Monday, March 20, 2006
Oregon released the eighth annual report on the Death with Dignity act that enables patients to have access to barbituates for physician-assisted suicide (PAS). While you may not agree with the ethics, morals, or legality of PAS, if you are in the field of palliative medicine or hospice it is very helpful to be aware of this data so that in our eternal job of public education about end-of-life issues, our discussions are not relegated to heated slings of mud about the 'rightness' or 'wrongness' of PAS.
One of the major concerns about PAS in Oregon is the slippery slope effect. Here is the graph from the report showing that there seems to be a plateau effect over the last few years.
There are still a number of patients who request PAS and get the prescription filled but either die from their disease or are still living and have not decided to take it; most presume this is an issue of control and not a true desired for hastened death. 'If I have the means for PAS, then I won't have to do it, because I have control over my life.'
Another concern about PAS is that it will be encouraged for those of little means or education. The data from Oregon demonstrate a higher level of baccalaureate degrees (37% vs 15%) when compared to all deaths in Oregon. So the data does not necessarily support this argument.
Some interesting notes about PAS is that it is not without errors or complications. Two patients vomited the medicines back up, and there was one patient who took the barbituates for PAS but then woke 67 hours later, only to die of his underlying illness 14 days later. There is an article from the Netherlands about other complications, the most frequent one being that PAS or euthanasia took longer than expected. Somehow I find this odd when listed as a complication of euthanasia or PAS.
But the most interesting data is the reason for requesting PAS which is often tied to issues of dignity, decreasing ability to do activities, and loss of autonomy. These are things that medicine does not have an easy solution for. No pills, no surgeries to fix these problems. It often involves a lot of talking and approaching this sensitive topic with trust, sincerity, and respect for the person and where they are in their life. Chochinov's Dignity Therapy is one approach to start increasing awareness of these concerns in our vulnerable end-of-life patients. Hospice and palliative medicine services and the interdisciplinary, whole-person approach may avoid having to resort to PAS or euthanasia, especially if started early in the course of a life-threatening disease.
While I have had a number of patients request PAS or euthanasia, I have never performed it, but used the opportunity to build trust and explore what is the nature of their suffering to ask for such a final measure. It is these moments in connecting with patients that I truly enjoy palliative medicine.
(My Standard Disclaimer: Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)