Tuesday, July 19, 2005

Vermont Death with Dignity Act

Following Oregon's lead, the Vermont legislature is considering a bill (HB 168) to offer terminally ill patients the option of a prescription medication to hasten their death.. The law itself, in broad summary, provides that only the patient can initiate a request which must be in writing, there is a 15-day waiting period, two witnesses must attest the patient is acting voluntarily, two physicians must be involved, and counseling is required if the MD feels the pt is depressed or has any psychological pathology. The bill has the support of many people and institutions including the Burlington Universalist Church, the VT Alliance for Ethical Healthcare and others.

I'm not so enthusiastic. I greatly admire Timothy Quill and his work advancing a humane medical approach to the dying patient, but I feel that full-blown legalized physician assisted suicide will do more harm than good. Here's what former Surgeon General C. Everett Koop wrote about the Oregon law legalizing MD-assisted suicide, Measure #16:

As former United States Surgeon General, I have worked first hand in developing health care policies. Many proposed policies at first sound like good ideas, but in fact are very dangerous. Measure #16 is one of those policies...

Measure #16 prescribes suicide as a treatment for disease. A patient's request for suicide is a signal that certain needs are not being met. Most likely, the patient is suffering from unnecessary pain or treatable depression. Doctors too often fail to dispense adequate pain management. The solution is to provide mental health treatment or better pain management, not drugs for suicide. This is the time for the doctor to be the patient's support, not his/her killer.

Measure #16 is ripe for abuse. The so-called safeguards built into Measure #16 are inadequate. Patients remain vulnerable to outside pressures to choose suicide. Physicians are required only to suggest the patient notify family members, leaving many to choose suicide without the support of loved ones.

Measure #16 strikes at the most vulnerable. Cost containment is a positive and necessary step toward health care reform. However, in this environment Measure #16 is dangerous. Poor, elderly, frail and disabled patients will be the victims if the "choice" to die becomes the "duty" to die.

A patient's request for suicide is a signal that certain needs are not being met.

In my own experience, there are two types of relevant situations. In the acutely ill patient with a dismal long-term prognosis from a terminal illness, the wish to control uncomfortable symptoms becomes paramount to any life-prolonging treatment and the patient is treated accordingly--these are patients who might be termed 'actively dying' before your eyes. They routinely recieve pain and sedation medications at doses which may hasten their death, in an effort to provide comfort.

These situations are not where a Death-with-Dignity law will apply. Instead, it mostly will be invoked for the ambulatory patient with uncomfortable symptoms, who despairs of further deterioration. These are the patients that palliative care services can help so much, but often are connected to them too late. Rather than presenting them with the initially appealing option--and perhaps eventually, in some sense a duty--to choose controlled early death, these folks should be referred for hospice and other palliative services. Their needs often involve a desire for control over the circumstances of their death, and assurance they will not be exposed to extreme suffering--we have the means now to meet these needs without assisting them with suicide. And my experience is that when such needs are addressed, the wish for hastened death vanishes.

Sometimes the meaning that patients find in the end of life is as simple yet profound as facing what comes as an example to their families, or as a final task for themselves they wish to do right. These things are not possible while symptoms are not well controlled, but when they can be, the death of a family member surrounded by loved ones and perhaps a minister is part of the cycle that makes up a family's story.

When patients' requests for assisted suicide are understood as a communication that their needs are not being met, setting up a state mechanism to administer lethal prescriptions seems absurd. When the Vermont legislature returns from its recess, I hope this bill does not reach the floor.


At 7:52 PM, Anonymous Anonymous said...

You are wrong about the Vermont Alliance for Ethical Health supporting the Death with Dignity (assisted suicide) bill. They are opposed. BTW, the bill died on the committee table last week. The vote was 5 to 5, essential killing it. Yah.

At 10:56 AM, Anonymous Anonymous said...

I had a family member who was dying of breast cancer. Everyday I watched her deteriorate before my eyes. This was in the 1990's so this bill wasn't even thought of at that time but I know that if she had the choice she would have support and used that bill. If their is no hope of getting better and not even pain medications are helping why shoudn't a person who is lucid beable to determine if they want to die or not? It is the peoples choice. I agree that the patient that is considering assisted suicide should be checked out to make sure that it is really what they want. But ultimately it is their choice. I do believe that suicide is the cowards way out. But if it would have made her experience less pain I would support it in a heart beat.

At 11:05 AM, Anonymous Anonymous said...

I would say that I am going to have to agree with this bill. I have had more than one close relative die from cancer, and they were in pain the whole time. My uncle was 32 years old when he died. He was left on life support for months. He tried to remove all tubes and had said in his will that he did NOT want to be on life support but he was put on it until the day he died. I know he would have wanted this bill to pass so people who are terminally ill and are in pain don't have to suffer. It's not right, if there is a good solution (if that's what you would like to call it) then I have to approve. My uncle died in 2001 and if he was still alive to day and was suffering like he was I know he too would have approved of the bill.


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