The End is a series about end-of-life issues.
The patient was terminally ill. He had decided to end his life under his state’s “death with dignity” law, and his doctor prescribed the medication he would use to do it. But his death was unexpectedly delayed because he drank a large soda before taking the medication — an ordinarily lethal dose — and it apparently interfered with the drug’s absorption. I’ve been told that patients who want to die are now warned not to drink carbonated beverages before or after taking the medication.
In another situation, a physician assisting in a death for the first time prescribed less than the recommended dose of the lethal drug. Although the patient died, it might have been otherwise. And an A.L.S. patient who requested the prescription from his physician met one criterion (having a terminal illness) but not the second (prognosis of six months to live). These are just some of the unexpected wrinkles that have come up in the still-new world of physician-assisted death.
Providing the means for immediate death is contrary to the long history of medicine, where the primary intent has been to work for the patient’s survival. As a bioethicist in Washington, one of the five states that have legalized this, I find that for doctors, having the opportunity to help a patient die may resolve certain ethical issues but raises many others. It is especially important to consider these now, as many states are considering legislation on this practice.
Medical aid in dying is now allowed in Oregon, Washington and Vermont by legislation and in Montana and New Mexico through court decisions. The laws provide direction and protection for those involved. For example, in Oregon, Washington and Vermont, when terminally ill patients request physician assistance in dying, it is not considered suicide, and the death certificate notes the underlying illness as the cause of death.
In Washington State, two doctors must verify that the patient is competent, suffering from a terminal illness and that death is expected within six months. The request must be made and confirmed by a second request after a 15-day waiting period. The process requires a doctor who is willing to write the prescription and a pharmacist who is willing to fill it. The patient must have the capacity to take the prescription independently; that is, it must not be administered by another party.
Once a patient has the medication, he or she may decide when or whether to take it. Many patients have delayed taking the medication for weeks as they assessed when the timing was right. Most patients are not in a hurry to die. Some die of their diseases, never taking the medication. Surviving family members usually say that such patients felt a great sense of comfort in knowing they had the means to bring about their death if their suffering intensified. Many were willing to accept a certain level of pain as long as they were able to relate to loved ones and find at least a minimal level of satisfaction in living.
Legally, the act of aiding or abetting the death of another has been considered a felony. Ethically, physician assistance in the death of a patient has been contrary to the precepts of bioethics, and in earlier times physicians took an oath that they would not provide any deadly substance to patients. The passage of this law in 2008 in Washington has opened a new window on this practice and served as a reminder to physicians that many feel we are not doing a good enough job in caring for the dying by providing excellent palliative care at the end of life.
This is a new day for physicians. As one physician friend said: “I voted for this law when it was on the ballot, in principle, it seemed like a good idea. I never imagined that one of my patients would ask me to write a lethal prescription and participate in their decision to die.” Another doctor mused: “All of my training was to provide medications with the intent of curing illness or relieving pain. Writing a lethal prescription has a different intent.” Some physicians have examined their consciences and decided that they will not participate. Some health care organizations have decided to “opt out,” usually for religious reasons, and have established policies forbidding any employee of the institution from participating in physician assisted dying. Others have opted in.
Imagine, however, that a physician has decided to assist patients in situations deemed appropriate. When a patient makes a request for aid in dying, how should that conversation go? Is the patient driven by unreasonable fears or by discomforts that could be resolved through excellent palliative care? The request should trigger a careful discussion. These questions were not covered in medical school or resident training. To whom should one turn for this information?
If a decision is made to assist the patient, what happens next? Secobarbital — or seconal — is currently the most widely used prescription. Patients are advised to open the capsules and mix the powder with sweetened applesauce or a drink. There are a handful of cases where patients have regurgitated part of the medication, so an antiemetic should be taken first. The patient usually loses consciousness within moments of taking the medication, and death follows quickly. Physicians who prescribe medication in death with dignity cases usually seem to want to fly below the radar, avoiding publicity; they do not want to become known as “Dr. Death.” Given the desire for anonymity, there is little in the way of support from colleagues. I have recently met privately with two groups of physicians in the state, at their request, to discuss such issues and to provide support in the face of these complexities.
If other states pass death with dignity laws, learning from Washington State’s experience, they should require that the Department of Health provide standardized information to assist physicians. Additionally, professional support groups providing a neutral source of information and guidance for participating physicians should be offered. Even then, doctors will continue to struggle with their role in the process. As one physician I know put it, “a prognosis of six months or less is the same criterion for participation in hospice as it is for participation in physician-assisted death under the Death With Dignity Act — but I worry a lot more about the accuracy of the prognosis if a patient requests a prescription for a lethal dose of medication.”
Thomas R. McCormick is a senior lecturer emeritus in the Department of Medical History and Ethics at the University of Washington School of Medicine.