1. Physician Opposition to Assisted Suicide Kerrianne P. Page, MD, HMDC Chief Medical Officer Hospice, Palliative Care, & Home Care Services Catholic Health Services of Long Island

2. Physician Assisted Suicide The process by which a physician prescribes a lethal drug regimen to a terminally ill patient that the patient may self-administer to bring about his/her death – Terminal illness – life expectancy of less than 6 months – Process of repeated requests, evaluation by 2 independent physicians – Patient must self administer medication

3. Alternate Terms Used to Describe Physician Assisted Suicide (PAS) Physician Aid-in-Dying/Aid-In-Dying Physician Assisted Death Death with Dignity practices Death Hastening practices Right to Die

4. Physician Assisted Suicide is NOT Prescription of medications for the relief of pain & other symptoms Withdrawal/withholding of life sustaining treatments Palliative sedation for control of intractable symptoms Expressions of readiness/hope for death by terminally ill patients Active administration of medications by a physician with the intent to end the patient’s life (euthanasia)

5. Our “Culture of Control” Views Death as Optional Denial of death as a consequence of disease or advanced age – Interest in reversal of aging – Reluctance to accept limited life expectancy – Overutilization of life prolonging treatments at the end of life despite lack of benefit – Low rates/late enrollment in hospice Desire for a “controlled ending” – Principle of autonomy as absolute priority – Desire to control timing, circumstances – Avoidance of suffering, loss of function

6. Characteristics of Physician Assisted Suicide in Oregon & Washington

7. PAS Statistics in Oregon & Washington 2014 Oregon 155 lethal prescriptions written 105 deaths associated with ingestion (67%) Diagnosis: cancer 68%; ALS 16% 3 patients referred for psychiatric evaluation 83 physicians provided prescriptions 10,509 total physicians Washington 176 lethal prescriptions written 126 deaths associated with ingestion (72%) Diagnosis: cancer 70%; 13% ALS 6 patients referred for psychiatric evaluation 109 physicians provided prescriptions 15,421 total physicians

8. Data on Requests for PAS In a 2004 population based study of 1384 deceased Oregonians: – 1/6 patients discuss PAS with family members – 1/50 patients made a formal request to their physician for PAS Tolle, et al. J Clin Ethics 2004 Few published data about how frequently patients ask for PAS

9. Reasons Underlying PAS Requests in Oregon Concern about losing autonomy (91.5%) Being less able to engage in activities that make life enjoyable (88.7%) Loss of dignity (79.3%) Losing control of bodily functions (50.1%) Being a burden to family/friends/caregivers (40%) Concern about inadequate pain control (24.7%) Oregon Health Authority - Death with Dignity Act website

10. Physician Opposition to Assisted Suicide

11. Principal Role of Physician as Healer – Violates the pledge to preserve health, alleviate suffering, & maintain solidarity with the sick – Imperils trust in the physician-patient relationship – Fundamental threat to medicine as a profession rather than physician as provider of services – Devaluation of human life Hippocratic Oath – “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect…”

12. Physician Opposition to Assisted Suicide Uncertainty In the Trajectory of Illness – Prognostication is an inexact science, especially in non-cancer illnesses – Occurrence of symptoms/complications vary between patients; dying is a unique experience, which cannot easily be generalized from one patient to another – Patients’ acceptance of “intolerable states” often change throughout the course of illness Provision of Comprehensive Palliative Care Sharply Reduces Requests for PAS – Not all health care providers are skilled in the arena of symptom management – Symptoms may be complex/refractory & require specialist assessment – No requirement to ensure that best standards of practice have been implemented to address patient’s suffering – Data are anecdotal, but provider’s experiences are remarkably consistent More research that documents/quantifies the impact of palliative care strategies in PAS requests is needed.

13. Physician Opposition to Assisted Suicide Survey of Physician Attitudes – Demonstrate that physicians are mostly opposed to PAS New England Journal 2013 computer survey: 1712 US physicians, 65% oppose PAS – Some suggestions that acceptance among physicians is growing – Few recent data about the number of physicians willing to prescribe PAS prescriptions

14. Professional Societies’ Opposition to Assisted Suicide American Medical Association (1996) …allowing physicians to participate in assisted suicide would cause more harm than good. Physician assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. American College of Physicians-American Society of Internal Medicine (2001) Legalization would undermine the patient-physician relationship and trust necessary to sustain it, alter the medical profession’s role in society, and endanger the value our society places on life… Catholic Medical Association (2016) Series of public service announcements

15. Professional Societies’ Opposition to Assisted Suicide National Hospice & Palliative Care Association (2005) When symptoms or circumstances become intolerable to a patient, effective therapies are now available to assure relief from almost all forms of distress during the terminal phase of an illness without purposefully hastening death as the means to an end. Hospice & Palliative Care Association of New York State (2015) Physician assisted death falls outside the scope of the acute pain & symptom management and supportive care that hospice and palliative care promote at the end of life.

16. Professional Societies’ Opposition to Assisted Suicide American Academy of Hospice & Palliative Medicine (2007, 2015) – Takes a position of “studied neutrality” whether PAS should be legally regulated or prohibited…. – Supports intense efforts to alleviate suffering & to reduce any perceived need for PAD. – Advises “great caution” before pursuing PAD where legal…

17. How Should We Respond to Requests for Assisted Suicide?

18. Responding to Requests for Assisted Suicide We must see these requests as an expression of suffering & unmet symptom needs – Pain – Other physical symptoms (shortness of breath, nausea/vomiting, etc.) – Depression/anxiety/emotional suffering – Anticipatory grief – Psychosocial suffering (dignity, identity, dependence, burden) – Spiritual suffering

19. Responding to Requests for Assisted Suicide Physicians must have open & in depth conversations with patients who make a request. – Determine the nature of the request (immediate vs. “proactive”) – Identify causes of intractable suffering – Evaluate decision making capacity – Explore emotional & situational factors – Provide education about effective palliative care

20. Responding to Requests for Assisted Suicide Provide access to high quality, multidisciplinary palliative & hospice care – Meticulous symptom control – Time intensive, emotionally complex work for health care providers – Not financially well supported in the current health care system. Strengthen the therapeutic relationship with patients – provide empathic response to suffering & reinforcing the commitment to provide care.

21. Conclusion “You matter until the last moment of your life and we will do all we can, not only to help you die peacefully, but to help you live until you die.” Dame Cicely Saunders