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