EEPPEECC

EEPPEECC

Physician-Assisted Suicide

Physician-Assisted Suicide

Module 5Module 5Module 5Module 5

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

Objectives . . .Objectives . . .

Define physician-assisted suicide Define physician-assisted suicide (PAS) and euthanasia(PAS) and euthanasia

Describe their current status in the Describe their current status in the lawlaw

Identify root causes of suffering that Identify root causes of suffering that prompt requests prompt requests

Define physician-assisted suicide Define physician-assisted suicide (PAS) and euthanasia(PAS) and euthanasia

Describe their current status in the Describe their current status in the lawlaw

Identify root causes of suffering that Identify root causes of suffering that prompt requests prompt requests

. . . Objectives. . . Objectives

Understand a 6-step protocol for Understand a 6-step protocol for responding to requestsresponding to requests

Be able to meet most patients’ needsBe able to meet most patients’ needs

Understand a 6-step protocol for Understand a 6-step protocol for responding to requestsresponding to requests

Be able to meet most patients’ needsBe able to meet most patients’ needs

Physician-assisted suicide / euthanasia . . .Physician-assisted suicide / euthanasia . . . Ancient medical issueAncient medical issue

Aiding or causing a suffering Aiding or causing a suffering person’s deathperson’s death

physician-assisted suicidephysician-assisted suicide

physician provides the means, physician provides the means, patient actspatient acts

euthanasiaeuthanasia

physician performs the physician performs the interventionintervention

Ancient medical issueAncient medical issue

Aiding or causing a suffering Aiding or causing a suffering person’s deathperson’s death

physician-assisted suicidephysician-assisted suicide

physician provides the means, physician provides the means, patient actspatient acts

euthanasiaeuthanasia

physician performs the physician performs the interventionintervention

. . . Physician-assisted suicide / euthanasia. . . Physician-assisted suicide / euthanasia Many physicians receive a requestMany physicians receive a request

Requests are a sign of patient crisisRequests are a sign of patient crisis

Many physicians receive a requestMany physicians receive a request

Requests are a sign of patient crisisRequests are a sign of patient crisis

Why patients ask for PASWhy patients ask for PAS

Asking for helpAsking for help

Fear ofFear of

psychosocial, mental sufferingpsychosocial, mental suffering

future suffering, loss of control, future suffering, loss of control, indignity, being a burdenindignity, being a burden

DepressionDepression

Physical sufferingPhysical suffering

Asking for helpAsking for help

Fear ofFear of

psychosocial, mental sufferingpsychosocial, mental suffering

future suffering, loss of control, future suffering, loss of control, indignity, being a burdenindignity, being a burden

DepressionDepression

Physical sufferingPhysical suffering

The legal and ethical debate . . .The legal and ethical debate . . . PrinciplesPrinciples

obligation to relieve pain and sufferingobligation to relieve pain and suffering

respect decisions to forgo life-respect decisions to forgo life-sustaining treatmentsustaining treatment

The ethical debate is ancientThe ethical debate is ancient

US Supreme Court recognizedUS Supreme Court recognized

NO right to PASNO right to PAS

PrinciplesPrinciples

obligation to relieve pain and sufferingobligation to relieve pain and suffering

respect decisions to forgo life-respect decisions to forgo life-sustaining treatmentsustaining treatment

The ethical debate is ancientThe ethical debate is ancient

US Supreme Court recognizedUS Supreme Court recognized

NO right to PASNO right to PAS

. . . The legal and ethical debate. . . The legal and ethical debate The legal status of PAS can differ The legal status of PAS can differ

from state to statefrom state to state

Oregon is the only state where PAS Oregon is the only state where PAS is legal (as of 1999)is legal (as of 1999)

Supreme Court Justices supportedSupreme Court Justices supported

right to palliative careright to palliative care

The legal status of PAS can differ The legal status of PAS can differ from state to statefrom state to state

Oregon is the only state where PAS Oregon is the only state where PAS is legal (as of 1999)is legal (as of 1999)

Supreme Court Justices supportedSupreme Court Justices supported

right to palliative careright to palliative care

6-step protocol to respond to requests . . .6-step protocol to respond to requests . . .

1.1. Clarify the request Clarify the request

2.2. Assess the underlying causes of the Assess the underlying causes of the requestrequest

3.3. Affirm your commitment to care for Affirm your commitment to care for the patientthe patient

1.1. Clarify the request Clarify the request

2.2. Assess the underlying causes of the Assess the underlying causes of the requestrequest

3.3. Affirm your commitment to care for Affirm your commitment to care for the patientthe patient

. . . 6-step protocol to respond to requests. . . 6-step protocol to respond to requests

4.4. Address the root causes of the Address the root causes of the requestrequest

5.5. Educate the patient and discuss Educate the patient and discuss legal alternativeslegal alternatives

6.6. Consult with colleagues Consult with colleagues

4.4. Address the root causes of the Address the root causes of the requestrequest

5.5. Educate the patient and discuss Educate the patient and discuss legal alternativeslegal alternatives

6.6. Consult with colleagues Consult with colleagues

Step 1: Clarify the requestStep 1: Clarify the request

Immediate, compassionate responseImmediate, compassionate response

Open-ended questionsOpen-ended questions

Suicidal thoughts, plans?Suicidal thoughts, plans?

Be aware ofBe aware of

personal biasespersonal biases

potential for counter-transferencepotential for counter-transference

Immediate, compassionate responseImmediate, compassionate response

Open-ended questionsOpen-ended questions

Suicidal thoughts, plans?Suicidal thoughts, plans?

Be aware ofBe aware of

personal biasespersonal biases

potential for counter-transferencepotential for counter-transference

Step 2: Assess underlying causes . . .Step 2: Assess underlying causes . . . The 4 dimensions of sufferingThe 4 dimensions of suffering

physicalphysical

psychological psychological

socialsocial

spiritualspiritual

The 4 dimensions of sufferingThe 4 dimensions of suffering

physicalphysical

psychological psychological

socialsocial

spiritualspiritual

. . . Step 2: Assess underlying causes. . . Step 2: Assess underlying causes Particular focus onParticular focus on

fears about the futurefears about the future

depression, anxietydepression, anxiety

Particular focus onParticular focus on

fears about the futurefears about the future

depression, anxietydepression, anxiety

Assess for clinical depression . . .Assess for clinical depression . . . Underdiagnosed, undertreatedUnderdiagnosed, undertreated

Source of sufferingSource of suffering

Barrier to life closure, “good death”Barrier to life closure, “good death”

Diagnosis challengingDiagnosis challenging

no somatic symptomsno somatic symptoms

helplessness, hopelessness, helplessness, hopelessness, worthlessnessworthlessness

Underdiagnosed, undertreatedUnderdiagnosed, undertreated

Source of sufferingSource of suffering

Barrier to life closure, “good death”Barrier to life closure, “good death”

Diagnosis challengingDiagnosis challenging

no somatic symptomsno somatic symptoms

helplessness, hopelessness, helplessness, hopelessness, worthlessnessworthlessness

. . . Assess for clinical depression. . . Assess for clinical depression Treatment choices depend on time Treatment choices depend on time

availableavailable

fast-acting psychostimulantsfast-acting psychostimulants

SSRIsSSRIs

tricyclic antidepressantstricyclic antidepressants

Treatment choices depend on time Treatment choices depend on time availableavailable

fast-acting psychostimulantsfast-acting psychostimulants

SSRIsSSRIs

tricyclic antidepressantstricyclic antidepressants

Psychosocial suffering, practical concerns . . .Psychosocial suffering, practical concerns . . .

Sense of shameSense of shame

Not feeling wantedNot feeling wanted

Inability to copeInability to cope

Loss of Loss of

functionfunction

self-imageself-image

control, independencecontrol, independence

Sense of shameSense of shame

Not feeling wantedNot feeling wanted

Inability to copeInability to cope

Loss of Loss of

functionfunction

self-imageself-image

control, independencecontrol, independence

. . . Psychosocial suffering, practical concerns. . . Psychosocial suffering, practical concerns

Tension with relationshipsTension with relationships

Increased isolation, miseryIncreased isolation, misery

Worries about practical mattersWorries about practical matters

who caregivers will bewho caregivers will be

how domestic chores will be tended to how domestic chores will be tended to

who will care for dependents, petswho will care for dependents, pets

Tension with relationshipsTension with relationships

Increased isolation, miseryIncreased isolation, misery

Worries about practical mattersWorries about practical matters

who caregivers will bewho caregivers will be

how domestic chores will be tended to how domestic chores will be tended to

who will care for dependents, petswho will care for dependents, pets

Physical sufferingPhysical suffering

PainPain

BreathlessnessBreathlessness

Anorexia / Anorexia / cachexiacachexia

Weakness / fatigueWeakness / fatigue

Loss of functionLoss of function

PainPain

BreathlessnessBreathlessness

Anorexia / Anorexia / cachexiacachexia

Weakness / fatigueWeakness / fatigue

Loss of functionLoss of function

Nausea / vomitingNausea / vomiting

ConstipationConstipation

DehydrationDehydration

EdemaEdema

IncontinenceIncontinence

Nausea / vomitingNausea / vomiting

ConstipationConstipation

DehydrationDehydration

EdemaEdema

IncontinenceIncontinence

Spiritual sufferingSpiritual suffering

Existential concernsExistential concerns

Meaning, value, purpose in lifeMeaning, value, purpose in life

Abandoned, punished by GodAbandoned, punished by God

questions faith, religious beliefsquestions faith, religious beliefs

angeranger

Existential concernsExistential concerns

Meaning, value, purpose in lifeMeaning, value, purpose in life

Abandoned, punished by GodAbandoned, punished by God

questions faith, religious beliefsquestions faith, religious beliefs

angeranger

Common fearsCommon fears

FutureFuture

Pain, other symptomsPain, other symptoms

Loss of control, independenceLoss of control, independence

Abandonment, lonelinessAbandonment, loneliness

Indignity, loss of self-imageIndignity, loss of self-image

Being a burden on others Being a burden on others

FutureFuture

Pain, other symptomsPain, other symptoms

Loss of control, independenceLoss of control, independence

Abandonment, lonelinessAbandonment, loneliness

Indignity, loss of self-imageIndignity, loss of self-image

Being a burden on others Being a burden on others

Step 3: Affirm your commitmentStep 3: Affirm your commitment Listen, acknowledge feelings, fearsListen, acknowledge feelings, fears

Explain your roleExplain your role

Commit to help find solutionsCommit to help find solutions

Explore current concernsExplore current concerns

Listen, acknowledge feelings, fearsListen, acknowledge feelings, fears

Explain your roleExplain your role

Commit to help find solutionsCommit to help find solutions

Explore current concernsExplore current concerns

Step 4: Address root causesStep 4: Address root causes Professional competence in: Professional competence in:

withholding, withdrawalwithholding, withdrawal

aggressive comfort measuresaggressive comfort measures

palliative care principlespalliative care principles

local palliative care programslocal palliative care programs

Address suffering, fearsAddress suffering, fears

Professional competence in: Professional competence in:

withholding, withdrawalwithholding, withdrawal

aggressive comfort measuresaggressive comfort measures

palliative care principlespalliative care principles

local palliative care programslocal palliative care programs

Address suffering, fearsAddress suffering, fears

Address psychological sufferingAddress psychological suffering TreatTreat

depressiondepression

anxietyanxiety

deliriumdelirium

Individual, group counselingIndividual, group counseling

Specialty referral as appropriateSpecialty referral as appropriate

TreatTreat

depressiondepression

anxietyanxiety

deliriumdelirium

Individual, group counselingIndividual, group counseling

Specialty referral as appropriateSpecialty referral as appropriate

Address social suffering, practical concerns . . . Address social suffering, practical concerns . . . Family situationFamily situation

FinancesFinances

Legal affairsLegal affairs

Family situationFamily situation

FinancesFinances

Legal affairsLegal affairs

. . . Address social suffering, practical concerns. . . Address social suffering, practical concerns

What setting of careWhat setting of care

Who caregivers will beWho caregivers will be

How to manage domestic choresHow to manage domestic chores

Who will care for dependents, petsWho will care for dependents, pets

What setting of careWhat setting of care

Who caregivers will beWho caregivers will be

How to manage domestic choresHow to manage domestic chores

Who will care for dependents, petsWho will care for dependents, pets

Address physical sufferingAddress physical suffering Aggressive symptom managementAggressive symptom management

Engage physical, occupational Engage physical, occupational therapytherapy

exercisesexercises

aids to optimize functionaids to optimize function

Aggressive symptom managementAggressive symptom management

Engage physical, occupational Engage physical, occupational therapytherapy

exercisesexercises

aids to optimize functionaids to optimize function

Address spiritual sufferingAddress spiritual suffering Explore Explore

prayerprayer

transcendental dimensiontranscendental dimension

meaning, purpose in lifemeaning, purpose in life

life closurelife closure

gift giving, legaciesgift giving, legacies

Consult chaplain, psychiatrist, Consult chaplain, psychiatrist, psychologistpsychologist

Explore Explore

prayerprayer

transcendental dimensiontranscendental dimension

meaning, purpose in lifemeaning, purpose in life

life closurelife closure

gift giving, legaciesgift giving, legacies

Consult chaplain, psychiatrist, Consult chaplain, psychiatrist, psychologistpsychologist

Address fear of loss of control . . .Address fear of loss of control . . . Explore areas of control, Explore areas of control,

independenceindependence

Right to determine one’s own Right to determine one’s own medical caremedical care

accept or refuse any medical accept or refuse any medical interventionintervention

life-sustaining therapieslife-sustaining therapies

Explore areas of control, Explore areas of control, independenceindependence

Right to determine one’s own Right to determine one’s own medical caremedical care

accept or refuse any medical accept or refuse any medical interventionintervention

life-sustaining therapieslife-sustaining therapies

. . . Address fear of loss of control. . . Address fear of loss of control Select Select

personal advocate(s)personal advocate(s)

proxy for decision-makingproxy for decision-making

Prepare advance directivesPrepare advance directives

Plan for deathPlan for death

Make a commitment to help patient Make a commitment to help patient maintain as much control as possiblemaintain as much control as possible

Select Select

personal advocate(s)personal advocate(s)

proxy for decision-makingproxy for decision-making

Prepare advance directivesPrepare advance directives

Plan for deathPlan for death

Make a commitment to help patient Make a commitment to help patient maintain as much control as possiblemaintain as much control as possible

Address fear of pain, other symptomsAddress fear of pain, other symptoms Explain aboutExplain about

control of pain, other symptomscontrol of pain, other symptoms

sedation for intractable symptoms sedation for intractable symptoms

Commitment to manage symptoms Commitment to manage symptoms

Explain aboutExplain about

control of pain, other symptomscontrol of pain, other symptoms

sedation for intractable symptoms sedation for intractable symptoms

Commitment to manage symptoms Commitment to manage symptoms

Address fear of being a burdenAddress fear of being a burden Establish specificsEstablish specifics

worry about caregivingworry about caregiving

family willingfamily willing

alternate settingsalternate settings

worry about financesworry about finances

resources, services availableresources, services available

Refer to a social worker Refer to a social worker

Establish specificsEstablish specifics

worry about caregivingworry about caregiving

family willingfamily willing

alternate settingsalternate settings

worry about financesworry about finances

resources, services availableresources, services available

Refer to a social worker Refer to a social worker

Address fear of indignityAddress fear of indignity

Discuss what indignity means to the Discuss what indignity means to the individualindividual

dependence, burden, embarrassment dependence, burden, embarrassment

Importance of controlImportance of control

Explore resources to maintain Explore resources to maintain dignitydignity

Reassure patientReassure patient

Discuss what indignity means to the Discuss what indignity means to the individualindividual

dependence, burden, embarrassment dependence, burden, embarrassment

Importance of controlImportance of control

Explore resources to maintain Explore resources to maintain dignitydignity

Reassure patientReassure patient

Address fear of abandonmentAddress fear of abandonment Assurance that physician will Assurance that physician will

continue to be involved in carecontinue to be involved in care

Resources provided by hospice and Resources provided by hospice and palliative carepalliative care

Assurance that physician will Assurance that physician will continue to be involved in carecontinue to be involved in care

Resources provided by hospice and Resources provided by hospice and palliative carepalliative care

Step 5: Educate, discuss legal alternativesStep 5: Educate, discuss legal alternatives Information givingInformation giving

Refusal of treatmentRefusal of treatment

Withdrawal of treatmentWithdrawal of treatment

Declining oral intakeDeclining oral intake

SedationSedation

Information givingInformation giving

Refusal of treatmentRefusal of treatment

Withdrawal of treatmentWithdrawal of treatment

Declining oral intakeDeclining oral intake

SedationSedation

Decline oral intake . . .Decline oral intake . . .

Any person can decline oral intakeAny person can decline oral intake

Force-feeding not acceptable Force-feeding not acceptable

Ensure food, water always Ensure food, water always accessibleaccessible

Any person can decline oral intakeAny person can decline oral intake

Force-feeding not acceptable Force-feeding not acceptable

Ensure food, water always Ensure food, water always accessibleaccessible

. . . Decline oral intake. . . Decline oral intake

Accept / decline artificial hydration, Accept / decline artificial hydration, nutritionnutrition

Educate, support family members, Educate, support family members, caregiverscaregivers

refocus their need to give carerefocus their need to give care

Accept / decline artificial hydration, Accept / decline artificial hydration, nutritionnutrition

Educate, support family members, Educate, support family members, caregiverscaregivers

refocus their need to give carerefocus their need to give care

End-of-life sedation . . .End-of-life sedation . . .

When symptoms are intractable at When symptoms are intractable at the end of lifethe end of life

Continuous, intermittentContinuous, intermittent

Death attributed to illness, not Death attributed to illness, not sedationsedation

When symptoms are intractable at When symptoms are intractable at the end of lifethe end of life

Continuous, intermittentContinuous, intermittent

Death attributed to illness, not Death attributed to illness, not sedationsedation

. . . End-of-life sedation. . . End-of-life sedation

BenzodiazepinesBenzodiazepines

AnestheticsAnesthetics

BarbituratesBarbiturates

Continue analgesicsContinue analgesics

BenzodiazepinesBenzodiazepines

AnestheticsAnesthetics

BarbituratesBarbiturates

Continue analgesicsContinue analgesics

Step 6: Consult with colleaguesStep 6: Consult with colleagues Seek support from trusted Seek support from trusted

colleaguescolleagues

Reasons for reluctance to consultReasons for reluctance to consult

Seek support from trusted Seek support from trusted colleaguescolleagues

Reasons for reluctance to consultReasons for reluctance to consult

EEPPEECC

EEPPEECC Physician-Physician-

Assisted Suicide Assisted Suicide

SummarySummary

Physician-Physician-Assisted Suicide Assisted Suicide

SummarySummary