Helen

Medical Aid in Dying

As the nation's 75 million baby boomers enter into a new phase of their life, care for their aging parents, and contemplate their own mortality, many have come to realize that our end-of-life care system is hamstrung by outdated modes of dying. This chapter discusses the current status of medical aid in dying in the United States as a legal and medically recognized medical option for supporting patients at life's end.

Suicide in later life: failed treatment or rational choice?

Suicide is the deliberate act of causing death by self-directed injurious behavior with intent to die. Assisted dying, also known as assisted suicide, involves others to help hasten death. Physician-assisted dying specifically refers to the participation of a physician in facilitating one's death by providing a lethal means. Any decision to actively end a life has profound emotional and psychological effects on survivors. The article discusses the effects that older adults' deaths through suicide, assisted dying, and physician-assisted dying have on survivors and the implications for clinical practice.

Impact of euthanasia on primary care physicians in the Netherlands

BACKGROUND

There is only limited knowledge about the emotional impact that performing euthanasia has on primary care physicians (PCPs) in the Netherlands.

OBJECTIVE

To obtain more insight into the emotional impact on PCPs of performing euthanasia or assisted suicide, and to tailor the educational needs of vocational PCP trainees accordingly.

METHODS

Qualitative research, consisting of four focus group studies. The setting was primary care in the Netherlands; 22 PCPs participated, in four groups (older males, older females, younger males and a group with interest with regard to euthanasia).

RESULTS

Various phases with different emotions were distinguished: before (tension), during (loss) and after (relief) the event. Although it is a very rare occurrence, euthanasia has a major impact on PCPs. Their relationship with the patient, their loneliness, the role of the family, and pressure from society are the main issues that emerged. Making sufficient emotional space and time available to take leave adequately from a patient is important for PCPs.

CONCLUSIONS

Many PCPs stressed that young physicians should form their own opinions about euthanasia and other end-of-life decisions early on in their career. We recommend that these issues are officially included in the vocational training programme for general practice.

A critical analysis of criticisms of the Oregon Death with Dignity Act

This article critically examines the validity of common criticisms of the Oregon Death with Dignity Act, primarily through reviewing published research and analyses. After summarizing the law and recent developments, 11 areas of concerns are examined: (a) the amount of data collected, (b) the availability of the data, (c) the reporting process, (d) protection of physicians, (e) terminal illness as a requirement, (f) the amount of data on palliative care interventions, (g) data on lethal prescriptions, (h) data on psychological/psychiatric evaluations, (i) whether the decision to request medication is informed, (j) whether the request is voluntary, and (k) financial factors. The authors examine each of these areas of concern and find criticisms to be unfounded given the research and analyses conducted to date.

Oregon Physicians' Responses to Requests for Assisted Suicide: A Qualitative Study

In 1997, the Oregon Death with Dignity Act was enacted, allowing physicians to prescribe lethal dosages of medication to competent, terminally ill patients who request them. To improve our understanding of physicians' reactions to requests for assisted suicide, we performed semistructured interviews of 35 Oregon physicians who had received requests from patients. Interviews were completed in 2000, and audiotaped, transcribed, and analyzed using qualitative techniques. Requests for assisted suicide had a powerful impact on physicians and their practices. Physicians often felt unprepared, and experienced apprehension and discomfort before and after receiving requests. Prominent sources of discomfort included concerns about adequately managing symptoms and suffering, not wanting to abandon patients, and incomplete understanding of patients' preferences, especially when physicians did not know patients well. Participation in assisted suicide required a large investment of time and was emotionally intense. Regardless of whether they prescribed or not, physicians did not express major regrets about their decisions. Requests often facilitated discussion of important issues, and many physicians felt that the process increased their confidence and assertiveness in discussing end-of-life issues with other patients. Physicians rarely sought support from colleagues; instead, they tended to discuss emotional aspects of their experiences with their spouses.

Physicians' experiences with the Oregon Death with Dignity Act

BACKGROUND

Physician-assisted suicide was legalized in Oregon in October 1997. There are data on patients who have received prescriptions for lethal medications and died after taking the medications. There is little information, however, on physicians' experiences with requests for assistance with suicide.

METHODS

Between February and August 1999, we mailed a questionnaire to physicians who were eligible to prescribe lethal medications under the Oregon Death with Dignity Act.

RESULTS

Of 4053 eligible physicians, 2649 (65 percent) returned the survey. Of the respondents, 144 (5 percent) had received a total of 221 requests for prescriptions for lethal medications since October 1997. We received information on the outcome in 165 patients (complete information for 143 patients and partial for on an additional 22). The mean age of the patients was 68 years; 76 percent had an estimated life expectancy of less than six months. Thirty-five percent requested a prescription from another physician. Twenty-nine patients (18 percent) received prescriptions, and 17 (10 percent) died from administering the prescribed medication. Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication. In the case of 68 patients, including 11 who received prescriptions and 8 who died by taking the prescribed medication, the physician implemented at least one substantive palliative intervention, such as control of pain or other symptoms, referral to a hospice program, a consultation, or a trial of antidepressant medication. Forty-six percent of the patients for whom substantive interventions were made changed their minds about assisted suicide, as compared with 15 percent of those for whom no substantive interventions were made (P<0.001).

CONCLUSIONS

Our data indicate that in Oregon, physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 requests actually result in suicide. Substantive palliative interventions lead some--but not all--patients to change their minds about assisted suicide.