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Aging: Change and Adaptation Death and Dying April 8, 2003.

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1 Aging: Change and Adaptation Death and Dying April 8, 2003

2 Euthanasia: “a good death” Voluntary, active euthanasia: at the patient’s request, a physician or someone else causes the person’s death, for example, by administering a lethal injection.

3 Euthanasia Attitudes “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it?”

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5 Physician-assisted suicide The patient causes his/her own death, i.e., commits suicide using means--usually a lethal dose of medication--provided by a physicianThe patient causes his/her own death, i.e., commits suicide using means--usually a lethal dose of medication--provided by a physician Euthanasia: someone else causes the deathEuthanasia: someone else causes the death PAS: the patient causes his/her own deathPAS: the patient causes his/her own death

6 Suicide Attitudes “Do you think a person has the right to end his or her own life if this person has an incurable disease?”“Do you think a person has the right to end his or her own life if this person has an incurable disease?”

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8 Autonomy A person is autonomous if he/she is self- governing, capable of making decisions, and fixing a course of action in the absence of controlling constraintsA person is autonomous if he/she is self- governing, capable of making decisions, and fixing a course of action in the absence of controlling constraints It involves self-determination, freedom, independence, liberty of choice and actionIt involves self-determination, freedom, independence, liberty of choice and action

9 Autonomy It refers to human agency free of outside intervention and interference.It refers to human agency free of outside intervention and interference.

10 Other Perspectives Beneficence: The ethical obligation to minimize pain and suffering, to reduce and remove harms, and to bring about benefits to an individual.Beneficence: The ethical obligation to minimize pain and suffering, to reduce and remove harms, and to bring about benefits to an individual. Nonmaleficence: Do no harmNonmaleficence: Do no harm Justice: What principles should guide the allocation of scarce resources?Justice: What principles should guide the allocation of scarce resources?

11 Chronology of Recent Developments 1991: Washington’s Initiative : Washington’s Initiative 119 Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in-dying?Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in-dying?

12 Aid in dyingAid in dying “a medical service, provided in person by a physician,“a medical service, provided in person by a physician, that will end the life of a conscious and mentally competent qualified patient...

13 in a dignified, painless, and humane manner,in a dignified, painless, and humane manner, when requested voluntarily by the patient through a written directive.”when requested voluntarily by the patient through a written directive.” Defeated: 54-46%Defeated: 54-46%

14 1992: California’s Proposition : California’s Proposition 161 Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in dying?Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in dying?

15 Aid in dyingAid in dying “a medical procedure that will terminate the life of the qualified patient“a medical procedure that will terminate the life of the qualified patient in a painless, humane, and dignified manner,...in a painless, humane, and dignified manner,...

16 whether administered by the physician at the patient’s choice or direction orwhether administered by the physician at the patient’s choice or direction or whether the physician provides means to the patient for self- administration.”whether the physician provides means to the patient for self- administration.”

17 Defeated: 54-46%Defeated: 54-46% 1994: Oregon’s Ballot Measure 16 - The Oregon Death with Dignity Act1994: Oregon’s Ballot Measure 16 - The Oregon Death with Dignity Act

18 Shall law allow terminally ill adult Oregon patients voluntary informed choice to obtain a physician’s prescription for drugs to end life?Shall law allow terminally ill adult Oregon patients voluntary informed choice to obtain a physician’s prescription for drugs to end life?

19 The Oregon Death with Dignity Act RequirementsRequirements The patient must be 18, terminally ill (having less than 6 months to live), and an Oregon resident.The patient must be 18, terminally ill (having less than 6 months to live), and an Oregon resident. The patient must voluntarily make an oral request...The patient must voluntarily make an oral request...

20 to the attending physician for a prescription for medication to end his or her life.to the attending physician for a prescription for medication to end his or her life. A 15-day waiting period then begins.A 15-day waiting period then begins.

21 The attending physician makes sure the patient understands the diagnosis and prognosis.The attending physician makes sure the patient understands the diagnosis and prognosis. The patient is informed of all options, including pain control, hospice care, and comfort care.The patient is informed of all options, including pain control, hospice care, and comfort care.

22 The attending physician also must inform the patient of the risks and expected result of taking the medication.The attending physician also must inform the patient of the risks and expected result of taking the medication. The attending physician…The attending physician…

23 determines whether the patient is capable of making health care decisions and is acting voluntarily;determines whether the patient is capable of making health care decisions and is acting voluntarily; encourages the patient to notify his or her next of kin;encourages the patient to notify his or her next of kin;

24 informs the patient that he or she can withdraw the request for medication at any time and in any manner;informs the patient that he or she can withdraw the request for medication at any time and in any manner;

25 refers the patient to a consulting physician who is asked to confirm the attending physician’s diagnosis and prognosis.refers the patient to a consulting physician who is asked to confirm the attending physician’s diagnosis and prognosis.

26 The consulting physician also decides whether the patient is capable of making the decision and is acting voluntarily.The consulting physician also decides whether the patient is capable of making the decision and is acting voluntarily. If either or both physicians believe the patient is suffering...If either or both physicians believe the patient is suffering...

27 from a psychiatric or psychological illness or depression that causes impaired judgment, the patient will be referred for counseling.from a psychiatric or psychological illness or depression that causes impaired judgment, the patient will be referred for counseling.

28 Once the preceding steps have been satisfied, the patient voluntarily signs a written request witnessed by two people.Once the preceding steps have been satisfied, the patient voluntarily signs a written request witnessed by two people. At least one witness cannot be a relative or an heir of the patient.At least one witness cannot be a relative or an heir of the patient.

29 The patient then makes a second oral request to the attending physician for medication to end his/her life.The patient then makes a second oral request to the attending physician for medication to end his/her life.

30 The attending physician again informs the patient that he or she can withdraw the request for medication at any time and in any manner.The attending physician again informs the patient that he or she can withdraw the request for medication at any time and in any manner.

31 No sooner than 15 days after the first oral request and 48 hours after the written request, the patient may receive a prescription for medication to end his or her life.No sooner than 15 days after the first oral request and 48 hours after the written request, the patient may receive a prescription for medication to end his or her life.

32 The attending physician again verifies at this time that the patient is making an informed decision.The attending physician again verifies at this time that the patient is making an informed decision. SafeguardsSafeguards

33 Immunity: Physicians who prescribe medication for a terminally ill patient to end his or her life would be protected from civil or criminal liability. Physicians are not obligated to participate.Immunity: Physicians who prescribe medication for a terminally ill patient to end his or her life would be protected from civil or criminal liability. Physicians are not obligated to participate.

34 Residency requirements: Only requests made by Oregon residents may be granted. Physicians must be licensed in Oregon.Residency requirements: Only requests made by Oregon residents may be granted. Physicians must be licensed in Oregon.

35 Reporting requirements: Each year, the Oregon Health Division must review a sample of records of deaths that occur under this law.Reporting requirements: Each year, the Oregon Health Division must review a sample of records of deaths that occur under this law.

36 Effect on insurance or annuity policies: A qualified patient’s act of ingesting medication to end his or her life will not have an effect upon a life, health, or accident insurance or annuity policy.Effect on insurance or annuity policies: A qualified patient’s act of ingesting medication to end his or her life will not have an effect upon a life, health, or accident insurance or annuity policy.

37 A qualified person who takes medication to end his or her own life will not have his/her insurance policies affected -- even if those policies specify that death by suicide is not covered.A qualified person who takes medication to end his or her own life will not have his/her insurance policies affected -- even if those policies specify that death by suicide is not covered.

38 Liabilities: Coercion of a patient, altering or forging a request for medication or concealing a withdrawal of that request, with the effect of causing the patient’s death, are Class A felonies.Liabilities: Coercion of a patient, altering or forging a request for medication or concealing a withdrawal of that request, with the effect of causing the patient’s death, are Class A felonies.

39 Passed 51-49% by a margin of 32,000 votes on Nov. 4, Passed 51-49% by a margin of 32,000 votes on Nov. 4, On Dec. 8, 1994: District Court issues a temporary injunction preventing the law from going into effect. On Dec. 8, 1994: District Court issues a temporary injunction preventing the law from going into effect.

40 On Dec. 28, 1994: injunction continuedOn Dec. 28, 1994: injunction continued “Surely, the first assisted suicide law in this country deserves a considered thoughtful constitutional analysis.”“Surely, the first assisted suicide law in this country deserves a considered thoughtful constitutional analysis.”

41 Aug. 3, 1995: law ruled unconstitutionalAug. 3, 1995: law ruled unconstitutional “There is little assurance that only competent terminally ill persons will voluntarily die.“There is little assurance that only competent terminally ill persons will voluntarily die.

42 Some ‘good results’ cannot outweigh other lives lost due to unconstitutional errors and abuses.”Some ‘good results’ cannot outweigh other lives lost due to unconstitutional errors and abuses.”

43 Ruling overturned in Feb., 1997 by the US Court of Appeals and the US Supreme Court on October 14, 1997.Ruling overturned in Feb., 1997 by the US Court of Appeals and the US Supreme Court on October 14, 1997.

44 Both courts held that the persons who brought the challenge were not in good standing, i.e., were not immediately affected or threatened by the law.Both courts held that the persons who brought the challenge were not in good standing, i.e., were not immediately affected or threatened by the law. Oregon legislature asks voters to vote on the proposed law again.Oregon legislature asks voters to vote on the proposed law again.

45 In November, 1997: the original law passed again by a margin of 60% to 40%.In November, 1997: the original law passed again by a margin of 60% to 40%.

46 Oregon’s Physician-Assisted Suicide Law Update

47 Legal and LegislativeChallenges

48 Pain Relief Promotion Act June 1999—Introduced in U.S. House by Hyde, Stupak, & NicklesJune 1999—Introduced in U.S. House by Hyde, Stupak, & Nickles –Would prohibit use of federally controlled drugs for PAS

49 Pain Act, cont. –Encourages aggressive pain management for dying –Would impede or stop PAS under Oregon’s law

50 PAS Act, cont. October 27, 1999—U.S. House votes 271–156 to pass the Pain Relief Promotion ActOctober 27, 1999—U.S. House votes 271–156 to pass the Pain Relief Promotion Act Pain Relief Promotion Act has since languished in the U.S. Senate and has not been reported out of the Committee on Health, Education, Labor, and PensionsPain Relief Promotion Act has since languished in the U.S. Senate and has not been reported out of the Committee on Health, Education, Labor, and Pensions

51 Attorney General Ashcroft Nov. 6, 2001Nov. 6, 2001 Doctors who prescribe drugs to hasten the death of terminally ill patients are in violation of the federal Controlled Substances Act.Doctors who prescribe drugs to hasten the death of terminally ill patients are in violation of the federal Controlled Substances Act.

52 Court Ruling April 17, 2002April 17, 2002 U.S. District Court Judge Robert JonesU.S. District Court Judge Robert Jones The 11/6 directive “…is not entitled to deference under any standard and is invalid.”The 11/6 directive “…is not entitled to deference under any standard and is invalid.”

53 Court Ruling (cont.) “The fact that opposition to assisted suicide my be fully justified-- morally, ethically, religiously, or otherwise--does not permit a federal statute to be manipulated from its true meaning to satisfy even a worthy goal.”“The fact that opposition to assisted suicide my be fully justified-- morally, ethically, religiously, or otherwise--does not permit a federal statute to be manipulated from its true meaning to satisfy even a worthy goal.”

54 PAS So Far

55 Oregon State Statistics PatientsPatients –91 received and used lethal prescriptions –out of 117,896 deaths –1/1,296 deaths (.08%)

56 Statistics, cont. VitalsVitals –44 Men –47 Women –97% were white –Median age—69

57 Statistics, cont. IllnessIllness –Cancer: 70 –ALS: 7 –COPD: 7 –Other: 7

58 Statistics, cont. Educational LevelEducational Level –Some high school: 10 –High school graduate: 42 –College graduate: 39

59 Statistics, cont. Reasons identifiedReasons identified –Loss of autonomy: 74 –Inability to participate: 67 –Loss of bodily control: 55 –Burden on others: 30 –Inadequate pain control: 18

60 Statistics, cont. InsuredInsured –Private: 65 –None: 1 Place of deathPlace of death –Home: 82 –Hospital: 1

61 Statistics, cont. Minutes between ingestion and unconsciousness: median = 5Minutes between ingestion and unconsciousness: median = 5 Minutes between ingestion and death: median = 30Minutes between ingestion and death: median = 30

62 Vermont Death with Dignity Act

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