Wednesday, March 19, 2008

Oregon's Death With Dignity Annual Report 2007

2008 marks the 11th year of the nation's first physician-assisted suicide (PAS) state law, also known as the Death With Dignity (DWD) Act. Every year by law, the Oregon Department of Health Services releases an annual report and characteristics of the patients who died and received prescriptions for the intended self-administration to hasten their death.

The summary of the 2007 annual report is now available for pdf download as well as the supplementary data and all annual reports from the Oregon DHS website. Since this may hit the news and your patients and colleagues may ask how this relates to palliative care where you practice it is important to become somewhat familiar with this report.

For background, here are the Pallimed posts from Annual Report 2006 and Annual Report 2005, as well as a primer on confusing hastened death terms.

The basic summary highlights that the small increase in the number of deaths under the DWD act. There was a fairly significant increase in the number of prescriptions given in the past year, but without a similar rise in the deaths via PAS.

It is important to look at the other outcomes of patients who receive a prescription, because it is not just life or death by DWD. The other outcome is that a patient dies by natural means without ever ingesting meds for physician-assisted suicide. The graphs with the annual reports do not show this trend well, which is why I have laid them out in two different ways.

The first graph shows the change over the past 10 years in absolute numbers and the second shows the change in percentage. The three outcomes are: death via physicians-assisted suicide/DWD (red), death by natural means (beige), alive (green). As you can see there was a larger amount of patients who died by natural means in 2007 after receiving a prescription. Most people interpret this as reinforcing the control a patient has in a situation with increasing loss of control, dignity (86%) and autonomy (100%) % indicates number of prescription recipients whose physicians marked these reasons for the request for PAS. These existential sufferings are not exactly manifested as a simple depression and inherently difficult to treat with medications or intense human interventions as any palliative care person will tell you. I quote Drew from an earlier Pallimed post:

"Death, pretty much by definition, sucks--full of anguish in even the best of circumstances--for patients, families, and frequently clinicians."
But as he goes on to say in the post, it doesn't mean we need to stop trying to work with dying patients and families to make the most of bad situations. As more PAS legislature get presented in states across the US, how will our field respond when they look to us for advice? (By the way Kevorkian is running for Congress. Hold on to your hats, the media should have fun with that one.)

Another way of looking at the proportion of PAS deaths is there are 15.6 PAS deaths for every 10,000 deaths in Oregon or 0.156% Oregon deaths. Other interesting data to review is that no African American has received a prescription from the PAS despite being 1% of all deaths in Oregon. And although the numbers are small so it is hard to draw a conclusion, Asians have had a larger proportions of PAS deaths compared to all Asian deaths in Oregon (54.6 Asian PAS deaths for 10,000 Asian Deaths in Oregon). Email me if that last sentence doesn't make sense.


The other demographics show most were older 55-84 year olds making up 75% and most ahd some college and all had insurance, so less likely to reinforce a poverty/low SES discrimination slippery slope argument against PAS. In fact the most heavily weighted non-disease demographic likely to use PAS were those with Baccalaureate (83/10,000 deaths) or Post-Bacc degrees (113/10,000 deaths). Any hypothesis on why the advanced degrees are more likely to make use of PAS? We don't know how many of those people are also health care professionals.

HIV/AIDS, ALS are the diseases that more associated with PAS with oral cancer being the highest odds ratio of using PAS. Interestingly CHF and COPD are very very underrepresented in PAS deaths, possibly secondary to the more fluctuating course of the disease?

Complications (yes this could go wrong) were few, including regurgitation in 3 and a unexpected length of 3.5 days after ingestion before death occurred.

So I hope this enlightens some to what is often glossed over or misunderstood or not even realized at all. I cannot tell you how many medical students, residents, nurses and other health care professionals lack basic background knowledge on this subject. Make up your mind either way, but start with some facts to make sound reasoned arguments for or against.

Homework question given to me from a medical student with a small Pallimed prize to anyone who can answer this correctly for me (in the comments). Drew has speculated on an answer but we don't have anything definitive yet.

If a person dies by physician-assisted suicide, can the family still collect on the insurance policy, or was that even considered when the law was legislated?

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