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EPECEPECEPECEPEC EPECEPECEPECEPEC Physician- Assisted Suicide Physician- Assisted Suicide Module 5 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation
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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
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... Objectives l Understand a 6-step protocol for responding to requests l Be able to meet most patients’ needs l Understand a 6-step protocol for responding to requests l Be able to meet most patients’ needs
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Physician-assisted suicide / euthanasia... l Ancient medical issue l Aiding or causing a suffering person’s death physician-assisted suicide physician provides the means, patient acts euthanasia physician performs the intervention l Ancient medical issue l Aiding or causing a suffering person’s death physician-assisted suicide physician provides the means, patient acts euthanasia physician performs the intervention
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... 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
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Why patients ask for PAS l Asking for help l Fear of psychosocial, mental suffering future suffering, loss of control, indignity, being a burden l Depression l Physical suffering l Asking for help l Fear of psychosocial, mental suffering future suffering, loss of control, indignity, being a burden l Depression l Physical suffering
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The legal and ethical debate... l Principles obligation to relieve pain and suffering respect decisions to forgo life- sustaining treatment l The ethical debate is ancient l US Supreme Court recognized NO right to PAS l Principles obligation to relieve pain and suffering respect decisions to forgo life- sustaining treatment l The ethical debate is ancient l US Supreme Court recognized NO right to PAS
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... 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
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6-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
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... 6-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
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Step 1: Clarify the request l Immediate, compassionate response l Open-ended questions l Suicidal thoughts, plans? l Be aware of personal biases potential for counter-transference l Immediate, compassionate response l Open-ended questions l Suicidal thoughts, plans? l Be aware of personal biases potential for counter-transference
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Step 2: Assess underlying causes... l The 4 dimensions of suffering physicalpsychologicalsocialspiritual physicalpsychologicalsocialspiritual
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... Step 2: Assess underlying causes l Particular focus on fears about the future depression, anxiety l Particular focus on fears about the future depression, anxiety
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Assess for clinical depression... l Underdiagnosed, undertreated l Source of suffering l Barrier to life closure, “good death” l Diagnosis challenging no somatic symptoms helplessness, hopelessness, worthlessness l Underdiagnosed, undertreated l Source of suffering l Barrier to life closure, “good death” l Diagnosis challenging no somatic symptoms helplessness, hopelessness, worthlessness
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... Assess for clinical depression l Treatment choices depend on time available fast-acting psychostimulants SSRIs tricyclic antidepressants l Treatment choices depend on time available fast-acting psychostimulants SSRIs tricyclic antidepressants
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Psychosocial suffering, practical concerns... l Sense of shame l Not feeling wanted l Inability to cope l Loss of functionself-image control, independence l Sense of shame l Not feeling wanted l Inability to cope l Loss of functionself-image control, independence
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... Psychosocial suffering, practical concerns l Tension with relationships l Increased isolation, misery l Worries about practical matters who caregivers will be how domestic chores will be tended to who will care for dependents, pets l Tension with relationships l Increased isolation, misery l Worries about practical matters who caregivers will be how domestic chores will be tended to who will care for dependents, pets
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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
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Spiritual suffering l Existential concerns l Meaning, value, purpose in life l Abandoned, punished by God questions faith, religious beliefs anger l Existential concerns l Meaning, value, purpose in life l Abandoned, punished by God questions faith, religious beliefs anger
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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
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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
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Step 4: Address root causes l Professional competence in: withholding, withdrawal aggressive comfort measures palliative care principles local palliative care programs l Address suffering, fears l Professional competence in: withholding, withdrawal aggressive comfort measures palliative care principles local palliative care programs l Address suffering, fears
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Address psychological suffering l Treat depressionanxietydelirium l Individual, group counseling l Specialty referral as appropriate l Treat depressionanxietydelirium l Individual, group counseling l Specialty referral as appropriate
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Address social suffering, practical concerns... l Family situation l Finances l Legal affairs l Family situation l Finances l Legal affairs
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... 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
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Address physical suffering l Aggressive symptom management l Engage physical, occupational therapy exercises aids to optimize function l Aggressive symptom management l Engage physical, occupational therapy exercises aids to optimize function
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Address spiritual suffering l Explore prayer transcendental dimension meaning, purpose in life life closure gift giving, legacies l Consult chaplain, psychiatrist, psychologist l Explore prayer transcendental dimension meaning, purpose in life life closure gift giving, legacies l Consult chaplain, psychiatrist, psychologist
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Address fear of loss of control... l Explore areas of control, independence l Right to determine one’s own medical care accept or refuse any medical intervention life-sustaining therapies l Explore areas of control, independence l Right to determine one’s own medical care accept or refuse any medical intervention life-sustaining therapies
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... Address fear of loss of control l Select personal advocate(s) 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 personal advocate(s) 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
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Address fear of pain, other symptoms l Explain about control of pain, other symptoms sedation for intractable symptoms l Commitment to manage symptoms l Explain about control of pain, other symptoms sedation for intractable symptoms l Commitment to manage symptoms
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Address fear of being a burden l Establish specifics worry about caregiving family willing alternate settings worry about finances resources, services available l Refer to a social worker l Establish specifics worry about caregiving family willing alternate settings worry about finances resources, services available l Refer to a social worker
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Address fear of indignity l Discuss what indignity means to the individual dependence, burden, embarrassment l Importance of control l Explore resources to maintain dignity l Reassure patient l Discuss what indignity means to the individual dependence, burden, embarrassment l Importance of control l Explore resources to maintain dignity l Reassure patient
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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
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Step 5: Educate, discuss legal alternatives l Information giving l Refusal of treatment l Withdrawal of treatment l Declining oral intake l Sedation l Information giving l Refusal of treatment l Withdrawal of treatment l Declining oral intake l Sedation
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Decline 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
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... Decline 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
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End-of-life 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
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... End-of-life sedation l Benzodiazepines l Anesthetics l Barbiturates l Continue analgesics l Benzodiazepines l Anesthetics l Barbiturates l Continue analgesics
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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
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EPECEPECEPECEPEC EPECEPECEPECEPEC Physician- Assisted Suicide Summary Summary
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