Presentation on theme: "The History of Physician-Assisted Suicide and the True Oregon Experience www.pccef.org Title of your talk Insert your name and position."— Presentation transcript:
1The History of Physician-Assisted Suicide and the True Oregon Experience Title of your talkInsert your name and position
2Definitions Euthanasia: Physician-assisted suicide: Death caused by an intentionally lethal dose of medication ordered by a physician and administered by a physician or nurse.Voluntary: with patient awareness and consentInvoluntary: without patient awareness or consentPhysician-assisted suicide:Death caused by an intentionally lethal dose of medication ordered by a physician and self-administered by a patient.Define euthanasia and assisted suicide.Note that from the physician perspective :ordering a lethal dose of medication, there is no difference between the two. The only difference is in who delivers the medication
3Why Physician-Assisted Suicide? Experience of a tragic deathWitness of terrible sufferingFear about suffering and painFear about loss of controlFear of being a burdenFear of the loss of “Dignity”Depression at end of lifeThere are many reasons why people might rationally choose assisted suicide.Most of the physician-assisted suicide cases in Oregon are associated with concerns about loss of autonomy and control, not fear of pain or suffering. In the Netherlands, loss of control and "tiredness of life" were much more commonly reported than pain as the reasons for requesting euthanasia.The suffering of patients at the end of life can be great (somatic symptoms, such as pain and nausea, or psychological conditions, such as depression and anxiety. It encompasses interpersonal suffering due to dependency on other persons or to unresolved interpersonal conflicts, or existential suffering based on a sense of hopelessness, indignity, or the belief that one's life has ended in a biographical sense but not yet ended biologically.Often, many aspects of suffering cannot be satisfactorily controlled with standard pharmacologic or surgical interventions. Many proponents of assisted suicide have argued that trust is eroded when physician-assisted suicide is not an option, or an option for discussion, in these circumstances. Physician-assisted suicide is, in this view, an act of compassion that respects patient choice and fulfills an obligation of non-abandonmentPositions in favor of legalizing physician-assisted suicide are related to the contemporary trend toward emphasizing patient autonomy in bioethics and law. It is argued that the decision to end one's life is intensely personal and private, harms no one else, and ought not be prohibited by the government or the medical profession
4Suffering vs. Pain Pain: physical, social, psychological, or spiritual Suffering: distress that is perceivedIncreased sufferingLoss of controlSource of pain is unknown or meaning is direPain is chronic or can’t be controlledDecreased sufferingWhen pain is understood (childbirth, sciatica, trauma)Minor pain + uncertainty = great sufferingConcern about future is a key feature of sufferingMany suffer not only from disease but also from its treatment. One cannot anticipate sources of suffering, you need to ask. Many conditions are painful, upsetting, uncomfortable, and distressing, but not a source of suffering. In the care of the dying, patients and their friends and families do not make a distinction between physical and nonphysical sources of suffering in the same way that doctors do. We have a mind-body dichotomy in our medical theory. Suffering is experienced by the person and in the separation between mind and body, the concept of the person, or personhood, has been associated with that of mind, spirit, and the subjective. However, “Personhood” has many facets (personality, life experiences, family ties, cultural background, roles (personal, social, family, etc), relationships, behaviors, dreams, and aspirations. It is ignorance of them that actively contributes to patients' suffering.Patients report suffering when one does not expect it, or do not report suffering when one does expect it. Furthermore, a person can suffer enormously at the distress of another, especially a loved one. Suffering can occur in relation to any aspect of the person, whether it is in the realm of social roles, group identification, the relation with self, body, or family, or the relation with a transcendent source of meaning. Pain causes suffering when patients feel out of control, when the pain is overwhelming, when the source of the pain is unknown, when the meaning of the pain is dire, or when the pain is chronic. In all these situations, persons perceive pain as a threat to their continued existence - not merely to their lives, but to their integrity as persons.We can relieve the suffering, even in the presence of continued pain, by making the source of the pain known, changing its meaning, and demonstrating that it can be controlled and that an end is in sight. Suffering has a temporal element. Fear itself always involves the future and suffering goes away when the future is not a major concern. Suffering can occur-when physicians do not validate the patient's pain.Suffering may be expressed by sadness, anger, loneliness, depression, grief, unhappiness, melancholy, rage, withdrawal, or yearning. The only way to learn whether suffering is present, is to ask the sufferer. We all recognize certain injuries that almost invariably cause suffering: the death or distress of loved ones, powerlessness, helplessness, hopelessness, torture, the loss of a life's work, betrayal, physical agony, isolation, homelessness, memory failure, and fear.Persons are able to enlarge themselves in response to damage, so that instead of being reduced, they may indeed grow. This response to suffering has encouraged the belief that suffering is good for people. To some degree, and in some persons, this may be so. The ability to recover from loss without succumbing to suffering is sometimes called resilience. Recovery from suffering often involves help, as though people who have lost parts of themselves can be sustained by the personhood of others until their own recovers. This is one of the latent functions of physicians: to lend strength. A group, too, may lend strength, consider the success of groups of the similarly afflicted in easing the burden of illness.
5Limiting extreme suffering: Principle of Double Effect An action that causes harm (such as the death of a human being) is permissible as a side effect of promoting some good end, ifAct itself is goodIntention is for the good effectGood outweighs the badGood effect is not caused by the bad effect (i.e., the bad is a side effect)The principle of double effect (PDE) or doctrine of double effect (DDE), sometimes simply called double effect for short, is a thesis in ethics, usually attributed to 13th Century Philosopher Thomas Aquinas ( ) The principle seeks to explain under what circumstances one may act in a way that has both good and bad consequences (a "double effect").It states that an action having an unintended, harmful effect (e.g., an early death) is defensible on four conditions as follows:the nature of the act is itself good, or at least morally neutral;the intention is for the good effect and not the bad;the good effect outweighs the bad effect in a situation sufficiently grave to merit the risk of yielding the bad effect (e.g., risking a patient's death to stop intolerable pain);the good effect (relieving pain) does not go through the bad effect (e.g., death).A fifth condition is sometimes added:that the bad effect must be at least as causally distant from the act as is the good effect.Thomas Aquinas: discussion of the permissibility of self-defenseSumma Theologica (II-II, Qu. 64, Art.7)
6An Example of “Double Effect” End-stage lung cancerShortness of breathChest discomfortExtreme anxietyAdminister IV morphineEasier breathing, decreased painMuch less anxiety, now relaxedThis is good medical careMay hasten death, but this was not the intentionMany are confused about thisCase example:65 year old female with extensive lung cancer who is anxious, in pain, short of breath due to a large tumor burden in her chest.IV morphine, which is a pulmonary vaosdilator, anxiolytic, and pain reliever, is given in a small amount, or sometimes even a large amount if needed, and it helps with decreasing shortness of breath, lessens anxiety, decreases pain, patient is more relaxed.This may hasten death, however, it is primarily about treating symptoms, and is not PURPOSEFULLY causing death. This is excellent medical care.Many are confused about this and fear morphine at end of life.
7“Life-Support”: a Separate Issue Artificial Administration Nutrition & Hydration (AAHN) is a separate issueNasogastric tube feeding or a direct gastric tubeArtificial breathing or ventilator support (breathing machine)Cardio-pulmonary resuscitation (DNR order)These issues are related and very important topics and each is worthy of a separate discussionToday’s discussion: physician-assisted suicide (direct and intentional medical killing)Try to not get side-railed by other very important end-of-life issues. The Terry Schaivo case has raised many concerns, but try to focus the talk on the issue of assisted suicide.
8For over 2400 years the medical profession has withstood the allure of promoting death.
9Historical Perspective Ancient Greece and Rome (500 B.C.)Tolerant of infanticide and active euthanasiaHippocrates, the Father of Medicine (460–370 B.C.)Hippocratic Corpus (collection of medical works)“The physician must be able to tell the antecedents, know the present, and foretell the future, must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.”*Hippocrates of Kos (c. 460 BCc. 380 BC) was an ancient Greek physician. He has been called "the father of medicine", and is commonly regarded as one of the most outstanding figures in medicine of all time.Writings attributed to him (Corpus hippocraticum, or "Hippocratic writings") rejected the superstition and magic of primitive "medicine" and laid the foundations of medicine as a branch of science. Little is actually known about Hippocrates's personal life, but some of his medical achievements were documented by such people as Plato and Aristotle.The Hippocratic writings introduced patient confidentiality, a practice which is still in use today. This was described under the Hippocratic Oath and other treatises. Hippocrates recommended that physicians record their findings and their medicinal methods, so that these records may be passed down and employed by other physicians. Other Hippocratic writings associated personality traits with the relative abundance of the four humours in the body: phlegm, yellow bile, black bile, and blood, and was a major influence on Galen and later on medieval medicine.The Hippocratic Corpus is a collection of about sixty treatises, most written between 430 BC and AD 200. They are actually a group of texts written by several different people holding several different viewpoints erroneously grouped under the name of Hippocrates, perhaps at the Library of Alexandria. None of the texts included in the Corpus can be considered to have been written by Hippocrates himself, and one of them at least was written by his son-in-law Polybus. The best known of the Hippocratic writings is the Hippocratic Oath; however, this text was most likely not written by Hippocrates himself. A famous, time-honoured medical rule ascribed to Hippocrates is Primum non nocere ("first, do no harm"); another one is Ars longa, vita brevis ("art is long, and life short").*Of the Epidemics, Book I, Section II, Part V:
10Hippocratic Oath “I will follow that system of regimen, which, according to my ability,I consider for the benefit of my patientsand abstain from what is deleteriousand mischievous.I will give no deadly medicine to anyone if asked, nor suggest such counsel.”Hippocrates of Kos (c. 460 BCc. 380 BC) was an ancient Greek physician. He has been called "the father of medicine", and is commonly regarded as one of the most outstanding figures in medicine of all time.Writings attributed to him (Corpus hippocraticum, or "Hippocratic writings") rejected the superstition and magic of primitive "medicine" and laid the foundations of medicine as a branch of science. Little is actually known about Hippocrates's personal life, but some of his medical achievements were documented by such people as Plato and Aristotle.The Hippocratic writings introduced patient confidentiality, a practice which is still in use today. This was described under the Hippocratic Oath and other treatises. Hippocrates recommended that physicians record their findings and their medicinal methods, so that these records may be passed down and employed by other physicians. Other Hippocratic writings associated personality traits with the relative abundance of the four humours in the body: phlegm, yellow bile, black bile, and blood, and was a major influence on Galen and later on medieval medicine.The Hippocratic Corpus is a collection of about sixty treatises, most written between 430 BC and AD 200. They are actually a group of texts written by several different people holding several different viewpoints erroneously grouped under the name of Hippocrates, perhaps at the Library of Alexandria. None of the texts included in the Corpus can be considered to have been written by Hippocrates himself, and one of them at least was written by his son-in-law Polybus. The best known of the Hippocratic writings is the Hippocratic Oath; however, this text was most likely not written by Hippocrates himself. A famous, time-honoured medical rule ascribed to Hippocrates is Primum non nocere ("first, do no harm"); another one is Ars longa, vita brevis ("art is long, and life short").
11The Traditional View of the Doctor’s Role in Society was captured in this painting by Sir Luke Fildes “The Doctor” who was inspired by the death of his son and the professional devotion of Dr Gustavus Murray who treated him in the 1880’s.This work shows the moment when a child shows the first sign of recovery. The small child is central in the picture, in a white nightshirt on a large white pillow and covered with pale blankets. The makeshift bed consists of two unmatched dining room-type chairs. The child's hair is tousled and the left arm flung out, with hand supinated and beyond the edge of the pillow. Nonetheless, the child rests quite peacefully, as the pose appears quite natural.To the right and rear of the painting are the parents. They are placed in such deep shadows that it is frequently difficult to make out these figures in reproductions. The mother sits at a table and hides her face in her clasped hands. The father stands beside her, with a comforting hand on her shoulder, as he gazes at the physician.The painting is set in the interior of a small cottage. Rafters are low, furniture simple. Colors are muted; earth tones predominate. Although the majority of the light comes from the lamp, a bit of light also enters from the recessed window near the mother.This image of an ordinary doctor’s quiet heroism reflects the traditional role of the physician which is to care always, cure when, possible, and provide comfort.
12The Eugenics Movement 1883: Alexander Graham Bell 1907: Indiana law Forced sterilization of poor, mentally disabled, and “undesirable” citizens to improve humanity’s breeding stock1909: Washington eugenics lawForced sterilization of “feeble-minded, insane, epileptic, habitual criminal, degenerates, and sexual perverts.”After two millennia, in the late 19th and early 20th centuries, a Eugenics Movement again surfaced. One of the earliest advocates was Alexander Graham Bell, who presented a lecture about hereditary deafness and suggested that couples where both were deaf should not marry, in his lecture Memoir upon the formation of a deaf variety of the human race presented to the National Academy of Sciences in November 1833In 1907, Indiana was first state to adopt measures to sterilize, without consent, poor, mentally disabled, and so-called "undesirable" citizens in the name of improving humanity's breeding stock.The second state to pass eugenics laws was Washington, inspired by a proposed measure in Oregon. In 1909, Washington's law adopted similar language to allow forced sterilization of the "feeble minded, insane, epileptic, habitual criminal, degenerates, and sexual perverts."In the early 20th century, eugenics not only had mainstream support, including the endorsement of the U.S. Supreme Court, but this was on the cutting edge of progressive ideas for maintaining public health and welfare.Memoir Upon the Formation of a Deaf Variety of the Human Race. Publisher:Alexander Graham Bell Association for the Deaf, Inc., th St., N. W., Washington, D.C Publication Date:
13Eugenics in Oregon1917: Oregon State Board of Eugenics established.In total, 33 states adopted similar laws.“Eugenics represents the highest type of public health workand is the greatest service to the human race.Feeble-minded, paupers, criminals, insane, and morally degenerateare a burden to civilization economically and socially.Criminals are recruited mainly from certain families.Feeble-mindedness can usually be traced to heredity.”Washington’s sterilization law was overturned by the state Supreme Court in IN 1917, Oregon established a State Board of Eugenics, and Oregon's Eugenics law was on the books until the 1980s. We're generally horrified by this idea now — especially following the full application of eugenics practices by the National Socialist Party of Nazi Germany in the 1930’s. Hitler said U.S. eugenics and immigration laws gave him ideas for how to cleanse Germany.1921 Annual Report of the Oregon State Board of HealthMemoir Upon the Formation of a Deaf Variety of the Human Race. Publisher:Alexander Graham Bell Association for the Deaf, Inc., th St., N. W., Washington, D.C Publication Date:
15History of Assisted Suicide 1960: Euthanasia viewed as “choice”1980: Derek Humphrey forms “Hemlock Society”1990:Derek Humphrey’s best-selling book Final Exit stimulates a national “Right to Die” movementJack Kevorkian assists Oregonian Janet Adkins“Compassion in Dying” is founded and submits several assisted-suicide ballots in Washington and California1994: the Oregon “Death with Dignity” Act passesNo other legislation has passed despite attempts in dozens of states, UK, and Canada.
16The Oregon AnomalyWhy have no other states followed Oregon’s example? Why is Oregon’s social experiment failing to influence other political jurisdictions? To use a medical analogy, here in the United States assisted suicide remains a “local infection” confined to Oregon while its harmful effects are becoming more widely know. Perhaps the presence of assisted suicide in Oregon is providing an “immunologic response” which is keeping this harmful infection from spreading. Learning from the Oregon experience, leaders across the world are recognizing that it is better to put efforts into promoting palliative and hospice care rather than to give doctors the legal right to directly and intentionally kill patients.
17Oregon’s “Death with Dignity” Act After patient request for a deadly prescription:Second opinion required (can be done over phone)2-week waiting period prior to fillingDoctor writes prescription, usually barbituratesBarbiturates: sedatives commonly used by anesthesiologists for surgeries
18Oregon’s “Death with Dignity” Act No peer-reviewDoctor protected from civil lawsuitReporting is voluntaryThe law provides for doctor-ordered,doctor-prescribed, and doctor-directedsuicide
19The Romanticized View of Oregon’s DWDA The Exploitation of an Oregon Physician-Assisted Suicide, a “media-orchestrated event”.Lovelle Svart died of physician-assisted suicide on September 28, 2007 in Portland, Oregon, from an overdose of barbiturates.She was a 62-year old retired newspaper librarian for The Oregonian. She had a 5 year-history of lung cancer. An article in June 1, 2004 The New York Times newspaper, which included her photo and statement, reported that as of that date she had already registered for Oregon’s Death with Dignity law. This was 40 months before she died. Her last three months were chronicled in print and video blog by The Oregonian newspaper. She died in a Portland, Oregon assisted-living center where she had lived with her mother.She was the first to admit that she liked being in control. She was starting to have problems with swallowing and had started taking pain medication. She did not look deathly ill. In the video blog of her last day she said “I look healthier than I did 10 years ago.” She had invited some family and friends to be with her on the day she died. In the few hours prior to taking the overdose she danced the polka with George Eighmey, Executive Director of the pro-death Compassion & Choices organization. George Eighmey told The Oregonian reporter he had attended more than three dozen deaths of this kind. When George asked Lovelle, “Is this what you really want to do?” her initial response was “Actually, I’d like to go on partying today, but yes”. At that time, George could have said, “Well, let us put this off for another day”, but he didn’t. She had taken anti-nausea medication a few hours before taking the lethal barbiturate solution at 5 pm. After drinking the lethal solution, she exclaimed, “Most godawful stuff I ever tasted in my life.” She was in a coma for 5 ½ hours before she died.The media coverage of Lovelle Svart’s last day is similar to the “exit party” of Karen Janoch of Eugene, Oregon on April 7, 2004, reported by James Estrin in The New York Times, June 1, 2004, D5. George Eighmey also supervised that death, and told that reporter it was the 25th doctor-assisted suicide he had attended. Lovelle Svart’s photo, comments and the reporting that she had registed under the Oregon physician-assisted suicide law were in an accompanying article on that date.Comments:George Eighmey, executive director of the pro-death Compassion & Choices organization, supervised her assisted suicide. He reported that he had attended more than three dozen deaths of this kind. Why is he attending/supervising so many of these assisted suicide deaths in Oregon?Her doctor and hospice personnel were conspicuously absent in the media articles and video blog.She reportedly had “registered” for the Oregon assisted suicide law over 40 months prior to her death, which far exceeds the 6-month expected life expectancy associated with a terminal prognosis that is required by the law.She died prematurely. In the video blog, she said she looked healthier than she had 10 years before. She had just started to take pain medication.She was enjoying her last day so much that she wanted to “go on partying” with family and friends.There was exploitation in this media-orchestrated-event by three parties: by Lovelle Svart, by George Eighmey of Compassion & Choices, and by The Oregonian newspaper.News Media Applaud ‘Death with Dignity’of Lovelle Svart1945–2007
20By asking for a "right to die“ Oregonians have given physicians Oregon’s “Death with Dignity Act”No rights for patientsLegal protection (civil and criminal) for physicians involved in medical killingIndependent verification not permittedWhat if they fail to treat depression?What if the patient is not mentally competent?What about influence of those with financial interest?What about coercion of the patient by family?No funding for state validation or enforcementBy asking for a "right to die“Oregonians have given physiciansa license to kill
21Assisted Suicide and the Vulnerable The Case of Kate Cheney d. 29 Aug 1999, age 85Mrs. Kate Cheney was an elderly Oregon woman with growing dementia and a diagnosis of a potentially terminal cancer. Her daughter, Erika, asked her primary physician for assisted suicide. This physician found the patient incompetent and denied this initial request. A second opinion was obtained by a psychiatrist who found that Mrs. Cheney had short-term memory deficits and dementia, and that this assisted suicide request appeared to be the daughter's "agenda.” The daughter, who also accompanied Mrs. Cheney to this appointment, "coached her" in her answers, even when the psychiatrist asked her not to do so. Concerning the patient, the psychiatrist observed, "She does not seem to be explicitly pushing for this." Thus, the psychiatrist concluded that the patient lacked sufficient capacity to weigh options about assisted suicide and she was ineligible for doctor-assisted suicide. The daughter, however, would not take ‘no’ for an answer, and sought a second mental health evaluation where the patient could not even remember when she was diagnosed with terminal cancer, although it had only been within the last three months. It was noted by this second mental health opinion that the patient's "choices may be influenced by her family's wishes and her daughter, Erika, may be somewhat coercive". The pressure directed at Ms. Cheney from her family was so great that her own motivations could not clearly be distinguished from those of her daughter's. Despite these facts, this Kaiser patient had a home visit by her “managed care” administrator who decided she was a good candidate for assisted suicide and sought out a physician who could write for a lethal prescription. Fifteen days later she died from this lethal barbiturate overdose, and this ‘psychiatric evaluation’ was no protection for her.“Kate’s choices may be influenced by her family’s wishes; and her daughter may be somewhat coercive.”— evaluating psychologist
22Assisted Suicide and Medical Care The Case of Michael Freeland History of suicide attemptsLung cancer; given a lethal prescriptionDoctor: attendant care at home needed, but…might be a "moot point" because he had “life-ending medication”Doctor who wrote lethal prescription did nothing to care for his pain and palliative care needsMichael Freeland, a 63-year-old cancer patient, had been haunted by thoughts of suicide since his early 20's when he made his first suicide attempt. In March 2000, his doctor diagnosed him with lung cancer and the following year he sought out, and was given a lethal dose of medication by a ‘Compassion & Choices’ physician. Subsequently, Mr. Freeland was hospitalized with depression and because of both suicidal and homicidal thoughts. The attending psychiatrist, declared that Mr. Freeland was incompetent and said "The guns are now out of the house, which resolves the major safety issue." Yet, the same report claimed, "He keeps this [the lethal barbiturate overdose] safely at home." Two weeks before his death, members of Physicians for Compassionate Care (PCC), an organization which promotes palliative care, found Mr. Freeland alone, in pain, dehydrated, and suffering from painful constipation. He was depressed, confused, and afraid to take his pain medication and was about to take the lethal overdose because of pain. He had called his suicide doctor and this “Compassion & Choices’ physician offered to sit with him while he took the lethal overdose. The PCC members, on the other hand, encouraged him to take his pain medication and arranged for 24-hour attendant and receive an infusion pump for better pain care. Several weeks later, Mr. Freeland died comfortably, just having reconciled with his daughter and without taking the lethal drugs.This seriously ill patient was receiving poor advice and medical care because he had lethal drugsHamilton & Hamilton, Am J Psychiat 2005;162:1060–5
23Assisted Suicide and the Slippery Slope Dr. Gallant saw an unconscious patient in the Corvallis Emergency Department who had suffered a stroke. The patient’s daughter decided that her mother would be better off dead and asked Dr. Gallant to remove life support. He did so but the patient kept breathing. He then gave serial doses of valium and morphine to this unconscious patient (in no pain) trying to stop her breathing. This didn’t work. Then he placed a magnet over her pacemaker in a deliberate effort to stop her heart. This, too, did not cause her to die. He then gave her a massive dose of succinylcholine, a drug that paralyzes all of the body’s muscles including the breathing muscles. This medication should not be given any patient unless breathing is supported artificially because it will paralyze all of the body’s breathing muscles, as it did in this case. The patient died within minutes of being deliberately and completely paralyzed by Dr. Gallant. The Oregon Board of Medical Examiners chose to reprimand Dr. James Gallant for unprofessional and dishonorable conduct and suspended his license for 60 days for engaging in active euthanasia with respect to his patient, Clarietta Day, who died as a result of a lethal injection administered by a nurse. Criminal charges were filed in connection with the patient's death, but were eventually dropped by the Lane County Prosecutor because he felt that he could not get a jury to convict. The Oregonian, in reporting on this act of involuntary euthanasia, called Dr. Gallant’s action a “case of assisted suicide”. This doctor continues to practice.Involuntary euthanasia (lethal injection)No criminal charges filedMedical license suspended for two months
24Assisted Suicide and Trust The Case of Mrs. Stevens Failing chemotherapy and radiation therapy for lymphomaPhysician offered ‘extra large’ amount of pain medsThe message: “Your life is no longer of value. You are better off dead.”This is a personal story of Dr. Ken Stevens. "We had been married for 18 years and had 6 children. For three years my wife had been suffering from advancing malignant lymphoma. It had spread from the lymph nodes to her brain, to her spinal cord and to her bones. She had received extensive chemotherapy and radiation treatments. She required considerable pain medication, antidepressants and other supportive measures. In late May, 1982, we met again with her physician to review what more could be done. It was obvious that there was no further treatment that would halt the cancer's progressive nature. As we were about to leave his office, her physician said, "Well, I could write a prescription for an 'extra large' amount of pain medication for you." He did not say it was for her to hasten her death, but she and I both felt his intended message. We knew that was the intent of his words. We declined the prescription. As I helped her to our car, she said, "He wants me to kill myself." She and I were devastated. How could her trusted physician subtly suggest to her that she take her own life with lethal drugs? We had felt much discouragement during the prior three years, but not the deep despair that we felt at that time when her physician, her trusted physician, subtly suggested that suicide should be considered. His subtle message to her was, "Your life is no longer of value, you are better off dead." Six days later she died peacefully, naturally, with dignity and at ease in her bed, without the suggested lethal drugs. Physician-assisted suicide does destroy trust between patient and physician
25Assisted Suicide and Trust The Case of Mrs. Stevens “We had felt much discouragementduring the prior three years,but neverthe deep despair that we felt at that timewhen her trusted physician suggested suicide.”This is a personal story of Dr. Ken Stevens. "We had been married for 18 years and had 6 children. For three years my wife had been suffering from advancing malignant lymphoma. It had spread from the lymph nodes to her brain, to her spinal cord and to her bones. She had received extensive chemotherapy and radiation treatments. She required considerable pain medication, antidepressants and other supportive measures. In late May, 1982, we met again with her physician to review what more could be done. It was obvious that there was no further treatment that would halt the cancer's progressive nature. As we were about to leave his office, her physician said, "Well, I could write a prescription for an 'extra large' amount of pain medication for you." He did not say it was for her to hasten her death, but she and I both felt his intended message. We knew that was the intent of his words. We declined the prescription. As I helped her to our car, she said, "He wants me to kill myself." She and I were devastated. How could her trusted physician subtly suggest to her that she take her own life with lethal drugs? We had felt much discouragement during the prior three years, but not the deep despair that we felt at that time when her physician, her trusted physician, subtly suggested that suicide should be considered. His subtle message to her was, "Your life is no longer of value, you are better off dead." Six days later she died peacefully, naturally, with dignity and at ease in her bed, without the suggested lethal drugs. Physician-assisted suicide does destroy trust between patient and physicianEven proponents don’t want their physicians to be in favor of doctor-assisted suicide
26Telling the truth about PAS in Oregon Five Oregonians to Remember The vulnerable are at riskPatients with dementia: Kate CheneyPatients with Depression: Michael FreelandChanging roles of doctors and nursesDoctors give lethal injection: Clarietta DayNurses now getting involved: Wendy MelcherIt doesn’t always workWaking up after 5 days: David PruittTwo other cases to discuss:Nurses are now getting into the act: The case of Wayne MelcherTwo nurses (Rebecca Cain and Diana Corson) gave an overdose to a patient, Wayne (Wendy) Melcher, who had throat cancer, who died in August 2005 as a result of the overdose of morphine and phenobarbital. They claimed Melcher had requested an assisted suicide, but they administered the drugs without her doctor’s knowledge in clear violation of Oregon’s law. One nurse admitted that she was following the “plan” that had been developed by the patient for his own suicide. The nurses acted independently without following hospice protocol or even asking for any physician directive or order in giving overdoses of two different drugs . This assisted suicide effort was never reported to the Oregon Health Division as is required by the assisted suicide law. As one of the nurses is reported to been having a relationship with Melcher’s significant other, there is a clear conflict of interest. After this action of direct and intentional medical killing, these two nurses continue to practice in the State of Oregon. No criminal charges have been filed against the two nurses, perhaps because of the good faith standard in the Oregon law.Attempts at assisted suicide are failing: The case of David PruittDavid Pruitt, a man from Oregon with lung cancer, obtained from a physician the standard lethal overdose by prescription, and when he felt it was time, he took the entire amount. He went to sleep for 65 hours and woke up saying “What the hell happened? Why am I not dead?” He was so unnerved by the experience that he didn’t want to go through it again. He died naturally nearly two weeks later.
27Assisted Suicide in Oregon: Truth No Safeguards No requirement for mental health examinationNo requirement for family notificationNo mechanism for reporting pressure on patients or penalty for failure to report undue influence
28Assisted Suicide in Oregon: Truth No Safeguards No standard of careLegal protection for “good faith” lethal prescribingNegligence unlikely to be prosecuted (surviving parties may gain financially)
29Assisted Suicide in Oregon: Truth Its about Money Finances are driving the decision makingMed Director of Kate Cheney’s HMO wrote her prescription after 2 of her MD’s declined.Oregon Medicaid pays for physician-assisted suicide, but denies payment for surgery, radiation therapy and chemotherapy for cancer patients with < 5% 5-year survival, even when such treatment may prolong survival and improve function.Oregon’s QualMed HMO pays for physician-assisted suicide (cost approx. $50), but has a cap on hospice care.In February 2005, I [Dr. Kenneth Stevens]became aware that essentially all of the cancer diagnostic categories for the October 1, 2004 Prioritized List of Health Services for the Oregon Health Plan had added the following statement: “Where treatment will result in a greater than 5% 5-year survival.” I sent a letter regarding this to Tom Turek, M.D., Medical Director of Office of Medical Assistance Programs (OMAP), Department of Human Services, State of Oregon. In my letter I indicated that I felt that many patients who had a less than 5-% 5-year survival, benefited from with surgery, radiation therapy and chemotherapy. I told him that patients with advanced pancreatic cancer or patients with brain cancer with a less than 5% 5-year survival may have prolonged survival and improved function with such treatment.“Thank you for your recent letter regarding the Oregon Health Plan. You are correct in that the phrase “where treatment will result in a greater than 5% 5-year survival was not noted on those lines [in prior years]. It was put there to remind physicians what had been implied on those lines since the beginning of the Oregon Health Plan. There has always been a line (693-cancer of various sites where treatment will not result in a 5% five-year survival) that has been in the legislatively non-funded portion of the list.”His written response to me on Feb. 23, 2005 included the following:The html information for the current April 2008 Prioritized List is: . Cancer diagnoses are listed as line items 124-Testis, 125-Eye & Orbit, 145-Cervix, 160-Choriocarcinoma, 168-Colon, Rectum, Small Intestine, Anus, 198-Breast (I have included the statement in the current Prioritized list, showing the statement “where treatment will result in a greater than 5% 5-year survival”, 208-Soft Tissue, 209-Bone, 219-Uterus, 221-Thyroid, 229-Kidney, 230-Stomach, 243-Malignant Melanoma, 252-Ovary, 275-Penis, 276-Endocrine System, excluding Thyroid, 277-Retroperitoneal, 278-Lung, 286-Bladder & Ureter, 291-Skin, excluding melanoma, 310 Vagina, Vulva, 311-Oral Cavity, Pharynx, Nose, Larynx, 319-Brain & Nervous System, 337-Esophagus, 338-Liver, 339-Pancreas, 353-Prostate, 453-Gallbladder & Other Biliary. All of those diagnoses have the statement about greater than 5% 5-year survival.Note this statement:Line Item #71 in the current Prioritized list has been crossed-out and replaced with the statement located at the end of the list. That current statement near the end of this note, and you will see that services under the Oregon Death with Dignity Act are included in the “Comfort/Palliative Care” category. Examples of services which are not intended to be covered as comfort/palliative care include:disease progression; and1) Chemotherapy or surgical interventions with the primary intent to prolong life or alterAs a cancer doctor (Radiation Oncologist), I have been concerned that the Oregon Health Plan covers the costs related to physician-assisted suicide, yet does not cover the costs of surgery, radiation therapy and chemotherapy in those patients with cancer who have a 5% or less 5-year survival. That is true even when such treatment may prolong life or alter disease progression. In the financial rationing of healthcare in Oregon, cancer patients with advanced disease are being refused financial coverage for surgery, radiation therapy and chemotherapy; but they do receive financial coverage for physician-assisted suicide. That is a why we say that legalized physician-assisted suicide is dangerous to vulnerable patients with serious illness. In a way, they are being sacrificed.Ken Stevens, April 15, 2008Sincerely,The following are from the current, April 1, 2008 Prioritized List of the Office of Medical Assistance Programs, Oregon Health Plan:Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY AND(See Coding Specification Below) (See Guideline Notes 1,3,7,11,26,64,65)Diagnosis: CANCER OF BREAST, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVALCPT: ,11623,11970,13102,13122, ,13153,19110,19120, ,19290-ICD-9: ,196.0,233.0,238.3,V45.71,V50.41-V50.42BREAST RECONSTRUCTION,99024,99051,99060,99070,99078, ,99366, , ,77315, , ,77427, , , , ,19298, ,19318, , ,58940,77014, ,77300,77305-Line: 198HCPCS: C9728,G0243,S0270,S0271,S0272,S0273,S0274,S2066,S2067,S2068,S9537,S956099477,Breast reconstruction is only coveredCOMFORT/PALLIATIVE CARESTATEMENTS OF INTENT FOR THE APRIL 1, 2008 PRIORITIZED LIST OF HEALTH SERVICESthe provision of services or items that give comfort to and/or relieve symptoms for suchillness with <5% expected 5 year survival be a covered service. Comfort/palliative care includesIt is the intent of the Commission that comfort/palliative care treatments for patients with anRules.length of life (e.g., six months) for such patients, except as specified by Oregon Administrativepatients. There is no intent to limit comfort/palliative care services according to the expectedIt is the intent of the Commission to not cover diagnostic or curative care for the primaryExamples of comfort/palliative care include:life or alter disease progression for patients with <5% expected 5 year survival.illness or care focused on active treatment of the primary illness which are intended to prolong3) Medical equipment (such as wheelchairs or walkers) determined to be medically appropriate2) In-home, day care services, and hospice services as defined by DMAP;1) Medication for symptom control and/or pain relief;for management of symptomatic complications or as required for symptom control; and4) Medical supplies (such as bandages and catheters) determined to be medically appropriatefor completion of basic activities of daily living;health evaluation and counseling, and prescription medications.limited to the attending physician visits, consulting physician confirmation, mental5) Services under ORS (Oregon Death with Dignity Act), to include but not beof time.2) Medical equipment or supplies which will not benefit the patient for a reasonable length29
30Assisted Suicide in Oregon: Truth No Oversight $0 funding for governmental oversightPrescriptions counted by Department of Human Services (DHS)Data collected are kept secretOriginal reports destroyed after annual summary made public by the DHSNo provision for medical record review to detect fraudulent reporting“Compassion and Choices” advocacy group is effectively the “Keeper of the Law” and controls all of the dataThe pro-assisted suicide organization “Compassion and Choices” have publicly reported that they are involved in approximately three-fourths of the physician-assisted suicide deaths in Oregon. They pressured the Oregon Department of Human Services to change the terminology of physician-assisted suicide in their annual reports. The Department of Human Services have destroyed basic assisted-suicide data, so that much scientific reporting of what is happening in Oregon cannot be done.
31Assisted Suicide in Oregon: Truth Spinning the Data “Compassion and Choices” advocacy groupattends most casescontrols most of the informationtells the stories it wants to tellused legal threats to get DHS to refer to “death with dignity” and not “assisted suicide”is effectively the Keeper of the Law
32Assisted Suicide in Oregon: Truth It’s Not about Pain Surveyed families of 83 Oregon patientsNo physical symptoms rated higher than 2 on scale of 1–5Most important reasons:wanting control of circumstances of death, dignity, and preferring to die at homeconcerns about independence, ability for self care and quality of lifeDoctors need to do their jobThis article “Why Oregon Patients Request Assisted Death: Family Member’s Views” by Linda Ganzini, Elizabeth R. Goy and Steven K Dobscha was just published in the Feb issue of Journal of General Internal Medicine 23 (2): It reports regarding what the patients’ families thought were the reasons for their family member requesting physician-assisted suicide (PAS). Much of the information came from family members who learned about the study through Compassion and Choices, formerly Compassion in Dying. We learn from this paper that that organization reported in 2005 that they had given information to or assisted 180 of the 246 persons who died of PAS in Oregon. This is further evidence regarding how that organization controls physician-assisted suicide in Oregon.The family members’ views on why patients requested PAS are given in table 2. Using a scoring system based on a scale of 1 to 5 (1=not at all important reason for request, 5=very important reason for request) none of the current physical complaint or suffering reasons had a median score of greater than 2. The scores of 3,4 & 5 are related to future fears and concerns, or of poor quality of life. This underscores that these people are not choosing PAS because of uncontrollable pain or suffering, although that was the argument used to pass the Oregon law in 1994 and 1997. They are concerned about their future. Rather than a doctor writing a prescription for a lethal overdose of sleeping medication, doctors should properly assess and deal with these patients’ fears and concerns.Ganzini et al., J Gen Intern Med Feb; 23(2):154–7
33Assisted Suicide in Oregon: Truth Pain Management Worsening In reality, the facts are that in Oregon, Pain relief became WORSE after the law took effect. After the law took effect, there were almost twice as many dying patients who had moderate or severe pain or distress.Fromme et al. Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to J Pall Med 7: , 2004Fromme et al. Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to J Pall Med 2004; 7:431–442
34Assisted Suicide in Oregon: Truth Pain Management Worsening Fromme et al. Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to J Pall Med 7: , 2004
35Morphine/Opioid Use in Oregon & the U.S. Increased morphine use has been similar in both Oregon and the rest of the U.S.OHSU researchers comparing pain medication use prior to and following Oregon’s PAS law found that inpatient morphine/opioid use did not increase for dying patients since the law was passed.States with new bans on PAS have had increased per capita use of morphine.Reported by Tolle, Hickman, Tilden, et al, Trends in Opioid Use Over Time: 1997 to Journal of Palliative Medicine 2004;7:39-45.Oregon has been a consistent leading state in per capita use of opioids/morphine. In recent years there has been no difference between the increased use of morphine in Oregon and the increased use in the rest of the U.S. Researchers at OHSU reported that while there had been a 2.5 fold increase in opioid use in Oregon in the three years from 1997 to 1999 (the same increase as in the rest of the U.S.), that inpatient morphine/opioid use at OHSU did not increase significantly to dying patients during that time.When other states have enacted recent new laws to ban assisted suicide or strengthen or clarify existing bans, the per capita use of morphine increase in each of those eleven states. (Americans for Integrity in Palliative Care, Presentation to AMA House of Delegates Meeting, Chicago, June 11, 2003)35
36Assisted Suicide in Oregon: How to Help the Patient "Our data suggests that when talking with a patient requesting PAD, clinicians should focus on eliciting and addressing worries and apprehensions about the future with the goal of reducing anxiety about the dying process. Some Oregon clinicians have expressed surprise at the paucity of suffering at the time of the request among these patients. Addressing patients’ concerns with concrete interventions that help maintain control, independence and self care, all in the home environment, may be an effective way to address requests for PAD and improve quality of remaining life."Read the last paragraph of this articleUnderscore “Some Oregon clinicians have expressed surprise at the paucity of suffering at the time of the request among these patients”,This paper demonstrates that the traditional role of comforting and caring is being replaced by disregarded in favor of intentional medical killing. Referencing a paper: “Oregon Physicians’ Responses to Requests for Assisted Suicide: a Qualitative Study” by Dobscha, Heintz and Ganzini in Journal Palliative Medicine 2004; 7:Ganzini et al., J Gen Intern Med Feb; 23(2):154-7