American Medical News
By — Posted Aug. 12, 2013
Three states now have laws allowing physicians to prescribe lethal doses of medication to terminally ill patients. These laws in Oregon, Vermont and Washington — and similar proposals elsewhere — have generated heated debates about quality end-of-life care, medical ethics, patient autonomy and the sanctity of life.
Most of that conversation has centered on the physician's role, the potential for elder abuse and whether patients seeking doctors' aid in dying are mentally ill. Yet there is another health care setting — hospice care — that plays a central role in how death-with-dignity laws are enacted but that has been largely ignored, said an article in July's Journal of Pain and Symptom Management.
According to the 2012 data from Oregon and Washington, more than 90% of the 160 patients who used the Death With Dignity laws were enrolled in hospice at the time they took their life-ending medication doses. That rate of hospice use among patients using the Death With Dignity laws has been pretty steady since Oregon's first doctor-assisted death in 1998. Vermont enacted its law in May, and there are no figures available on use of the law there.
While the lethal prescription must come from the patient's attending doctor, not a hospice physician, hospices still are affected by these laws, said Courtney S. Campbell, PhD, lead author of the study. He also chairs the ethics committee at Benton Hospice Service and is professor of religion and culture at Oregon State University, both in Corvallis, Ore.
“There's this precept in hospice that the care neither hastens nor prolongs death,” Campbell said. “It's supposed to be the opposite of using all this technology to extend life, as well as being against the idea of euthanasia. I wondered how hospices were reconciling that with the idea of physician-assisted death.”
Campbell and his colleagues obtained the doctor-assisted death policies of 33 hospice programs in Washington. Seven of the programs, or 21%, were opposed, meaning that their staff was not allowed to participate at all in the physician-assisted suicide process, except to say that they would not help patients secure doctor-aided death.
Fifty-four percent of hospice programs were classified as nonparticipating or noninterfering, meaning that their policies called for open discussion of the topic and referral of patients to other organizations that are expert in connecting patients with physicians willing to prescribe lethal medication doses. But these hospice programs drew the line at actually participating in the death by steps such as mixing the lethal medication dose or attending to potential complications after the medication is ingested.
Finally, eight hospice programs, or 24%, were classified as “respecting patient choice.” That means helping patients understand their options under the Death With Dignity Act. It also means that “the hospice responsibility encompasses respecting, honoring and supporting that choice as consonant with the patient's dignity,” the study said.
The figures were similar at Oregon hospice programs, said a study in the September-October 2010 Hastings Center Report. Sixty-five percent of hospice programs in Oregon were classified as noninterfering or nonparticipating, while 18% respected patient choice and 16% were opposed to any participation in doctor-aided death.
Whatever their broad-stroke policies are on physician-assisted suicide, most hospice programs draw the line at allowing staff to be present when patients take the lethal medication dose. About 80% of Washington hospices bar staff presence, while the rest allow nurses or others to be present at the time of ingestion or just after the dose is taken.
The choice to bar hospice professionals from being present when physician-assisted deaths occur raises questions, Campbell said.
“If you don't have a hospice nurse there or a physician there, I wonder about the commitment to nonabandonment to the patient,” he said. “That's a central concern.”
That conception of the obligation to dying patients is ill-founded, said William L. Toffler, MD, national director of the Physicians for Compassionate Care Education Foundation, based in Yakima, Wash., which opposes doctor-assisted suicide. He also is a professor of family medicine at Oregon Health & Science University in Portland.
“It's breathtaking,” Dr. Toffler said. “Charging abandonment because [health professionals] don't want to corrupt hospice with activity that's antithetical to the purpose and intent of the hospice? … It's an absolutely wrongheaded notion of patient abandonment.”
Since 1998, nearly 1,100 terminally ill U.S. patients have died after taking physician-prescribed lethal medications. The National Hospice and Palliative Care Organization opposes the legalization of doctor-assisted suicide, as does the American Medical Association. The AMA says the practice is “fundamentally inconsistent with the physician's role as healer.”