Physician-Assisted Suicide and Total Sedation

1. Physician-Assisted Suicide and Total Sedation Joel S. Policzer, MD, FACP, FAAHPM SVP-National Medical Director Vitas Innovative Hospice Care Miami, FL

2. Many ways to suffer at life’s end • Pain • Dyspnea • GI symptoms • Psychologic Distress

3. Distress of physical symptoms is easily comprehended • Does not require “stretch” to want to use whatever it takes to relieve suffering

4. Difficult symptom: • Existential suffering • “refractory spiritual or emotional pain”

5. Case • 65 yo man in VA Hospital in SW USA • After Army service, worked as cowboy and ranch-hand • Spent entire working life outdoors, on horse • Preferred working outdoors • Preferred to be solitary

6. Case • Was smoker and dipper • developed COPD and cancer of floor of mouth • Despite treatment, debility progressed to point where he need VA-LTC facility

7. Case • Current status • SOB controlled with meds, not SOB at rest • Has mass in mouth, able to eat small amounts for pleasure, pain controlled • No N/V, no other physical symptoms • Life expectancy ~3-4 months from metastatic disease

8. Case • Pt distressed because: • could not be outside • could no longer ride horse • had to be confined in facility with people • “my life is no longer worth living, I can’t stand this, do something”

9. Case • “Do something” • But what do you do??

10. Legal Framework

11. Withholding and withdrawal of life-sustaining treatments in terminally ill patient • justified by principles of informed consent and informed refusal • No treatment without consent x emergencies • Any treatment may be refused

12. Bartling v Superior Court, CA, 1984 • pt could be removed from vent at his request over objections of docs and hospital • *Competent patient*

13. Bouvia v Superior Court, CA, 1986 • conscious and competent pt could refuse nutrition and hydration • All American courts recognize right of competent patient to refuse LST

14. In re Quinlan, NJ, 1976 • pt had right to refuse tx, and if incompetent to exercise that right, parents could make “substituted judgment” • Barber v Superior Court, CA, 1983 • included nutrition and hydration

15. States vary in processes and rules for vindicating principles for incompetent patients • All have rules regarding selecting decision-makers • outline hierarchy and level of agreement

16. There are rules regarding what surrogates can decide and level of certainty as to what pt would have wanted • O’Connor, NY, 1988 • tx is obligatory unless there is ‘almost certain’ evidence • Cruzan, MO, US, 1990 • allowed ‘clear and convincing’ evidence • US Supreme Court held that refusal is right guaranteed under 14th Amendment

17. Washington v Glucksberg, WA, 1997 • Vacco v Quill, NY, 1997 • US Supreme Court concurred that states could prohibit assisted suicide • there is no right to PAS • but still, states could legalize practice

18. Physician Assisted Suicide

19. Definitions • Voluntary active euthanasia • administering meds to cause competent pt’s death at pt’s explicit request, with consent • Involuntary active euthanasia • administering meds to cause competent pt’s death without specific consent

20. Definitions • Nonvoluntary active euthanasia • administering meds to cause incompetent pt’s death • Physician Assisted Suicide • physician provides lethal dose of medication with understanding that pt will use them to commit suicide

21. Right-to-Die • Does this “right” exist? • comes as extension of right to terminate life-sustaining therapies • Supreme Court • upheld ability to stop LSTs • made it illegal to criminalize PAS • (BUT did not establish “right”)

22. Right-to-Die • There is no historical or philosophical precedent for a “right to be made dead” • Let alone force others to participate • There is argument of autonomy: • “I can make decisions for myself” • but autonomy implies sense of not belonging to others, not sense of doing anything one pleases

23. Right-to-Die • Still being debated • most recent attempt by U.S. Attorney General to overturn Oregon law was rebuffed by courts • Right-to-Life orgs in various states becoming much more active after Schiavo case

24. Physician Assisted Suicide • Arguments for: • Involves compassion from physician • Studies show strong support • Oregon and Michigan – majority of physicians and general public support PAS in at least some cases

25. Physician Assisted Suicide • Arguments for: • studies also show that significant percentage of physicians have participated in ending terminally ill patients lives: • increasing opioid dose • prescribing meds with tacit understanding what patient will do with them

26. Physician Assisted Suicide • Request for PAS – seen as ‘cry for help’ that is answered with compassion • Not just: “Oh!! OK!” • Should open a discussion of why request is made and what options are available

27. Physician Assisted Suicide • Conditions in Oregon law: • incurable illness with unrelenting suffering • not made because symptom palliation is inadequate • request made clearly and repeatedly

28. Physician Assisted Suicide • Conditions in Oregon law: • pt’s judgment not distorted • Psych eval? • Problem: DMS-IV lists suicide attempt as mental illness that requires treatment

29. Physician Assisted Suicide • Conditions in Oregon law: • done in context of meaningful doctor-patient relationship • should have 2nd medical consultation • everything documented

30. Physician Assisted Suicide • Arguments against • “shifting line in sand” • Example of ALS advocate • ‘my life will be unlivable when..’

31. Physician Assisted Suicide • Arguments against • “slippery slope” • acceptance of this leads to acceptance of other ‘interventions’ • Is it not better to refuse PAS to all and protect all life in general?

32. Physician Assisted Suicide • “Slippery slope” • spreads acceptance of causing death to disabled or incompetent • can reach point of involuntary euthanasia

33. Involuntary euthanasia • 2 examples in US in 20th Century • “Eugenics Movement” • tried to apply principles of Darwinism to general population • Goal: improve the human race through controlled breeding

34. “Eugenics Movement” • Poverty, crime, ignorance, alcoholism all blamed on defective genes • Therefore, society would be improved if “best and brightest” had more children and “undesirables” were prevented from having any

35. “Eugenics Movement” • Laws passed for involuntary sterilization • Buck v Bell, IN, US, 1927 • attempted to overturn law • "It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind…Three generations of imbeciles are enough."— Supreme Court Justice Oliver Wendell Holmes, Jr., in Buck v. Bell, 1927

36. “Eugenics Movement” • Led to sterilization of 65,000 citizens • Fell into disfavor in late 1930’s as scientists objected • One major figure who remained convinced…….

37. “Eugenics Movement” • Led to sterilization of 65,000 citizens • Fell into disfavor in late 1930’s as scientists objected • One major figure who remained convinced……. Adolf Hitler

38. Tuskeegee Experiment • Experiment of US Public Health Service • 1932 – 1972 • 399 illiterate sharecroppers in AL • All had syphilis, told they had “bad blood” • Goal: to follow ‘natural course’ of disease

39. Tuskeegee Experiment • Even when penicillin was known to be curative, men were denied therapy • Only stopped when media became involved • Test results = clinically irrelevant • Real results = 28 men died of syphilis, 100 died of related complications, 40 wives were infected, 19 had children with congenital syphilis

40. Tuskeegee Experiment • Consequence: • significant percentage of African-American population does not trust traditional medical system

41. Physician Assisted Suicide • Netherlands experience • no distinction between PAS and active euthanasia • 2007 report: • in 2005, 1.7% of all deaths due to PAS/euth. • 0.4% of all deaths were NOT result of patient request

42. Physician Assisted Suicide • Netherlands experience • overall decrease in PAS/euth from 2001, but concomitant increase in terminal sedation to hasten death • seen in context of increase in activity of hospice and palliative care services in Netherlands

43. Physician Assisted Suicide • Netherlands • recent reports in NEJM re: • pediatricians end lives of newborns with defects felt to be “too great” or incompatible with life • esp spina bifida

44. Physician Assisted Suicide • Oregon experience • law passed 1997 • to date ~145 Rx’s written • Med: Seconal 9 Gm

45. Physician Assisted Suicide • 1999 stats • 33 Rx’s written • 26 took meds and died • 5 died of underlying illness • 2 still alive

46. Physician Assisted Suicide • 63% had malignancy • Reasons • loss of autonomy 80% • loss of QOL 80% • loss of body fxn control 65% • burden on family 25% • inadequate pain control 25% • financial 0%

47. Physician Assisted Suicide • Minimal reports of complications • but they have to exist • should doc be present? • What is physician role in “caused death”?

48. Physician Assisted Suicide • 2007 update • From 2001 – 2006, approx 60 Rx’s written per year • Approx 40 patients yearly take meds and die • Demographics: white, educated, insured, enrolled in hospice • Reasons: concern re loss of autonomy, loss of dignity, loss of control of bodily function • none were clinically depressed

49. Physician Assisted Suicide • Oregon no longer considers these deaths to be “suicides” • Act is actually called Death with Dignity Act • AAHPM has also changed name of practice to “physician-assisted death”

50. Physician Assisted Suicide • In Oregon, 1/1000 deaths due to this • BUT, 1/50 dying Oregonians talk to their physicians about this, and 1/6 talk to their families • Legalization has resulted in more open conversations about how end-of-life should occur