When the patient says, 'I want to die'
Cynthia was a graduate student when she learned she had gastric cancer and that it had spread.
A bright student and a Buddhist, she researched her disease on the Internet and explored all the possibilities before deciding to embark on an experimental procedure to remove her stomach and insert a central line.
She came to Timothy Quill, MD, of Rochester, NY, to help her through her illness and, if necessary, her death.
"Before she made her decision about whether to follow through with the experimental procedure, she wanted know that certain conditions would be met," said Dr. Quill in his lecture, "Responding to Requests for a Physician-assisted Death" during this year's Scientific Assembly. His lecture was the 1997 Annual Critical Issues Facing Us as a Specialty Lectureship.
"She wanted to be able to stop treatment when she wanted to. And, if dying got hard, she wanted to know if I would help her find death, if I would keep her from dying in a hard way," said Dr. Quill.
Despite the removal of her stomach and chemotherapy, Cynthia died after spending one month in hospice care.
"In that month she was embraced and supported by the Buddhist community, got married to a long-time boyfriend, gave away some of her favorite possessions so she would always be remembered, and prepared herself for dying," said Dr. Quill. "In the end, she died very peacefully."
Dr. Quill used Cynthia's story to emphasize that the method of dying is far less important than the actual process of dying.
"Dying is a process, and as physicians we can bring in pills and treatments and help keep people alive even if they're suffering," he said. "But when we can help people through the process of dying and it works well, and people find a peaceful, meaningful death, that's what we're supposed to do."
When a patient says he or she wants to die, it's up to the physician to find out the patient's reasoning, he said. Often patients feel they have become a burden on their families, or they've seen a relative die after months of suffering and they're afraid.
Sometimes their problem can be solved with counseling, or just reassurance from their physician that pain medication will be available to ease their pain.
"Patients often 'go' with the worst death they've ever seen," said Dr. Quill. "When they think about death, they flash back to how someone close to them died in pain. Physicians need to ask themselves what the request really means and be able to explore what the patient's fears are about death. I ask the patient, 'What's your greatest fear?' And I try to reassure them."
Some patients just want to know that their physician will not abandon them, and that there is the option of physician-assisted death.
"For most patients, they just want to talk about it," said Dr. Quill. "They want to know it's going to be there, but few actually use it. An open-ended commitment from you is important in helping to end their fear.
Don't do it if it violates your values, your sense of right and wrong. If you can't provide the commitment and assist with the dying process, then think hard about how to reassure this patient."
- FP Report is published by the AAFP News Department.