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Some ‘Death With Dignity’ Proponents Want More Guidance On The Controversial Practice

BY DANIEL GAITAN | daniel@lifemattersmedia.org

As support for physician-assisted suicide grows and state lawmakers debate legalizing the controversial practice, some proponents want reliable clinical criteria for doctors prescribing life-ending drugs.

Supporters of the practice published a report in the Journal of Palliative Medicine in support of national standards. They hope to offer a safer and more reliable experience to terminally ill people seeking to end their lives.

“With more jurisdictions authorizing aid in dying, it is critical that physicians can turn to reliable clinical criteria,” researchers write. “As with any medical practice, aid in dying must be provided in a safe and effective manner.” Any criteria, they write, should be based on Oregon’s “Death with Dignity Act” of 1997.

In states where it is legal (through the courts or legislature), physicians may write prescriptions for life-ending drugs to terminally ill adults with less than six months to live. Patients must be of sound mind when requesting drugs and self-administer.

But although states require doctors to ensure their patients are making informed and voluntary decisions, current statutes provide insufficient guidance for doctors when assessing patients’ mental capacity.

To help address concerns, advocacy group Compassion & Choices convened a committee of lawyers, bioethicists and doctors to draft clinical criteria.

“In all of medicine, people want to know what’s considered best practices,” co-author and attorney Thaddeus Pope told Life Matters Media. “The idea is that this would fill in the gaps, that this will fill in the vacuum.”

However, Peg Sandeen, executive director of Death with Dignity National Center in Oregon, is opposed to national guidelines.

“The practice of medicine in the United States is governed by the states, that is the tradition, that each state and each state’s board of medical examiners establish for each state what the practice of medicine is,” she told LMM.

Guidance

The Life-Ending Drugs 

Ending life with doctor-prescribed drugs is a two-step process: First, the patient takes an antiemetic (metoclopramide or ondansetron). About an hour later, the patient ingests a small amount of a barbiturate (secobarbital or pentobarbital).

The barbiturate, usually in powdered form, is mixed with a half cup of water into a slurry and consumed. It must be consumed quickly, within 30 to 120 seconds, or the patient may fall asleep before ingesting an effective dose. Death comes in four to six hours.

“But what drugs should you use and in what dose?” co-author Dr. David Ordentlicher told LMM.  “There are gaps. In any field of medicine, you have guidelines for practicing physicians in the field.”

He worries patients may be given too little and suffer from complications.

Responding To Requests

A patient’s request for life-ending drugs must receive prompt evaluation, researchers write, with physicians exploring the physical, psychological, spiritual, financial and social issues influencing such a request.

Meaningful dialogue between doctor and patient may deter premature action by the patient, and help determine whether his or her request is sincere and free from external pressure.

“If the physician is concerned that a mental health condition may be impairing the patient’s judgment or decisional capacity, the physician should refer the patient to a licensed psychiatrist or clinical psychologist for evaluation,” researchers write.

Unfortunately, referral to a mental health expert is rare, Pope said.

Ensuring Informed Consent

Few Americans understand all the end of life care options available to them. When someone seeks help ending his or her life, their doctor must explore with that patient all alternatives, including hospice and palliative medicine– care designed to help alleviate unnecessary pain, suffering and anxiety.

“Patients who ask about aid in dying should be referred for hospice care if they are not already enrolled,” researchers write. “Furthermore, whenever feasible, the physician should obtain a second opinion from an experienced physician who ideally has palliative care experience.”

If someone wishes to die at a specific time or place, suicide is not the only option. Alternatives include discontinuing life-prolonging treatments, palliative sedation to unconsciousness and voluntarily stopping eating and drinking.

Providing A Prescription

Not all states require a waiting period between the first request for barbiturates and the writing of a prescription.

If a waiting period is not required, physicians may know a patient well enough to determine that his or her request is voluntary and rational. However, if a physician is uncertain, it is his or her responsibility to schedule a follow-up visit in ten to 15 days to revisit the request.

“Putting a time buffer between requests and prescription writing generally will clear up any residual doubts,” researchers write. “The attending physician also should encourage a meeting with the patient and family together to address any concerns about the patient’s request.”