>Killing me softly

>I was talking with my colleagues the other day about the new Washington State Initiative (dubbed I-1000 on this past November’s ballot)—the Washington Death with Dignity Act, usually referred to as physician-assisted suicide. The act went into effect on March 4th and for medical providers, it’s not just a personal consideration or a philosophical discussion. Everyone on the palliative care service has already been involved in patient-initiated discussions about it. I am a nurse practitioner and the act as written only allows physicians to prescribe lethal doses of medication to terminally ill patients who then must act on their own to decide if and when to take the medication and die a bit earlier than they might otherwise. I wish that the act included nurse practitioners, as I don’t believe that there are enough physicians in this State who are prepared to act in concert with this law. If I were allowed, I believe that I would be able to.

The act was passed by 60% of Washington State voters. Still, it allows for physicians, other health care providers, as well as institutions (hospitals, nursing homes, etc) to Opt Out. No one is forced to participate, either for personal, religious, political, or practical reasons; the act cannot force a single physician in the state to do the people’s bidding. If a hospital opts in, it does not guarantee than any of its staff will respond to requests by actually writing prescriptions. If a hospital opts out, it thereby forbids its physicians to provide life-ending medications when acting as an employee or staff and can terminate the staff privileges of doctors who do so.

I have a problem with this, as it will tend to isolate and make it all the more difficult for those who do want to act on behalf of patients who make the request. In Oregon, the only state in the US that has allowed physicians to prescribe lethal doses of barbiturates to terminally ill patients, only a handful of physicians have actually prescribed medications for this purpose. This is not to say that other health care providers abandoned patients, did not listen and empathize, or did not try their best to alleviate suffering. But at the end, most sent the patient to someone else to get what she came to them asking for. And the medical profession, including hospice and palliative care organizations, are playing it safe on this one. I’ve heard the arguments:

We can always relieve pain and suffering, no one should have to resort to this act.

–The act potentially will exploit the most vulnerable among us.

–Most people who want to commit suicide are depressed and if treated for depression, would not choose to die.

I feel that these arguments are arrogant, even if well intentioned. Those of us working with chronically and terminally ill people at the last months of their lives know that we are not always able to make life bearable for those suffering. The Oregon experience has shown us that those asking for life-ending medications are well educated and resourceful people. The most common attribute among them is willfulness and the need for control in an unbearable situation.

Although the scope differs, the situation is otherwise similar for women seeking abortions. I worked in a women’s health center in Tallahassee Florida during the decade after abortion was legalized in by the Supreme Court in January 1973. My center eventually had to sue doctors in the local community who refused to provide abortions, but were harassing our doctors who traveled in from other communities. Tragically, a friend and colleague, Bayard Britton (John Bayard Britton MD) was murdered along with his bodyguard by the antiabortion activist Paul Hill in Pensacola, Florida in 1994. Bayard was wearing a bullet-proof vest, he knew the risk he was taking, but he also knew that some doctors had to provide abortions if the law was to have any meaning to women. I also knew Dr. David Gunn, who was also murdered in Pensacola prior to Bayard’s murder. There were so few doctors at that time in the entire state that were willing to perform abortions, they were not hard to pick off.

My team is struggling with the issue. I don’t know if it is right or wrong to hasten death in this way and I don’t know if I will ever know. I have the sense that there is no way to make a moral issue out of how to best alleviate human suffering. I suppose it is because I will never truly understand human suffering that I am drawn to try to alleviate it. If you wish to use the concept of God and the idea of a reckoning after death, then I guess we will have to wait to know if living according to our best understanding of what is good, was good enough. We might find out that it is as wrong to kill and eat animals as it is to torture prisoners. At their best, ideas about life remain relative to our ability to understand them. As for me, I don’t believe in a God who wishes for us to suffer and judges us for doing what we can to help others.

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5 Responses to >Killing me softly

  1. marachne says:

    >Risa, I agree about, and do not understand the restriction on NPs prescribing. I think after the first measure failed, the WA supporters figured they'd have the best chance copying exactly the OR law.In Oregon, I do not know of any hospital that has opted in, but I also do not know what kind of restrictions they have placed on physicians with privileges.Your point about access is well taken: not only access to physicians for prescriptions, but to pharmacies for the actual medication — as usual, rural folks have it a lot harder in terms of access to services.I would highly recommend doing some reading to find out more about how things have unfolded in Oregon, and I'm adding a bio below. I have also offered (both directly to Darryl and to the WHA) to come and talk to any organization about the Oregon experience, from the perspective of the the hospice nurses and SW we interviewed.One last comment — the last thing in the list below is a link to the website of a person who kept a vido diary of her decision to use PAD. It's a very powerful and also humanizing thing.Back, A. L., Wallace, J. I., Starks, H. E., & Pearlman, R. A. (1996). Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses, JAMA, 275(12), 919-925.Carlson, B., Simopolous, N., Goy, E. R., Jackson, A., & Ganzini, L. (2005). Oregon hospice chaplains' experiences with patients requesting physician-assisted suicide. Journal of Palliative Medicine, 8(6), 1160-1166.Dobscha, S. K., Heintz, R. T., Press, N., & Ganzini, L. (2004). Oregon Physicians' Responses to Requests for Assisted Suicide: A Qualitative Study: Journal of Palliative Medicine 7(3) Jun 2004, 451-461.Fenn, D. S., & Ganzini, L. (1999). Attitudes of Oregon psychologists toward physician-assisted suicide and the Oregon Death With Dignity Act: Professional Psychology: Research and Practice 30(3) Jun 1999, 235-244.Ganzini, L., Beer, T. M., Brouns, M., Mori, M., & Hsieh, Y. C. (2006). Interest in physician-assisted suicide among Oregon cancer patients. Journal of Clinical Ethics, 17(1), 27-38.Ganzini, L., Beer, T. M., & Brouns, M. C. (2006). Views on physician-assisted suicide among family members of Oregon cancer patients. Journal of Pain & Symptom Management, 32(3), 230-236.Ganzini, L., Dobscha, S. K., Heintz, R. T., & Press, N. (2003). Oregon physicians' perceptions of patients who request assisted suicide and their families. Journal of Palliative Medicine, 6(3), 381-390.Ganzini, L., Goy, E. R., & Dobscha, S. K. (2008). Why Oregon patients request assisted death: family members' views. Journal of General Internal Medicine, 23(2), 154-157.Ganzini, L., Harvath, T. A., Jackson, A., Goy, E. R., Miller, L. L., & Delorit, M. A. (2002). Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. New England Journal of Medicine, 347(8), 582-588.Ganzini, L., Nelson, H. D., Lee, M. A., Kraemer, D. F., Schmidt, T. A., & Delorit, M. A. (2001). Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA, 285(18), 2363-2369.Ganzini, L., Nelson, H. D., Schmidt, T. A., Kraemer, D. F., Delorit, M. A., & Lee, M. A. (2000). Physicians' experiences with the Oregon Death with Dignity Act. New England Journal of Medicine, 342(8), 557-563.Ganzini, L., Silveira, M. J., & Johnston, W. S. (2002). Predictors and correlates of interest in assisted suicide in the final month of life among ALS patients in Oregon and Washington. Journal of Pain & Symptom Management, 24(3), 312-317.Harvath, T. A., Miller, L. L., Goy, E., Jackson, A., Delorit, M., & Ganzini, L. (2004). Voluntary refusal of food and fluids: attitudes of Oregon hospice nurses and social workers. International Journal of Palliative Nursing, 10(5), 236-241; discussion 242-233.Harvath, T. A., Miller, L. L., Smith, K. A., Clark, L. D., Jackson, A., & Ganzini, L. (2006). Dilemmas encountered by hospice workers when patients wish to hasten death. Journal of Hospice and Palliative Nursing, 8(4), 200-209.Kohlwes, R. J., Koepsell, T. D., Rhodes, L. A., & Pearlman, R. A. (2001). Physicians' Responses to Patients' Requests for Physician-Assisted Suicide. Archives of Internal Medicine, 161(5), 657-663.Miller, L. L., Harvath, T. A., Ganzini, L., Goy, E. R., Delorit, M. A., & Jackson, A. (2004). Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide. Palliative Medicine, 18(8), 685-691.Compassion & Choices http://www.compassionandchoices.orgLiving to the End http://next.oregonianextra.com/lovelle

  2. Petunia says:

    >I am a hospice RN. I hope to be of service. I hope I can help ease the burden faced by patients and their loved ones. I believe I was called to this work, and although it is often difficult it is also rewarding. It is rarely fun.I will not kill my patients, even at their request. I will not knowingly assist them to kill themselves. I will not be compelled to do this.I will walk with you, I will grieve with and for you and your family. I will not abandon you. I hope that you will also not abandon me.

  3. Petunia says:

    >Just re-read your post and am struck by the last paragraph wherein you candidly state that you don’t know if it’s right or wrong “to hasten death in this way”. That very unknowing makes it imperative that one Does No Harm….

  4. marachne says:

    >Petunia, a question for you — yo say you will not knowingly assist someone to kill themselves…what does that mean? Will you shut down a patient who starts asking you about the DWD law? Will you listen if they are just exploring it as part of processing their death, but turn away if it looks like they are getting serious in pursuing it?Will you refuse to provide care for someone who has enrolled in hospice, after having started the process of receiving the prescription?Will you stop caring for someone who is enrolled in hospice, and decides to pursue PAD?If you have a patient, who has already gotten their prescription, and wants help with managing their nausea, so they can take the medication and not throw up, will you control their symptoms, knowing it will allow them to hasten their death?Will you go further, do more for the patient who is thinking about PAD, in order to stop them from continuing down that path?I’m not asking you these questions to put you on the spot, I’m asking you because this is what hospice nurses have had to deal with in Oregon.It’s not easy, there are dilemmas. There are also really few black and white questions/answers/situations. Life is messy, and death can be too. You’re a hospice RN, you already know that.You ask that the patient “not abandon you.” Is your patient’s death about you, or about them?

  5. At least some bloggers can still write. Thank you for this blog.

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