1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC™-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC  - Oncology Education in Palliative and End-of-life Care - Oncology Module 14: Physician-Assisted Suicide Module 14: Physician-Assisted Suicide

3. Objectives... l Define physician-assisted suicide (PAS) and euthanasia. l Describe their current status in the law. l Identify root causes of suffering that prompt requests. l Define physician-assisted suicide (PAS) and euthanasia. l Describe their current status in the law. l Identify root causes of suffering that prompt requests.

4. ... Objectives l Understand a six-step protocol for responding to requests. l Be able to meet most patients’ needs. l Understand a six-step protocol for responding to requests. l Be able to meet most patients’ needs.

5. Video

6. Physician-assisted suicide / euthanasia... l Ancient medical issue l Aiding or causing a suffering person’s death o Physician-assisted suicide  Physician provides the means, patient acts o Euthanasia  Physician performs the intervention l Ancient medical issue l Aiding or causing a suffering person’s death o Physician-assisted suicide  Physician provides the means, patient acts o Euthanasia  Physician performs the intervention

7. ... Physician-assisted suicide / euthanasia l Many physicians receive a request. l Requests are a sign of patient crisis. l Many physicians receive a request. l Requests are a sign of patient crisis.

8. Why patients ask for PAS l Asking for help l Fear of: o Psychosocial, mental suffering o Future suffering, loss of control, indignity, being a burden l Depression l Physical suffering l Asking for help l Fear of: o Psychosocial, mental suffering o Future suffering, loss of control, indignity, being a burden l Depression l Physical suffering

9. The legal and ethical debate... l Principles: o Obligation to relieve pain and suffering o Respect decisions to forgo life- sustaining treatment l The ethical debate is ancient l US Supreme Court recognized No right to PAS l Principles: o Obligation to relieve pain and suffering o Respect decisions to forgo life- sustaining treatment l The ethical debate is ancient l US Supreme Court recognized No right to PAS

10. ... The legal and ethical debate l The legal status of PAS can differ from state to state l Oregon is the only state where PAS is legal (as of 1999) l Supreme Court Justices supported Right to palliative care l The legal status of PAS can differ from state to state l Oregon is the only state where PAS is legal (as of 1999) l Supreme Court Justices supported Right to palliative care

11. Six-step protocol to respond to requests... 1. Clarify the request. 2. Assess the underlying causes of the request. 3. Affirm your commitment to care for the patient. 1. Clarify the request. 2. Assess the underlying causes of the request. 3. Affirm your commitment to care for the patient.

12. ... Six-step protocol to respond to requests 4. Address the root causes of the request. 5. Educate the patient and discuss legal alternatives. 6. Consult with colleagues. 4. Address the root causes of the request. 5. Educate the patient and discuss legal alternatives. 6. Consult with colleagues.

13. Step 1: Clarify the request l Immediate, compassionate response l Open-ended questions l Suicidal thoughts, plans? l Be aware of: o Personal biases o Potential for counter-transference l Immediate, compassionate response l Open-ended questions l Suicidal thoughts, plans? l Be aware of: o Personal biases o Potential for counter-transference

14. Step 2: Assess underlying causes... l The four dimensions of suffering: o Physical o Psychological o Social o Spiritual l The four dimensions of suffering: o Physical o Psychological o Social o Spiritual

15. ... Step 2: Assess underlying causes l Particular focus on: o Fears about the future o Depression, anxiety l Particular focus on: o Fears about the future o Depression, anxiety

16. Assess for clinical depression... l Underdiagnosed, undertreated l Source of suffering l Barrier to life closure, “good death” l Diagnosis challenging o No somatic symptoms o Helplessness, hopelessness, worthlessness l Underdiagnosed, undertreated l Source of suffering l Barrier to life closure, “good death” l Diagnosis challenging o No somatic symptoms o Helplessness, hopelessness, worthlessness

17. ... Assess for clinical depression l Treatment choices depend on time available o Fast-acting psychostimulants o SSRIs o Tricyclic antidepressants l Treatment choices depend on time available o Fast-acting psychostimulants o SSRIs o Tricyclic antidepressants

18. Psychosocial suffering, practical concerns... l Sense of shame l Feeling unwanted l Inability to cope l Loss of : o Function o Self-image o Control, independence l Sense of shame l Feeling unwanted l Inability to cope l Loss of : o Function o Self-image o Control, independence

19. ... Psychosocial suffering, practical concerns l Tension with relationships l Increased isolation, misery l Worries about practical matters o Who caregivers will be o How domestic chores will be tended to o Who will care for dependents, pets l Tension with relationships l Increased isolation, misery l Worries about practical matters o Who caregivers will be o How domestic chores will be tended to o Who will care for dependents, pets

20. Physical suffering l Pain l Breathlessness l Anorexia / cachexia l Weakness / fatigue l Loss of function l Pain l Breathlessness l Anorexia / cachexia l Weakness / fatigue l Loss of function l Nausea / vomiting l Constipation l Dehydration l Edema l Incontinence

21. Spiritual suffering l Existential concerns l Meaning, value, purpose in life l Abandoned, punished by God o Questions faith, religious beliefs o Anger l Existential concerns l Meaning, value, purpose in life l Abandoned, punished by God o Questions faith, religious beliefs o Anger

22. Common fears l Future l Pain, other symptoms l Loss of control, independence l Abandonment, loneliness l Indignity, loss of self-image l Being a burden on others l Future l Pain, other symptoms l Loss of control, independence l Abandonment, loneliness l Indignity, loss of self-image l Being a burden on others

23. Step 3: Affirm your commitment l Listen, acknowledge feelings, fears l Explain your role l Commit to help find solutions l Explore current concerns l Listen, acknowledge feelings, fears l Explain your role l Commit to help find solutions l Explore current concerns

24. Step 4: Address root causes l Professional competence in: o Withholding, withdrawal o Aggressive comfort measures o Palliative care principles o Local palliative care programs l Address suffering, fears l Professional competence in: o Withholding, withdrawal o Aggressive comfort measures o Palliative care principles o Local palliative care programs l Address suffering, fears

25. Address psychological suffering l Treat: o Depression o Anxiety o Delirium l Individual, group counseling l Specialty referral as appropriate l Treat: o Depression o Anxiety o Delirium l Individual, group counseling l Specialty referral as appropriate

26. Address social suffering, practical concerns... l Family situation l Finances l Legal affairs l Family situation l Finances l Legal affairs

27. ... Address social suffering, practical concerns l What setting of care l Who caregivers will be l How to manage domestic chores l Who will care for dependents, pets l What setting of care l Who caregivers will be l How to manage domestic chores l Who will care for dependents, pets

28. Address physical suffering l Aggressive symptom management l Engage physical, occupational therapy o Exercises o Aids to optimize function l Aggressive symptom management l Engage physical, occupational therapy o Exercises o Aids to optimize function

29. Address spiritual suffering l Explore: o Prayer o Transcendental dimension o Meaning, purpose in life o Life closure o Gift giving, legacies l Consult chaplain, psychiatrist, psychologist l Explore: o Prayer o Transcendental dimension o Meaning, purpose in life o Life closure o Gift giving, legacies l Consult chaplain, psychiatrist, psychologist

30. Address fear of loss of control... l Explore areas of control, independence l Right to determine one’s own medical care o Accept or refuse any medical intervention o Life-sustaining therapies l Explore areas of control, independence l Right to determine one’s own medical care o Accept or refuse any medical intervention o Life-sustaining therapies

31. ... Address fear of loss of control l Select o Personal advocate(s) o Proxy for decision-making l Prepare advance directives l Plan for death l Make a commitment to help patient maintain as much control as possible l Select o Personal advocate(s) o Proxy for decision-making l Prepare advance directives l Plan for death l Make a commitment to help patient maintain as much control as possible

32. Address fear of pain, other symptoms l Explain about: o Control of pain, other symptoms o Sedation for intractable symptoms l Commitment to manage symptoms l Explain about: o Control of pain, other symptoms o Sedation for intractable symptoms l Commitment to manage symptoms

33. Address fear of being a burden l Establish specifics o Worry about caregiving  Family willing  Alternate settings o Worry about finances  Resources, services available l Refer to a social worker l Establish specifics o Worry about caregiving  Family willing  Alternate settings o Worry about finances  Resources, services available l Refer to a social worker

34. Address fear of indignity l Discuss what indignity means to the individual o Dependence, burden, embarrassment l Importance of control l Explore resources to maintain dignity l Reassure patient l Discuss what indignity means to the individual o Dependence, burden, embarrassment l Importance of control l Explore resources to maintain dignity l Reassure patient

35. Address fear of abandonment l Assurance that physician will continue to be involved in care l Resources provided by hospice and palliative care l Assurance that physician will continue to be involved in care l Resources provided by hospice and palliative care

36. Step 5: Educate; discuss legal alternatives l Information giving l Refusal of intervention l Withdrawal of treatment l Declining oral intake l Sedation l Information giving l Refusal of intervention l Withdrawal of treatment l Declining oral intake l Sedation

37. Declining oral intake... l Any person can decline oral intake l Force-feeding not acceptable l Ensure food, water always accessible l Any person can decline oral intake l Force-feeding not acceptable l Ensure food, water always accessible

38. ... Declining oral intake l Accept / decline artificial hydration, nutrition l Educate, support family members, caregivers Refocus their need to give care l Accept / decline artificial hydration, nutrition l Educate, support family members, caregivers Refocus their need to give care

39. Palliative sedation... l When symptoms are intractable at the end of life l Continuous, intermittent l Death attributed to illness, not sedation l When symptoms are intractable at the end of life l Continuous, intermittent l Death attributed to illness, not sedation

40. ... Palliative sedation l Benzodiazepines l Anesthetics l Barbiturates l Continue analgesics l Benzodiazepines l Anesthetics l Barbiturates l Continue analgesics

41. Step 6: Consult with colleagues l Seek support from trusted colleagues l Reasons for reluctance to consult l Seek support from trusted colleagues l Reasons for reluctance to consult

42. Summary Requests for physician-assisted suicide are a sign of patient crisis. Use the six-step protocol to respond to requests, and address patients' needs.