EEPPEECC

Physician-Assisted Suicide

Module 5Module 5

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

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

. . . 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

Physician-assisted suicide / euthanasia . . . Ancient medical issueAncient medical issue Aiding or causing a suffering Aiding or causing a suffering

person’s deathperson’s deathphysician-assisted suicidephysician-assisted suicide

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

euthanasiaeuthanasiaphysician performs the physician performs the

interventionintervention

. . . 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

Why patients ask for PAS Asking for helpAsking for help Fear ofFear of

psychosocial, mental sufferingpsychosocial, mental sufferingfuture 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 . . . PrinciplesPrinciples

obligation to relieve pain and sufferingobligation to relieve pain and sufferingrespect 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 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 . . .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 requests4.4. 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 request Immediate, compassionate responseImmediate, compassionate response Open-ended questionsOpen-ended questions Suicidal thoughts, plans?Suicidal thoughts, plans? Be aware ofBe aware of

personal biasespersonal biasespotential for counter-transferencepotential for counter-transference

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

physicalphysicalpsychological psychological socialsocialspiritualspiritual

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

fears about the futurefears about the futuredepression, anxietydepression, anxiety

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 symptomshelplessness, hopelessness, helplessness, hopelessness,

worthlessnessworthlessness

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

availableavailablefast-acting psychostimulantsfast-acting psychostimulantsSSRIsSSRIstricyclic antidepressantstricyclic antidepressants

Psychosocial suffering, practical concerns . . . Sense of shameSense of shame Not feeling wantedNot feeling wanted Inability to copeInability to cope Loss of Loss of

functionfunctionself-imageself-imagecontrol, independencecontrol, independence

. . . 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 behow 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 suffering PainPain BreathlessnessBreathlessness Anorexia / Anorexia /

cachexiacachexia Weakness / fatigueWeakness / fatigue Loss of functionLoss of function

Nausea / vomitingNausea / vomiting ConstipationConstipation DehydrationDehydration EdemaEdema IncontinenceIncontinence

Spiritual 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 beliefsangeranger

Common 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

Step 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

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

withholding, withdrawalwithholding, withdrawalaggressive comfort measuresaggressive comfort measurespalliative care principlespalliative care principleslocal palliative care programslocal palliative care programs

Address suffering, fearsAddress suffering, fears

Address psychological suffering TreatTreat

depressiondepressionanxietyanxietydeliriumdelirium

Individual, group counselingIndividual, group counseling Specialty referral as appropriateSpecialty referral as appropriate

Address social suffering, practical concerns . . . Family situationFamily situation FinancesFinances Legal affairsLegal affairs

. . . 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

Address physical suffering Aggressive symptom managementAggressive symptom management Engage physical, occupational Engage physical, occupational

therapytherapyexercisesexercisesaids to optimize functionaids to optimize function

Address spiritual suffering Explore Explore

prayerprayertranscendental dimensiontranscendental dimensionmeaning, purpose in lifemeaning, purpose in lifelife closurelife closuregift giving, legaciesgift giving, legacies

Consult chaplain, psychiatrist, Consult chaplain, psychiatrist, psychologistpsychologist

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 careaccept or refuse any medical accept or refuse any medical

interventioninterventionlife-sustaining therapieslife-sustaining therapies

. . . 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

Address fear of pain, other symptoms Explain aboutExplain about

control of pain, other symptomscontrol of pain, other symptomssedation for intractable symptoms sedation for intractable symptoms

Commitment to manage symptoms Commitment to manage symptoms

Address fear of being a burden Establish specificsEstablish specifics

worry about caregivingworry about caregivingfamily willingfamily willingalternate settingsalternate settings

worry about financesworry about financesresources, services availableresources, services available

Refer to a social worker Refer to a social worker

Address fear of indignity Discuss what indignity means to the Discuss what indignity means to the

individualindividualdependence, 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 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

Step 5: Educate, discuss legal alternatives Information givingInformation giving Refusal of treatmentRefusal of treatment Withdrawal of treatmentWithdrawal of treatment Declining oral intakeDeclining oral intake SedationSedation

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

. . . Decline oral intake Accept / decline artificial hydration, Accept / decline artificial hydration,

nutritionnutrition Educate, support family members, Educate, support family members,

caregiverscaregiversrefocus their need to give carerefocus their need to give care

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

. . . End-of-life sedation BenzodiazepinesBenzodiazepines AnestheticsAnesthetics BarbituratesBarbiturates Continue analgesicsContinue analgesics

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

colleaguescolleagues Reasons for reluctance to consultReasons for reluctance to consult

EEPPEECC Physician-Physician-

Assisted Suicide Assisted Suicide SummarySummary