Death with dignity: Issues states need to consider

Vermont became the first state to enact a law authorizing physician-assisted suicide through the legislative process.  As the governor signed the bill, Jean Mallary watched carefully over his shoulder. She’s the widow of the late Dick Mallary, a former speaker of the House and U.S. Congressman.  Mallary was in pain and suffered from terminal cancer when he chose to end his life over a year ago. Jean Mallary’s story about her husband’s choice – and that he had to die alone without his family at his side – was compelling personal testimony that pushed the bill forward.

I happen to live in one of the other two States with passed a “death with dignity” (DWD) law through the voter initiative process.  It’s been pretty much a non-issue here in Washington state with no blaring media articles.  Only about one in 500 deaths are a result of utilizing our state’s law.  The individuals I’ve talked to who have witnessed the deaths, have found the process humane and comforting.

For example consider the following.  John was a rather robust fellow at 190 pounds and a well preserved physique at age 68.  One day he notices blood in his urine, and shortly thereafter multiple lumps on his scalp.  The diagnosis was a type of cancer which was non-responsive to chemotherapy.  Cancer was found also in the lungs, lymph notes, spine and liver.  He started loosing weight rapidly – then the pain started in his back plus now bleeding scalp cancerous lesions.

John’s wife and children were supportive and they had open discussions about his impending death – which was predicted to be in 3 to 5 months.  He sought advice from his pastor, doctors and friends.  One thing that was so important to him was that he wanted to be pain free, not uselessly suffering, and pass from this life in a dignified way.  John received excellent hospice and palliative care but the pain persisted despite accelerating use of narcotics.  Radiation to the spine didn’t help.  His scalp and back were exquisitely painful and he couldn’t get rest unless he was “knocked out” by pills.

Though John’s cancer care specialists, he received counseling and screening about his options for assisted suicide.  Ultimately he was prescribed a lethal dose of a barbiturate.  The family supported his decision when he went ahead with the self administered dose, became rapidly unconscious and died peacefully within 20 minutes.  Tearful loved ones were at his bedside.

I must admit, however, that I still have some qualms about the potential of abuse of the DWD laws.  So I’ve stayed neutral in my own stance, waiting to see how it plays out and trying to stay vigilant for the potential of abuse.  As more and more of us reach advanced age, and the pressure to conserve health resources mounts, we need to make sure that the individual is making an autonomous choice.  Also, we need widely available and affordable health care for these very ill patients, plus superb hospice and palliative care.  The DWD option needs to be a “last resort” when very good care has failed to relieve or address the individual’s concerns.

Another area of concern is the continuing lack of Medicare payment for end of life discussions with an individual’s physician.  There is some hope that progress will be made by the United States Senate Special Committee on Aging.  It’s certainly worth viewing or reading reports from Senator Susan Collins, plus representatives from Five Wishes, the Conversation Project, and the Physician’s Orders for Life Sustaining Treatment (POLST) paradigm.

Some concerns also are warranted with reports of abuses of England’s Liverpool Care Pathway where, at times, physicians may have written “do not resuscitate” without the consent of the patient.  Additionally, there is potential for the misapplication of Washington State’s POLST.  Some retirement homes in our area are “requiring” that all residents, even those in independent living, have completed POLST forms.  This is not the intent of POLST forms which are applicable as active medical orders for those in the last six months of life or the very frail elderly who are clear about their wishes.

Fortunately the DWD laws in Oregon and Washington have been carefully crafted, monitored, and transparently reported.  To maintain their good record, it will require on-going funding and oversight particularly if the financial burden of health issues continues to weigh heavily on patients, families, medical institutions, and governments.

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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