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10/5/17
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Oregon’sDeathWithDignityLaw:SeventeenYearsandLessonsLearned
SusanHedlund,LCSW,OSW-CManager,Patient&FamilySupportServicesKnightCancerInstituteAssociateProfessor,DivisionofHematology/OncologyOregonHealth&SciencesUniversity
Objectives:• ToprovideanoverviewofthehistoryofOregon’sunprecedentedDeathWithDignityLaw
• Toexamineitschallengesandcontroversies• ToconsiderclinicalimplicationsforworkingwithpatientsrequestingDWD
• Disclaimer:itisthisspeaker’sintenttopresentthehistoryanddatacollectedasweknowthem.Itisnotmyintenttopromoteoropposethelegislationitself.
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AboutCatherine*…• In1994,Oregon’sDWDlaw,hadpassed,butwasimmediatelyheldupintheCourts
• Catherine,age47,hadsevereosteoarthritisandanewdiagnosisoflungcancer
• CatherineandhusbandstronglysupportedtheDWDlaw
• IwastheirCancerCounselor
• Catherine’shusbandwasthechiefofpsychiatryinourinstitution…..
• *(namehasbeenchanged)
HistoryofPhysicianAidinDyinginU.S.
• Firsteffort(byballot)Washington1991-defeated• California(byballot)– 1992- defeated
• Oregon(byballot)1994- approved,repealdefeatedin1997)• Washington(byballot)-2008-approved• MontanaSupremeCourtlegalizedin2009• Vermontlegislature,2013approved• California-EndofLifeOptionActsignedintolaw–Oct.2015• Colorado-EndofLifeOptionsAct-2016• DistrictofColumbia-DCDeathwithDignityAct-2017*
• In2017-23StatesandtheDistrictofColumbiahavesoughttocodifythepracticeofphysicianaidindying
• *FederalBudgetwillnotsupportthis
ATurningPoint?• ConstitutionalityandState’sRights
• EvidenceEvaluatingthePracticeofPAD• Incompatibilitywithmedicalpractice?• Devaluinghumanlife?
• Openingthefloodgate?• Disproportionateaccessforthepoor?• AbuseofPAD?
• TurningPointinSocialandEthicalThought
• Gostin,Roberts,JAMAVol.315,No.3,Jan.2016
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ATurningPoint?• Isthetideturning?
“ValuesandBeliefsPoll”- Gallup- 2015:• 7of10peoplepolledinUSarenowfavorablydisposedtopracticeofPAD(increaseof20%overlast2years)
• 18-34yo’s infavorofPADincreasedby19%thisyearaloneto81%
• LegislaturesinMassachusettsandNewJerseyslatedtodebateissuelaterthisyear
• Clodfelter,Adashi- JAMA- Vol.315.No.3,Jan.2016
Issuesremainunsettledandcontroversial
• Proponents:PADrepresentscompassionandbeneficenceandtherighttoexercisefreechoiceandautonomyofwill
• Opponents:PADviolatesdeeplyheldviewsonthesanctityoflife,distortstheimperativeofthehealingmission,devaluestheroleofpalliation,andriskscoercionoftheelderly,disabled,destitute,anddespondent
• Clodfelter &Adashi,JAMA,Vol.315,No.3,Jan.2016
ThePacificNorthwest• HistoricalandCulturalContext
• “pioneer”spirit,ruggedindividualism
• Re-settlement,economics,environmentalism
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Oregon’sDemographics• Ruralvs.urbandemographics• Growingpopulation:1950- population,1.5million,by2020projectedpopulationwillbe4.3million
• Oregon’slifeexpectancyisslightlyhigherthattheUnitedStatesforbothwomenandmen
• Largelyhomogenousracially• White- 78%• Hispanic- 12%(mostrapidlygrowinggroup)• AsianandPacificIslanders-4%• AfricanAmerican-2%• Native(Indian)American2%• 2ormoreraces- 2%
• OregonStateCensus-2012
Oregon’sReferendumProcess• “progressivedemocracy”,est.1902
• Allowsvoterstoproposelegislation,andvoteonproposal
• MarkedOregonasapioneerstateinthe“progressivemovement”
• Oregon’sDeathWithDignityActwasestablishedthroughthisprocess
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Oregon’sUniqueHistoryinEndofLifeInitiatives• OneofthefirstStateswithAdvancedDirectives(1977)
• HealthCarePowerofAttorney(1980)
• FirstStatetocombinethetwo(1980)
• OneoftheStatestodemonstrateMedicareHospiceDemonstrationProject(1980’s)
Oregon’sUniqueHistory(cont.)
• RighttoHospiceandComfortCare(1989)
• Righttopainrelief(1993)
• Righttorefuseorwithdrawtreatment(1993)
WheredoOregonian’sDie?• Oregon’shospitaldeathrateisamongthelowestinthecountry
• Oregonhomedeathrateisamongthehighest
• Oregon’shospicepenetrationrateisamongthetop5or6
• Oregon’scostofEOLcareislowest,withhighsatisfaction
• LessonsfromOregoninEmbracingComplexityinEndofLifeCareTolle,S.andTeno,JM-NEng JMed-3/16/2016
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AccesstoPalliativeCare• Receivedan“A”fromCAPC’sReportCard- America’sCareofSeriousIllness
• 100%ofhospitalsinOregonwithgreaterthan300bedshavepalliativecareteams.
• America’sCareofSeriousIllness,State-by-StateReportCardonAccesstoPalliativecareinOurNationsHospitals- 2015
• CentertoAdvancePalliativeCare
OregonDeathwithDignityAct
• Passedbyacitizen’sinitiativein1994(51%to49%)• Seriesoflegalchallenges• Repealreferendumdefeated11/97(60%-40%)• DEAthreatensphysicians11/97• Renoreversal4/98• Ashcroftre-reversal11/01
OregonDeathwithDignityAct• 2002,Ashcroftappealedtothe9th USCourtofAppealstooverturnDistrictCourt’sruling
• May,2004,Ashcroftvs.Oregon,USCourtofAppealsdecidesthatControlledSubstanceActdoesnotapplytoOregon’sDWDLaw
• Current-Oregon’sDeathwithDignityLawstands
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Otherhistory• MediaCoverageandpubliceducationeffortswereintenseprecedingthe1994and1997votesonDeathwithDignity
• Publicawarenesswasraisedregardinghospice,painmanagement,andendoflifecare
• TheTaskForcetoImprovetheCareofTerminallyIllOregonianswasestablished
TaskForcetoImprovetheCareofTerminallyIllOregonians• Aconsortiumofhealthprofessionalorganizations,agencies,andinstitutionswhichsoughttopromoteexcellentcareofthedying
• ToaddresstheethicalandclinicalissuesposedbytheenactmentoftheDeathwithDignityAct
• Wewerechallengedtomaintainaneutralposition
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TheTaskForcetoImprovetheCareofTerminallyIllOregonians• ConvenedbytheCenterforEthicsinHealthCarefromOregonHealth&SciencesUniversityand3otherEthicsCentersfrommajorhealthsystemsinPortland
• Representativesfromhealthsystems:AdventistMedicalCenter,Dept.ofVeteran’sAffairs,LegacyHealthSystem,ProvidenceHealthSystem,KaiserPermanente,OregonHealth&SciencesUniversity
• RepresentativesfromStateBoards: HealthLawSection,OregonStateBarAssociation,OregonBoardofMedicalExaminers,OregonBoardofPharmacy,OregonHealthDivision,OregonHospiceAssociation,OregonNursesAssociation,OregonPsychiatricAssociation,OregonPsychologicalAssociation,StateEMS,NationalAssociationofSocialWorkers,AssociationofOncologySocialWork
Taskforcemission:• Toshareinformation,experience,andunderstandingofavailableresourcesforthecareofterminallyillOregoniansandassistindevelopmentofresourceswhereneeded
• FacilitatethedevelopmentofprofessionalstandardsrelatingtotheDeathwithDignityAct
• Developandcoordinateeducationalresourcesonallaspectsofcompetentandcompassionatecareofterminallyillpatients
• Fosterrelationshipsandnetworkingoncareoftheterminallyill
ProvisionofODWDA• Allowsterminally-illresidentprescriptionforself-administeredmedicationtoendlife
• EndinglifeundertheActisnotconsideredsuicide
• Prohibitseuthanasia
• “physician-assistedsuicide”hasbeenreplacedwith“physicianaidindying”or“medicallyassisteddeath”
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PatientRequirements• Oregonresident*
• 18yearsofage
• “Capable”(abletomakeandcommunicatehealthcaredecisions)
• Terminalillnesswith6monthsorlesstolive• (ifthepatienthasaterminalorchronicillness,buttheirlifeexpectancycannotbe
predictedwithinreasonablemedicaljudgmenttobelessthan6months,thenhe/sheisnoteligibletousetheAct).
• Requestmustbevoluntary
• *thereisnominimumlengthoftimetoestablishresidency-ItmustbedemonstratedbyaDriver’sLicense,leaseorpropertyagreement,taxreturn,voter’sregistration.Physiciansseemtohonorboththeletterandspiritofthelaw,andaremorelikelytoworkwithpeoplewithsignificanttiestotheState.
PrescriptionRequirements• 1writtenrequest,2witnesses
• 2verbalrequests,15daywaitingperiod
• Prescribing&consultingphysiciansmustconfirmdiagnosis/prognosis,determinepatientcapability,considermentalhealthreferral
• Patientinformedofalternatives(ie:palliative,hospicecare)
• Legalprotectionsforpatient,MD’s,pharmacist
Whatisprescribed?• UsuallySeconal.(Secobarbital)Alethaldoseis100tablets,100mg.
• Usuallycapsulesareemptiedofthepowdereddrugandstirredintoaliquid.Patientsmustingestitquicklytoavoidfallingasleepbeforeallisingested.
• Currentcostisapproximately$4300,andmostinsurancesdonotpayforthis.
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OregonHealthDivisionData
• Sincethelawwaspassedin1997,totalof1,749peoplehavehadDWDAprescriptionswrittenand1,127havediedfromingestingmedicationsprescribedundertheDWDA
• During2016,therateofDWDAdeathswas37.2per10,000totaldeaths.
Patientcharacteristics• Ofthe133DWDAdeathsduring2016,mostpatients(80.5%)wereaged65yearsorolder.Themediandeathwas73years.Asinpreviousyears,decedentswerecommonlywhite(96.2%)andwell-educated(50.0%hadatleastabaccalaureatedegree).
• Patient’sunderlyingillnessesweresimilartothoseofpreviousyears.Mosthadcancer(78.9%),followedbypatientswithamyotrophiclateralsclerosis(ALS)(6.8%).Ofnote,6.8%ofpatientshadheartdiseaseastheirunderlyingillness,anincreasefrom2.0%duringprioryears.
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OregonHealthDivisionData• Mostdiedathome(88.6%)andmost(88.7%)wereenrolledinhospice
• Excludingunknowncases,most(99.2%)hadsomeformofhealthinsurance
• Similartopreviousyears,thethreemostfrequentlymentionedend-of-lifeconcernswere:• decreasingabilitytoparticipateinactivitiesthatmadelifeenjoyable(89.5%)
• Lossofautonomy(89.5%)• Lossofdignity(65.4%)
• LosingAutonomy91.5%• Lessabletoengageinactivitiesmakinglifeenjoyable88.9%• Lossofdignity80.6%• Losingcontrolofbodilyfunctions50.1%• Burdenonfamily,friends/caregivers40%• Inadequatepaincontrolorconcernsaboutit23.7%• Financialimplicationsoftreatment2.9%
EndofLifeConcernsOregonPublicHealthDivision(1998-2015N:994)
OregonHealthDivisionData
• In2016,5ofthe133patientswerereferredforformalpsychiatricorpsychologicalevaluation
• Prescribingphysiciansoranotherproviderwerepresentatthetimeofdeathfor27patients
• Among27patients,timefromingestionuntildeathrangedfrom5minutesto34hours.
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Whathavewelearned?• K.HedbergandS.Tollewrotein2009:• “thevastmajorityofOregondecedentsareeithernotinterestedin,oraremedicallyineligibletoparticipateinDWDA”
• Manyaremedicallyineligiblebecausetheydon’tmeettherequirementofhavinga6monthprognosis,andothersopposethelaw.
• Othersarenotdeemed“capable”ofmakingthedecision,ordiewithinthe15daywaitingperiod
• OneinonethousandOregonianswhodieannuallyusetheAct.*
• Hedberg,Tolle,TheJnlofClinicalEthics,Vol.20,No.2,2009
• *(Per2015dataitis4per1000deaths.)
Whathavewelearned?• Hedberg,Hopkins,Leman,Kohnwrotein2009:
• 10yearsafterlegalization,thelawremainedcontroversial.
• Proponentsandopponentsdisagreeonterminologybecauseoftheconnotationofthelanguage- Proponentsprefer“physicianaidindying”,“hasteneddeath”,and“deathwithdignity”.Opponentsprefer“physicianassistedsuicide”.
• Theterms“suicide”and“dignity”havepoliticalimplications
• Controversialissuesnotaddressedinthelaw:theactoutlinesrequirementspriortotheprescriptionbeingwritten,butnottheproceduresafteramedicationisdispensed(i.e.:Itdoesnotrequireaprescribingphysiciantofollowthepatientovertime,nortoreassessapatientforadeclineincognitivefunction.)
• Severalstudieshavefoundapatient’sinterestfluctuatesovertime,thusitmaybeprudenttohaveanongoingdiscussionwithpatientstoassurethatend-of-lifeconcernsarebeingmet.
ImpactonPhysicians• In2000only1/3ofphysicianspotentiallywillingtoprescribe
• Areasofdiscomfort:• Concernsaboutmanagingsymptoms• Notwantingtoabandonpatients
• Incompleteunderstandingofpatients’preferences• Largeinvestmentoftime• Emotionallyintense
• Ganzini,etal,2000;Dobscha etal2004
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Whathavewelearned:• DataregardingOregon’sexperiencewithDWDAareimportantforongoingpolicydebate.
• Oregon’sdemographicsmaybedifferentandnotreadilyapplicableelsewhere:• Oregon’sresidentsaremostlyWhite• Least“churched”Stateinthenation• Endoflifepractices(Oregonhashighlevelsofhospicecoverageandadvancedcareplanning)
• Nonetheless,providesanimportantperspectiveasajurisdictionthatallowsself-ingestionofalethalmedicationbutnoteuthanasia.
• JnlofClinicalEthics,Summer2009-Hedberg,Hopkins,Leman,&Kohn
Earlyfears- notfounded:• DWDAwillbedisproportionatelyusedbythedisabled,theuninsured,thepoorandthevulnerable(datasuggeststheoppositeistrue).
• OregonwillbefloodedwithpeoplemovingtotheStatetopursuethisoption.(noevidencetosupportthis).
• Insurancecompanieswillhaveaninfluenceinwhochoosesthis.(noevidencetosupportthis)
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Otherlessonslearned• Manyhealthcareprovidersearlyonfeltuncertainaboutthelaw(Miller,Messler,&Eggman,2002,Harvathetal,2006)
• Hospicecaregiversfeltparticularlychallenged:“ifweweredoingourjobswellenough,patientswouldnot
pursuethisoption”.(Milleretal–p.59)
• 16yearsofdatahasshownthatPADareusuallymotivatedbyconcernsnoteasilyamelioratedbyhospicecare
• Asurprisingfindingfromstudieswasthelackofimportanceofpaininarequest
• Desiretomaintainindependence,self-care,andqualityofliferemainimportant
LessonsLearned• Inthefirstfewyearsafterlegalization,mostpatientswerereferredforformalpsychiatricassessments.Thispracticelessonedovertheyearsapparentlyforseveralreasons:
• Veryfewpatientsmakingtherequestwerefoundtobeclinicallydepressed-ratherweredeterminedintheirwishfor“control”
• Depressedpatientsseemtolackthe“where-with-all”tofollowtheprocessthroughthelegalchannels
• Greaterfamiliarityand“comfort”withthelaw,basedondataaboutthosewhochosetopursuePAD
PrevalenceofdepressionandanxietyinpatientsrequestingPAD• Physicians,hospiceprofessionals,andfamilymembersdonotbelievethatdepressioninfluenceschoicesforhasteneddeath
• Healthcareprofessionalsmayfailtorecognizedepressionamongthemedicallyill
• 17%ofOregonianspotentiallyinterestedinaidindying,only1-2%actuallyrequestit.
• Conclusions:mostpatientswhorequestaidindyingdonothaveadepressivedisorder.
• IncreasedvigilanceandsystemicexaminationfordepressionamongpatientswhomayaccessPADisneeded.
• Ganzini,Goy,Dobscha,BMJ,2008
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Lessonslearned
• “Theseindividualshighlyvaluecontrolanddislikedependenceonothers;thisoftenrepresentsastrongenduringvalue,aphilosophyanddefininglife-longpersonalityattribute.”
Ganzini,etal,2014
(yetagain,itisnotsomuchabout“us”– thehealthcareprovider,itisabout“them”- thepatient:whotheyare,whatismostimportanttothem.)
ClinicalimplicationsSo,whatdoesthismeanclinicallyforuswhenapatientinquiresaboutthelaw,orindicatesthedesiretopursueOregon’sDeathwithDignityoption?
Inmanyways,itoffersustheopportunitytoexploremoredeeply:• Thereasonsfortherequest• Themeaningbehindit• Otherissuesthatneedtobeaddressed
(symptommanagement)• ExistentialconcernsRelationshipissues
ExploringinquiriesaboutPhysicianAssistedDeathPatientConcernsandUsefulClinicalQuestionsPatientisworriedaboutfuturesuffering:“Icanseewhat’sgoingtohappenandIdon’tlikeit.”
• Whatareyoumostworriedabout?
• Tellmemoreaboutwhatexactlyfrightensyou.
• Whatkindsofdeathshaveyouseeninyourfamily?
• HowareyouhopingIcanhelpyou?
• Quill,Back,&Block,JAMA,Vol.315,No.3,Jan.2016
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ExploringInquiriesAboutPhysician-AssistedDeathPatientConcernsandUsefulClinicianQuestionsPatientfeelsqualityoflifeisintolerable:
“I’vesufferedenough”
• Whatmakesyoursituationmostintolerablerightnow?
• Tellmemoreabouttheworstpart.
• Howdoyouthinkyourfamilyfeelsorwouldfeelaboutyourwish?
• ExactlyhowareyouhopingIcanhelpyou?• Quill,Back,Block,JAMA,Vol 315,No.3,Jan.2016
ApproachtopatientwhorequestsPAD• Clarifyrequest- patientsmayinfactbeaskingforreassuranceaboutfuturepain,symptoms• Forsomepatients,requestingPADiseasierthanexpressingfearsaboutthefuture
• Explorereasonsforrequest,fears,worriesaboutthefuturesourcesofsuffering
• Encouragehospice-mostcomprehensivewaytoaddressconcerns• Hospicemayincreasesenseofcontrol
• Patienthascontrolabouthowmuchhospicetheyreceive• EducationaboutalternativestoPAD
ApproachtopatientwhorequestsPAD• Ifindicated,exploreimminentriskofsuicide(suicideriskassessment,accesstoguns,etc.)
• Ruleoutdepressionorothermentalillness• StartwithdepressionscreeninginstrumentssuchasPatientHealthQuestionnaire(PHQ9)
• Assuredecisionmakingcapacity(doespatientunderstandrisk,benefits,alternatives,etc.?)
• Discussimpactonfamily
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Whenthepatientexpressesadesiretodie:Theintentcanonlybecomeclearbyexploringit:• Thepatientmaybeoverwhelmedwithfeelingofbeingaburden- (familyconference?)
• Thepatientmayhavephysicalsymptomsdegradingqualityoflifethatarenotfullyaddressed-(advocacywithmedicalteam?)
• Itmaybegivingvoicetopsychologicalorspiritualdistress(furtherassessment,faithpractitionerinvolvement?)
• He/shemaybe“practicing”anidea- (simplysharedinatrustedrelationship)
• Thepatientmaysimplyhaveneverfollowedthedesiretodiestatementstotheirlogicalconclusion
• (Schroepfer,Linder,Miller-2014)
Desiretodieinterminallyillpeople
• “desiretodie”statementsmadebypeoplewithterminalillnessmaybeexpressionsofdepression,suicidalintent,orcoping
• Differentiatingamongpatients’meaningsinthiswayleadstoappropriateinterventions
• DesiretoDieinTerminallyIllpeople:AFrameworkforAssessmentandIntervention,NationalAssoc.ofSocialWorkers,1999,RuthAnn VanLoon
Desiretodiestatements• Twoassumptions:• 1.Expressingadesirefordeathisassumedtobecommonandthereforea“normal”responseto,andwayofcopingwith,terminalillness
• 2.Adesirefordeathiscommonlythoughttobetheresultofdepression,andmanypeopleconsiderdepressionanormalandexpectedresponsetoterminalillness(Valente,Saunders,Cohen,1994)
• Theempiricalevidencesuggeststhatitisnot,buttheassumptionofnormalitymeansthatdepressionmaybeneglectedoruntreatedintheterminallyill(Billings&Block,1995)
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DesiretoDievs.Depression• Onestudysuggestsmorethan44%ofpatientsadmittedtoapalliativecareunitexpressedanoccasionalwishtodie,butatfollowup2weekslater,only8.5%continuedtoexpressthiswish Chochinov,etal,1995
• Anotherstudysuggestedthatdepressionwascorrelatedwithdesirefordeath,butnotcontemplationofsuicide
• Owenetal1994
• Painandlackoffamilysupportcouldexacerbatedepression• Chochinov etal,1995
• Thesefactorswerenotlinkeddirectlywithdesiretodie• Breitbart,Rosenfeld,&Passik,1996
Depression,Hopelessness,andDesireforHastenedDeath• Interminallyillcancerpatients:• Desireforhasteneddeathisnotuncommon
• Depressionandhopelessnessarethestrongestpredictorsforhasteneddeathinthispopulation
• Depressionandhopelessnessarenotidentical,thusclinicalinterventionsshouldbetailoredselectively
• Majordepressioncanbeeffectivelytreated,eveninterminalillness,butnoresearchhasaddressedwhethersuchtreatmentinfluencesthedesireforhasteneddeath.
• Breitbart,Rosenfeld,Pessin,Kaim,Funesti-Esch,Galietta,Nelson,Brescia- JAMA,Dec.2000,Vol.284,No.22
FrameworkforAssessmentVanLoon-1999
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Desiretodietalkascoping• Usedtopromotefeelingsofcontrol
• Inviteadiscussionofexistentialconcerns
• Elicithelp
• Expressionof“readiness”
DesiretoDietalkasRationalChoice
• ComponentsofaRationalChoiceforSuicide• Thepersonhasarealisticassessmentofthesituation*• Theperson’smentalprocessesareunimpairedbypsychologicalillnessorsevereemotionaldistress*
• Thepersonhasamotivationthatwouldbeunderstandabletoamajorityofuninvolvedcommunitymembers
• Thedecisionisdeliberatedandreiteratedoveraperiodoftime• Wheneverpossible,thedecisionshouldinvolvetheperson’ssignificantothers
• Asubstanceabusedisorderoracuteintoxicationprecludesrationalityasdescribedabove.
• Sources:a:Siegel,K.1986,b:Werth,(1995),c:Forstein(1994)
Surveyofhospicesocialworkers
• “considerationofhasteningdeathamonghospicepatientsdoesnotappeartobearareevent.”
• Arnold,Artin,Person,Griffith(2004)
• InOregon,issuesinvolvedpatientautonomy,self-determination,qualityoflife,spiritualconcerns,advocacy.
• Haworth,etal,2006)
• OtherthemesinOregon:unfinishedbusiness,patientautonomy,advocacy,empowerment.
• Miller,Hedlund,Soule,2006
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Annie……• 57yearoldwomanwith15yearhistoryofbreastcancer
• Metastaticdiseasefor5years;recentspinalcordcompression
• PatientandhusbandsupportersofPAD
• Iwastheirtherapist
• Shechosetoendherlifewithaprescriptionofmedicationatalethaldose
Yalom’swisdom
• Theexplorationandconsiderationofendingone’slifewhiledying“permitsonetocontrolthatwhichcontrolsone”.
• IrvinYalom
• Itmaybepartofhowwe,ashumans,questionourfateandourexamineourmortality.
Practiceimplications• Theprofessionalmustbeawareofhisorherownreactionstodesiretodiestatements,becausethesewillinfluenceconversationswiththepatient
• IfunabletosupportPAD,importanttorefer
• Itisimperativetofindmeaninginthepatient’swordsandcontinuetoassessconcerns,mentalhealth,andintent.
• Italsorequirestheabilityto“sitwithsuffering”,bearwitnesstoquestionsandconcerns,andtoleratenotbeingabletofixeverything
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• “wecan’tmakejudgments….everybodywhogetsinvolvedinthis(discussionsofhasteneddeath)…useitasanopportunity.Itisnotjustanopportunityforthepatients,tolookinsidethemselves,butitisanopportunityforalloftheteam,thefamily,andthecaregiverstodoit….towalkwithsomeonedownthepath,thattheyreallydotakesometimetolookinsidetheirhearts.”
• Miller,Mesler,&Eggman (2002)