Wednesday, April 10, 2013

How Does Physician Assisted Dying Work? Beyond philosophy and rhetoric

The New England Journal of Medicine released an article this week on the experience of implementing a Death with Dignity program in Washington at a University based Cancer Center. In the Fall of 2008, the voters of Washington State passed the Death with Dignity act allowing for the legal practice of prescribing medications for the self-administration by a person with a terminal illness with the goal of ending their life. This can be described using a variety of briefer terms: physician-assisted suicide, physician-assisted death, medically hastened death and others. (For the record it is not technically euthanasia since that describes an act where a health care professional adminsters medication. And that is illegal in the United States.) In the NEJM article the authors refer use the term physician-assisted death, likely because it has been utilized as the most descriptive term that remains value neutral in regards to the presumed psychological pathology of an act of suicide.

This is an important article because it describes how this center went about actually implementing the Death with Dignity program including the following challenges: were their enough doctors to actually prescribe the barbiturates? How would patients know about this programs availability given that is what a legally accessible medical option? Do you put fliers in the waiting room? What if the attending refuses to participate?

To really understand how they approached this I strongly recommend you read the article regardless of your feelings for or against physician-assisted death. With this issue coming up repeatedly on state ballots over the past decade, it could very be legal in your state sometime in the next several years and you may find yourself and your fellow staff grappling with these same difficult questions.  It is limited in that they only served patietns with cancer, and it would be interesting to see how patients with non-cancer terminal diagnosis were handled at this institution.

As has been seen in other reports on why people choose physician-assisted death, the main reasons were loss of autonomy, loss of enjoyable activities, and the loss of dignity.  The center reports that feedback was all generally postiive.

One important piece of data that many people will wonder about is how many deaths are tied to physician-assisted death and is that number changing from year to year. You can always check the Oregon and Washington Department of Health websites as they are mandated to report this data on a yearly basis. In 2012, Oregon had 115 prescriptions with 77 deaths related to Death with Dignity. In 2011 (the last year reported), Washington state had 103 participants and 70 deaths.

The NEJM has also developed a case around physician-assisted death, but curiously they refer to it as physician-assisted suicide (PAS) differently than the authors of the article. At the end of the case you have the opportunity to give your opinion about whether PAS should be permitted. As of the publishing of this post there are 275 responses with 54% against PAS and 45% in favor of allowing PAS.

I would encourage you to take the poll and post your opinion on NEJM, but also to share your responses here with our poll as well. (Feel free to copy your opinion from the NEJM poll and post it here) Our Pallimed poll asks for no identifying information. Results will be shared here in aggregate with some commentary.

Make sure to check the supplemental materials for the NEJM article if you do have a subscription or library access as they actually include the policy from the hospital.

ResearchBlogging.orgLoggers, E., Starks, H., Shannon-Dudley, M., Back, A., Appelbaum, F., & Stewart, F. (2013). Implementing a Death with Dignity Program at a Comprehensive Cancer Center New England Journal of Medicine, 368 (15), 1417-1424 DOI: 10.1056/NEJMsa1213398