Curbside Consultation

Medical Aid in Dying

 

Am Fam Physician. 2018 Mar 1;97(5):339-343.

Case Scenario

A 63-year-old man presented to my office with stage D, New York Heart Association class III heart failure due to coronary artery disease. He also had type 2 diabetes mellitus and hypertension. He was recently hospitalized for an exacerbation of heart failure, his third hospitalization in eight months. At the visit, he commented on his fatigue and restricted lifestyle compared with how he had lived until the previous 18 months. Despite paying good attention to his medications and managing his other diseases appropriately, his quality of life remained poor. He said that he knew there are now several states that allow patients to end their lives with physician assistance. Although I do not work in one of these states, he asked whether I would be willing to help him, saying, “I just want this to be over.” I was not prepared for his question. What is the appropriate way to respond to requests like this?

Commentary

Requests for hastened death are not unusual from patients with life-limiting illness, and many primary care physicians encounter these requests over the course of their career. Medical aid in dying is the practice of a physician providing a competent, terminally ill patient—at the patient's request—with a prescription for a lethal dose of medication that the patient intends to use to end his or her own life. This practice differs from euthanasia, in which a clinician causes the death of a patient by administering a lethal dose of medication with the intent of ending the patient's suffering. Patients' suffering and subsequent requests for hastened death raise ethical, legal, and social concerns among individuals, organizations, and institutions across the United States. Links to official position statements from select organizations are provided in eTable A.

 Enlarge     Print

eTABLE A

Links to Official Position Statements on Medical Aid in Dying

American Medical Association (AMA)

Officially opposed

The Code of Medical Ethics, updated in 2016, officially opposes medical aid in dying, stating that it is “incompatible with the physician's role as healer.”

https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-5.pdf

American Academy of Family Physicians (AAFP)

Officially opposed

The AAFP adheres to the AMA's Code of Medical Ethics.

http://www.aafp.org/about/policies/all/planning-care.html

American Academy of Hospice and Palliative Medicine

Officially neutral

http://aahpm.org/positions/pad

National Hospice and Palliative Care Organization

Officially opposed

https://www.nhpco.org/sites/default/files/public/PAS_Resolution_Commentary.pdf

eTABLE A

Links to Official Position Statements on Medical Aid in Dying

American Medical Association (AMA)

Officially opposed

The Code of Medical Ethics, updated in 2016, officially opposes medical aid in dying, stating that it is “incompatible with the physician's role as healer.”

https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-5.pdf

American Academy of Family Physicians (AAFP)

Officially opposed

The AAFP adheres to the AMA's Code of Medical Ethics.

http://www.aafp.org/about/policies/all/planning-care.html

American Academy of Hospice and Palliative Medicine

Officially neutral

http://aahpm.org/positions/pad

National Hospice and Palliative Care Organization

Officially opposed

https://www.nhpco.org/sites/default/files/public/PAS_Resolution_Commentary.pdf

Although euthanasia is illegal in the United States, medical aid in dying is legal in five states and Washington, DC, and similar statutes have been proposed in approximately two dozen other states (eTable B). However, this commentary does not review the legal or ethical issues involved in responding to such requests, nor do we advocate for any particular decision an individual physician might make. Instead, we outline a compassionate, stepwise response that honors patients' and physicians' experiences and beliefs, and moves toward improving patients' quality of life. Other examples of stepwise approaches are available in the literature.1,2

 Enlarge     Print

eTABLE B

Features of Medical-Aid-in-Dying Laws

Legislative mechanism

Approved by voter referendum

Oregon (1994; court challenges and an unsuccessful 1997 ballot initiative to overturn the referendum delayed implementation until 1998): https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/statute.pdf

Washington (2008): http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct

Colorado (2016): https://www.sos.state.co.us/pubs/elections/Initiatives/titleBoard/filings/2015-2016/145Final.pdf

Approved by legislative action

Vermont (2013): http://www.leg.state.vt.us/docs/2014/bills/intro/S-077.pdf

California (2015): https://leginfo.legislature.ca.gov/faces/billNavClient.

Address correspondence to David Nowels, MD, MPH, at David.Nowels@UCDenver.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Quill T, Arnold R. Fast facts and concepts #156. Evaluating requests for hastened death. https://www.mypcnow.org/blank-pbq3l. Accessed April 24, 2017....

2. Quill T, Arnold RM. Fast facts and concepts #159. Responding to a request for hastening death. https://www.mypcnow.org/blank-q24sj. Accessed April 24, 2017.

3. Smith KA, Harvath TA, Goy ER, Ganzini L. Predictors of pursuit of physician-assisted death. J Pain Symptom Manage. 2015;49(3):555–561.

4. Hudson PL, Kristjanson LJ, Ashby M, et al. Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review. Palliat Med. 2006;20(7):693–701.

5. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. BMJ. 2008;337:a1682.

6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–742.

7. Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomized controlled trial. Lancet Respir Med. 2014;2(12):979–987.

8. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–749.

9. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180–190.

10. Casarett D, Pickard A, Bailey FA, et al. Do palliative consultations improve patient outcomes? J Am Geriat Soc. 2008;56(4):593–599.

11. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013;(6):CD007760.

12. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe [published correction appears in JAMA. 2016;316(12):1319]. JAMA. 2016;316(1):79–90.

13. Kohlwes RJ, Koepsell TD, Rhodes LA, Pearlman RA. Physicians' responses to patients' requests for physician-assisted suicide. Arch Intern Med. 2001;161(5):657–663.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Nov 1, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article