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Deciding When and Where the Journey Ends

Pain Management, March 2011, Volume 4, Issue 2

Surveys indicate that the American public's attitude may be shifting toward supporting patients' right to die and to seek out physician-assisted suicide. Polls of physicians reveal that the profession remains split on this issue.

Surveys indicate that the American public’s attitude may be shifting toward supporting patients’ right to die and to seek out physician-assisted suicide. Polls of physicians reveal that the profession remains split on this issue.

An article posted recently on HCPLive highlighted a Harris/BBC World News America poll of more than 2,300 American adults that found large majorities in support of physician-assisted suicide for terminally ill patients in great pain who wish to end their lives in a time, place, and manner of their own choosing. Two-thirds of respondents think that doctors “should be allowed to advise terminally ill patients who request the information on alternatives to medical treatment and/or ways to end their lives.”

The poll also found that “a majority of people over 65 now have written directives regarding the type of care they would like to receive, or not to receive, at the end stages of their lives.” However, the likelihood that a patient has created a living will or other written instructions outlining his or her wishes for end-of-life treatment increases with age; only about one-quarter (28%) of all patients have written directives. The survey also reported that 56% of respondents “know someone, living or dead, who has created written directives or documented instructions for the end stages of their lives.”

Although the greater awareness among patients of the importance of end-of-life planning and directives shown by these survey results is encouraging especially given all of the recent furor and misinformation over “death panels” and advance care planning, the real story is the public’s seeming overwhelming support for the availability and use of physician-assisted suicide in at least some clinical situations. Nearly 70% of surveyed adults agreed that “people who are terminally ill, in great pain and who have no chance of recovery should have the right to choose to end their lives.” The level of support for this issue dropped only slightly among older (over age 65) respondents, 62% of whom were in favor. More than two-thirds (67%) of those surveyed said that “doctors should be allowed to advise terminally ill patients who request the information on alternatives to medical treatment and/or ways to end their lives,” with more than one-quarter (27%) saying this should apply “in all cases” and 40% saying it should apply “only in certain cases” (which were not defined in the survey). Nearly 58% of people surveyed said that “the law should allow doctors to comply with the wishes of a dying patient in severe distress who asks to have his or her life ended.”

How do physicians match up?

Physicians’ views on this topic are decidedly more mixed than those of the general public, as represented in the Harris/BBC survey. In a poll of 10,000 physicians by Medscape in August-September 2010 that included the question, “Are there situations in which physician-assisted suicide should be allowed?” 45% of physician respondents answered “Yes,” 41% said “No,” and 14% said “It depends.” These results are similar to those produced by a smaller physician survey in 2005 that asked “Do you think physicians should be given the right to dispense prescriptions to patients to end their life?” In that survey, 59% of physicians answered “Yes” and 41% said “No.” A 2007 survey of attitudes toward assisted suicide among Vermont physicians reported in the Journal of Medical Ethics found that more than one-third (38%) believed physician-assisted suicide should be legalized, about one-sixth (16%) said it should be prohibited, one-quarter (26%) said that it should not be legislated by the government at all, and another one-sixth (16%) were undecided on the matter. Interestingly, the survey found that physicians who did not care for patients through the end of life were “significantly more likely to favor legalization of [physician-assisted suicide] than physicians who do care for patients with terminal illness,” by a margin of 48% to 33%. A survey of 3,300 oncologists published in 2000 in the Annals of Internal Medicine found that only 22% of those surveyed “supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain,” a figure the authors at the time noted had decreased by nearly half (from 45%) from a similar survey in 1994.

These and other survey results reveal a deep divide on the issue of a patient’s right to die and questions about the nature of the medical profession and the proper role of the physician in hastening a patient’s death, with diverse factors such as the wording of survey questions (use of the word “suicide” decreases the likelihood that a respondent will support physician-assisted suicide), physicians’ experience with direct palliative care, physicians’ religious beliefs, and political concerns over further intrusion of the state into the physician-patient relationship coming into play.

As Oregon approaches the 15th anniversary of its pioneering Death with Dignity Act, which “allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose," this issue is increasingly in play in statehouses around the country. As the graphic on page 17 shows, several states are currently considering bills to legalize assisted suicide, with others moving in the opposite direction and taking up bills to explicitly ban the practice. With surveys showing a deepening split between the medical profession’s and the public’s support for physician-assisted suicide, and an aging population that will in coming years likely stretch our already inadequate palliative care services to the limit, it is clear that the issue of who gets to decide when and how a patient’s life journey will end is far from settled.

Reader Comments

Should physicians ever take an active role in helping a patient to end his or her life?

Life itself is a terminal illness. I support allowing competent indiviuals the freedom to determine when and how to end their lives and I support allowing physicians the freedom to advise or assist, depending on their own convictions.

-- Barry M. Mayberry, MD

I don’t believe physicians or patients have the sovereign right to take life. Life is a gift that can involve pain, hardship, and unbelievable challenges. It is not our decision to determine when life shall end.

-- Bruce Young, MD

Call me old fashioned, but doctors should not be involved with assisted suicide. It’s not our role to play God and decide when a life should end. I am not in favor of “mercy killing” for moral and ethical reasons. It’s one thing to provide palliative care and provide pain meds, or withhold life support measures, but an ethical fine line is crossed when you assist in a patient’s demise or advise them on how to hasten death at their own hands. The Hippocratic oath we all took as physicians is a sacred trust and should not be violated. It’s a slippery slope toward euthanasia if we venture too far down the road toward assisted suicide or hastening the death of the terminally ill. Our job is to keep terminally ill patients comfortable and pain free, and seek the assistance from hospices and others trained in end of life care.

-- Dr. Steve Farkas

A person should have freedom of will due to all of the arguments given. Mainly, if the quality of life is not there and the person endures great pain, their end-of-life directives should be honored and the family and attending physicians should by law have restricted rights to end their life.

-- Julius Barron

Providing patients with a means to kill themselves is not something health care providers should be doing. You wouldn’t place a loaded gun on the bedside of a desperate patient. Palliative care can help ease pain and give time for families to come together, to care and support. Often much healing of relations can take place during even the most difficult times. When the option of physicians ordering medications to kill a patient is legally available, some patients may feel that the family expects them to choose that option or put pressure on them to commit suicide. It also sends a message that because you have suffering in your life, it is no longer worth living.

-- Dianne Peterson, RN

HCPLive wants to know:

Do you support a patient’s right to choose the time, place, and manner in which his or her life ends? Are you in favor of physicians offering advice to patients who seek to end their own life?

Are you in favor of physicians actively assisting patients who wish to end their own life, whether by prescribing medications or some other method or intervention?

Does your opinion on this matter change in cases involving terminally-ill patients for whom adequate pain relief is not possible?

Have you been asked by a patient or relative of a patient for advice and/or assistance regarding ending a patient’s life?

Have you noticed an increase in the number of patients with written directives or documented instructions for end-of-life care?

What are the key concerns and consequences of allowing physicians to discuss assisted suicide or other options with their terminally ill patients?

Leave a comment below!