going to practice in Oregon, they need to know what the law is,” says Dr. Sorweide, an assistant professor of family medicine at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Northwest in Lebanon, Oregon.

Changing views

Physician-assisted suicide—sometimes referred to as “physician-assisted death” or “physician aid in dying”—has slowly been growing in acceptance among members of the medical profession and the public.

Washington state, Vermont and one county in New Mexico have joined Oregon in passing Death With Dignity laws; Montana decriminalized physician-assisted suicide in 2009.

[story-sidebar id=”180953″]

Currently, 14 states and the District of Columbia are considering Death With Dignity legislation or similar legislation, according to the Death with Dignity National Center.

More than half of doctors now believe physician-assisted suicide should be allowed, according to a 2014 Medscape survey. Four years earlier, 15% fewer physicians held that view, the 2010 survey revealed.

Brittany Maynard, a 29-year-old woman with terminal brain cancer, became a public champion of the right to physician-assisted suicide last year when she moved from California to Oregon to take advantage of Oregon’s Death With Dignity Act. A video she made on her choice to control the timing of her death has more than 11.5 million views. At home, surrounded by family, she died on Nov. 1 after taking lethal medication prescribed by a doctor.

‘Slippery slope’

But physician-assisted suicide remains highly controversial. Some doctors object to it on religious or moral grounds or describe it as a “slippery slope” that could lead to patients feeling pressured to end their lives.

“I can’t ethically justify participating in a process that would help people end their lives,” says Daniel E. Wolf, DO, a Seattle psychiatrist.

A year or so ago, a colleague asked Dr. Wolf to evaluate a dying patient’s mental competence to end his own life. Like the other states that have enacted Death With Dignity laws, Washington requires that a consulting physician confirm that the patient does not have clinical depression, another major psychiatric disorder or cognitive deficits that would impair judgment.

“I told the physician I wouldn’t do it,” Dr. Wolf recalls.

As a psychiatrist, Dr. Wolf often treats suicidal patients and seeks to help improve the quality of their lives.

“How can I differentiate between a person who wants to end his life because he has terminal cancer and someone who wants to kill himself or herself for nonmedical reasons?” he asks.

Physicians who work for Roman Catholic medical organizations cannot take part in any aspect of physician-assisted suicide, even in states where it is legal, notes Kathryn Kolonic, DO, a family physician with Providence Medical Group in Canby, Oregon.

While Dr. Kolonic recommends hospice and palliative care to dying patients, two of her patients have asked about Oregon’s Death With Dignity Act.

“When I explored the issue with them, both expressed that their biggest fear was being in pain and not having it treated,” she says.

Dr. Kolonic explained to the patients palliative medicine’s emphasis on pain and symptom management. But she also mentioned that they could learn more about physician-assisted suicide by visiting the website of Compassion & Choices, the leading Death With Dignity advocacy group. Neither patient ended up selecting this option, she says.

Besides religious views and national and state laws, physicians are heavily influenced by prevailing medical ethics when it comes to assessing Death With Dignity measures.

The osteopathic oath expressly forbids physician-assisted death, and the AOA and the American Medical Association oppose it on the grounds that it is incompatible with the physician’s role as a healer.

“The request for physician-assisted suicide is frequently a call for help,” states the AOA’s policy statement on end-of-life care. “The best alternative to physician-assisted suicide is physicians who are committed to providing excellence in end-of-life care and continuing to attend their dying patients.”

Osteopathic Physicians and Surgeons of Oregon (OPSO) has not taken a public stance on the morality of physician-assisted suicide. “OPSO’s position is simply that if you are going to take part in evaluating and writing a prescription for a patient under the Death With Dignity Act, you need to know and follow the law,” says Dr. Sorweide, the association’s president.

‘Some people simply don’t want to die that way’

The osteopathic oath and the AOA’s position on physician-assisted dying should be updated, maintains Al Turner, DO, a retired osteopathic manipulative medicine specialist in Portland, Oregon. He argues that it is disingenuous to claim that there is a major moral distinction between the palliative sedation of a suffering patient in hospice care and a prescription that offers terminally ill patients the choice to end their suffering.

“It is not immoral to offer someone who is already dying a means of hastening the process,” says Dr. Turner. “With hospice or palliative medicine, we can numb somebody enough so they don’t know what’s going on around them. Eventually their systems give out and they die. But some people simply don’t want to die that way.”

Oregon has implemented many safeguards to prevent misuse of the law, Dr. Turner notes. For instance, the state requires that a dying patient make two oral requests of the physician spaced at least 15 days apart and a written request signed by two witnesses. Also, the prescribing physician and a consulting physician must confirm the patient’s mental competence.

K. Turner Slicho, DO, another OMM specialist in Portland, echoes Dr. Turner’s sentiments.

“We are supposed to first do no harm,” Dr. Slicho observes. “Is breathing for one more day really quality of life? Aren’t we doing harm by prolonging suffering?”

Dr. Slicho has encountered a number of cases of suffering in which he feels physician-assisted suicide would’ve been appropriate. For instance, his aunt died last year in Louisiana after a long struggle with “wickedly aggressive” squamous cell carcinoma of the mouth.

“She was going through treatment after treatment after treatment and not getting anywhere with it,” he remembers. “She hadn’t eaten any solid foods for 18 months. She was so exhausted she could barely stay awake during the day.”

He wishes Oregon’s Death With Dignity Act had been available to his aunt, though she might not have taken advantage of the option, he notes.

What both sides agree on

While advocates and opponents of physician-assisted suicide wholeheartedly disagree on the morality of Death with Dignity laws, many share the opinion that end-of-life care in America leaves much to be desired.

“There is a true public health crisis that surrounds the way Americans are dying,” says Ira Byock, MD, a prominent palliative medicine physician who opposes physician-assisted suicide. “Despite more than three decades of progress in hospice and palliative medicine, many Americans today are receiving inadequate care during the last months, weeks and days of life.

“The assisted suicide folks are rightly fearful at how people are being cared for, and they are angry at the health system, and they’re angry at doctors. But their solution is to give the same doctors that they fear new authority to write lethal prescriptions. I look at that and say, ‘Really? Is that your solution?’ “

The Institute of Medicine’s 2014 report on end-of-life care should be a wake-up call for Americans, Dr. Byock argues.

“We all ought to be angry,” he says. “And we ought to be calling on the carpet the deans of medical schools who give degrees to young physicians who have not been trained to have serious conversations about end-of-life preferences with patients and who have not been adequately trained to assess and treat people’s pain.”

A professor of medicine, psychiatry and medical humanities at the University of Rochester (New York) medical school, Timothy E. Quill, MD, agrees that many medical colleges could do a better job of preparing future physicians to provide end-of-life care. But he views physician-assisted death as the last step in a continuum of choices that should be available to terminally ill patients.

“Why is it considered ethical to die of ‘natural causes’ after a long heroic fight against illness filled with ‘unnatural’ life-prolonging medical interventions and unethical to allow patients to take charge at the end of a long illness and choose to die painlessly and quickly?” Dr. Quill asked in his book Death and Dignity: Making Choices and Taking Charge.

As a hospice and palliative medicine specialist, Dr. Quill believes that all other possibilities should be considered before physician-assisted suicide.

“We should look at every alternative to this,” he says. “But there are tough cases, and there always will be tough cases. And some of the things we ask people to go through at the end of life are not acceptable to some patients.

“If we’re patient-centered and trying to keep the patient in charge, we will see cases in which individuals choose physician aid in dying. In our culture, we give people choices about how much treatment they are willing to go through and when they can stop the treatment and opt for hospice care. It’s pretty arbitrary to let dying patients have these choices but not the ability to choose how and when their lives will end.”