Medical aid in dying is not assisted suicide [PODCAST]

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“To help the reader understand the issues better, I would like to relate some stories. A friend of mine was dying of pancreatic cancer. He had an implantable morphine pump and was on both hospice and palliative care. Still, he found that his suffering was unbearable and wanted to die sooner. Doctors told him that his only option to end his suffering was to voluntarily stop eating and drinking, which he did. As a result, he developed psychosis, and his loving family has been scarred by the experience. He died after 10 agonizing days. I heard about an individual with ALS (Lou Gehrig’s disease), which is incurable and causes the death of neurons that control muscles and eventually leads to the inability to move and then the ability to breathe. This person killed himself with a gun before he lost the use of his arms. I had a number of patients with cancer that we were not able to control their pain, and I gave them palliative sedation (a morphine drip that caused them to become unconscious) to control their suffering. Had it been available, medical aid in dying could have helped all these people.

When my cancer gets worse, I expect to have a great deal of pain. I would like the option of having medication to put me to sleep, end my suffering, and to die, at home, with my family and friends around me.”

The author would like to correct the following statistics from the podcast:

• 17 percent of terminally Ill individuals discuss medical aid in dying with family and friends.
• 2 to 10 percent discuss medical aid in dying with a physician.
• 0.6 percent get medical aid in dying prescriptions.
• 0.3 to 0.4 percent use a medical aid in dying drug.

Roger Kligler is an internal medicine physician.

He shares his story and discusses his KevinMD article, “Medical aid in dying is not assisted suicide.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Roger Kligler. He’s an internal medicine physician, and he wrote the KevinMD article “Medical aid in dying is not assisted suicide.” Roger, thanks for being on the show.

Roger Kligler: You’re very welcome. Thanks for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Roger Kligler: OK. As you said, I’m an internal medicine physician. I started out in Brockton, which is a majority-minority community, in 1982. It was a very different time. There was no such thing as hospitalists; I kind of did it all. I’d start out in the morning in the hospital, go to the office, maybe run back and forth if someone was crashing in the unit, finish my office hours, and go back to the hospital. I also took care of patients in nursing homes. It was certainly a different time. I always enjoyed working with my patients at the end of life and would often take care of them when they were on hospice. There was no such thing as palliative care, and it was something that I didn’t shy away from. I try to help my patients with their end of life.

I developed cancer when I turned 50, so I’m now 68, and I’ve had it for 18 years. It’s metastatic. I’m now at a terminal phase with castrate-resistant prostate cancer. I needed to retire about, almost, six years ago because of medical, and as coincidence would have it, I went to a talk on medical aid in dying a week after I retired, and I said, “This is something that I really believe in. I want to work on it.” I’ve been working on it extensively. Your guests can Google me; I have many written articles that are out there, as well as other podcasts. And so I’m working towards getting legislation in Massachusetts so that we can have medical aid in dying authorized here. It’s currently available in 10 different jurisdictions. But anyway, I’ve been working on that, and we’ll get into that more later.

I have multiple medical problems. Just about every organ system for me is involved in one way or the other with the medical condition, so I’ve really learned the importance of medical care, and of dealing with doctors and trying to determine what care is appropriate and what care is not.

Kevin Pho: So let’s talk about your KevinMD article, which will go into a lot of the issues that you mentioned, “Medical aid in dying is not assisted suicide.” Now, for those who haven’t read that article, can you walk my audience through it and maybe share the story of why you decided to write it?

Roger Kligler: OK. Well, I wrote it because Dr. Minford had written an article saying that she had been a proponent of assisted suicide, and then she realized that she was not, because she believes in reincarnation. She talked about problems with religious philosophies, and I just felt that this was someone who really didn’t understand what medical aid in dying is.

Now, many doctors don’t know what medical aid in dying is, so I’m going to give you a really quick definition so that we’re all on the same page. Medical aid in dying is the ability of an adult, capable individual who’s terminally ill with a six-month life expectancy, so that’s a hospice definition, to be able to get medication to be able to end their life at a time of their choosing if their suffering becomes too severe. This is something that, as I said, is available in 10 jurisdictions in the country. I use the word “jurisdictions” instead of “states” because of Washington, D.C. And it covers about 22 percent of the country. Most Americans, and in poll after poll, most physicians, are in favor of having this. Basically, it allows the individual, in consultation with a couple of physicians, to be able to determine that they are not doing well, that their life is too onerous to them to continue, and that they want to end it. And they can do it quickly by swallowing medication that puts them to sleep, and they’re able to die in their sleep without further suffering.

Kevin Pho: Now, in your article, you make the distinction between medical aid and assisted suicide. Can you expound on that?

Roger Kligler: Sure. So suicide is usually done by someone with psychological problems who has no terminal illness, usually, that’s causing them to die, and they just decide that their life isn’t worth living. Medical aid in dying is for someone who’s going to die; it’s a question of whether it’s today, or in a week, or a few days from now, and they’re suffering.

So there are a couple of examples that help to distinguish this. For example, on 9/11, people jumped off the World Trade Center. The medical examiner had to determine their cause of death. Did they commit suicide because they jumped off a building? No. You determined that they died as an act of terrorism. The same thing goes with medical aid in dying. These are terminal people. They’ve gone through all the treatment that they’re going to. They have nothing to look forward to. They know today is the best day of the rest of their life, that tomorrow and tomorrow and tomorrow are just going to be worse, and they’ve decided that they don’t really want to go through that suffering. And there’s no need for them to go through that suffering. It doesn’t do anyone any good, or the individual.

And it’s completely optional. So it’s optional for the patient, the person. It’s optional for the physician to be involved, so if people have religious convictions that say, “I can’t help you,” all the laws say you can opt out. You don’t abandon your patient, but you can opt out, and another physician can write the prescription. People don’t have to use the medication after they get it, so about a third of people who get the prescription don’t use it, and it’s a very small number of people who end up using it. It’s approximately three to four out of a thousand deaths per year. So it’s there for some people who want to be able to avoid suffering, and it brings relief to many people.

It also improves the quality of medical care across the board. Most physicians are uncomfortable talking about death, and what this does is it kind of brings our game up to where it should be. In medical school, I don’t know, you went after I did, but being taught about death and how to deal with end-of-life issues was not covered at all. And so you need to be able to start talking about these issues with your patients, and you can find out what are the issues that are going on with people, and how can I help them. Not everyone needs medical aid in dying, but it increases the discussions that physicians have with their patients. It markedly increases the use of hospice and palliative care, and it helps people to decide when they’re getting too much care. As many of your listeners probably know, hospice extends life expectancy by over a month over usual medical care. So there’s something wrong here, that we as a profession are not helping our patients to make the decisions that will help them to live longer and healthier lives, but rather helping them to get more and more treatments, which aren’t always in their best interest.

Kevin Pho: Now, can you share a common scenario in the states where medical aid in dying is legal?

Roger Kligler: OK. So approximately 40 percent of people talk with their families about medical aid in dying when they have a terminal illness. About 17 percent will discuss it with their physicians, about 2 percent will ask, and about six in a thousand will get a prescription for medical aid in dying. They’ll usually have it, I think; the average is about 45 days, and I may be a little bit off on this, between when the process starts and when they get a prescription and take it.

The medications have changed. There is no single medication in any of the legislation, and it’s gone from Seconal to pentobarbital to drug combinations, as these drugs have not been able to be obtained anymore. Hopefully they will, but who knows. People fall asleep in minutes, and they end up dying in less than an hour, on average. Occasionally, people have GI intolerance to the medications. Rarely, people wake up afterwards, mainly because of problems with absorption or the GI tract. Many of your listeners know that people who are in the end stages of life often can’t tolerate anything in their stomachs, and they have problems with absorption, etc., with this. But no one has been harmed by it. There has been no coercion. It can only be done by the person who is taking the medication. If they’re not capable of making a decision for themselves, no one else can do it.

Kevin Pho: So you mentioned 10 states and jurisdictions across the country have medical aid in dying legislation, and you’re working on getting legislation through Massachusetts. Can you tell me about the state of the opposition, and what are some of the reasons the opposition pushes back against this?

Roger Kligler: So a lot of it is religious opposition. We had an initiative in 2012, and the Catholic Church came down strongly on the side of the opposition. They dumped in $5 million. It was underfunded. They had misleading ads. So that’s a major opposition.

Kevin Pho: Where do you see the next three to five years being in terms of medical aid in dying legislation going forward?

Roger Kligler: Last year, New Jersey and Maine passed their laws. We’re still potentially having medical aid in dying legislation pass this year in Massachusetts; they’re still in session. The bill’s on hold right now, mainly because of COVID things. There were 20 states where legislation was filed in 2020, and it generally takes about 10 years for the process to unfold. So this isn’t an overnight thing. It takes a lot of lobbying and talking. I mean, it’s happening in New Hampshire as well, which is where I know you’re practicing medicine, and it takes people to work on it.

Brittany Maynard was a young woman in 2014. She was 29. She developed glioblastoma and ended up dying. She knew she was going to die, she knew it was going to be a horrible death, and she moved to Oregon, and she really lit up the media on this issue. After seeing her and her example, I felt that I could help with this, and many of the other physicians who are involved can help with this as well, by joining Compassion and Choices, volunteering to be storytellers.

I’m sure that you’ve seen people who have died in less than optimal circumstances. I’ve had people to whom I’ve had to give palliative sedation because we couldn’t get their pain under adequate control. I watched friends die wanting to have medical aid in dying, and my mother and father-in-law both died of really bad cancers and suffered quite a bit, and I decided that I just wasn’t going to want to die that way.

Kevin Pho: We’re talking to Roger Kligler. He’s an internal medicine physician, and he wrote the KevinMD article “Medical aid in dying is not assisted suicide.” Roger, I have a lot of clinicians who listen to this podcast. From a palliative care standpoint, are there any lessons that you could share with them?

Roger Kligler: Hopefully your palliative care physicians are really, really good at this already, but it’s mainly listening to the person and seeing what their suffering is. People are going to die, and I think there’s a realization of that, especially in the palliative care world. But it should be up to the individual to decide when their suffering is too bad for them to handle, and not up to the physician. The physician shouldn’t be telling them how to live their lives and what’s important to them.

The other thing is to really look at what we’re talking to our patients about and make sure that we don’t overtreat our patients. Sometimes the third chemo is not the best idea, and while the person may have a 5 percent chance of living a longer life with it, they have a much larger chance of suffering and not living as long as they otherwise would, and with a lesser quality of life.

I used to try to talk with my patients about what was important to them, and try to have them understand that they’re still alive, and what are the things that bring them joy in life? Because we’re all going to be dead in a hundred years, and there’s no debating that at all. So what are the things that you want to do that kind of bring you joy while you’re still here, and not to focus on their bad part, on their disease? But at some point, that just ends for many, many people. I mean, 25 percent of people die with uncontrolled pain; 21 percent of people die with uncontrolled shortness of breath at the end. That’s not something that most people would find acceptable. And so, having another option, rather than having to last my last week or a few weeks: I have prostate cancer, and usually the last three months of that are pretty bad. I have a good pain tolerance, but I don’t know that I really want to be suffering at the end.

Kevin Pho: And my final question, Roger: What is your take-home message that you want to leave with the KevinMD audience?

Roger Kligler: My take-home message is that medical aid in dying should be available to everyone in this country, so that people who are dying have an option, a different way to die, and that they have the ability to have their voices heard by the medical community.

Kevin Pho: Roger, thank you so much for sharing your story and insight, and thanks again for being on the show.

Roger Kligler: Very welcome. Thanks for having me, Kevin.

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