Aging: Change and Aging: Change and

AdaptationAdaptation

Death and DyingDeath and Dying

April 8, 2003April 8, 2003

Euthanasia: “a good death”Euthanasia: “a good death”

• Voluntary, active euthanasia: at the patient’s request, a physician or someone else causes the person’s death, for example, by administering a lethal injection.

Euthanasia Attitudes

• “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it?”

Figure 1. Trends in Attitudes About Euthanasia: 1947-2000

37 38

53

60 5861 63 64 66 66 66

69 7065

68 68 68 68

30354045505560657075

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Physician-assisted suicidePhysician-assisted suicide

• The patient causes his/her own death, i.e., The patient causes his/her own death, i.e., commits suicide using means--usually a commits suicide using means--usually a lethal dose of medication--provided by a lethal dose of medication--provided by a physicianphysician

• Euthanasia: someone else causes the Euthanasia: someone else causes the deathdeath

• PAS: the patient causes his/her own PAS: the patient causes his/her own deathdeath

Suicide AttitudesSuicide Attitudes

• ““Do you think a person has the Do you think a person has the right to end his or her own life if right to end his or her own life if this person has an incurable this person has an incurable disease?”disease?”

Figure 2. Trends in Attitudes About Suicide: 1977-2000

38 38

45

48

44

5250

47

56 57 57

62 61 61

58

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65

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AutonomyAutonomy

• A person is autonomous if he/she is A person is autonomous if he/she is self-self-governinggoverning, capable of making decisions, , capable of making decisions, and fixing a course of action in the and fixing a course of action in the absence of controlling constraintsabsence of controlling constraints

• It involves It involves self-determinationself-determination, freedom, , freedom, independence, liberty of choice and independence, liberty of choice and actionaction

AutonomyAutonomy

• It refers to It refers to human agency free of outside human agency free of outside intervention and interferenceintervention and interference..

Other PerspectivesOther Perspectives

• Beneficence:Beneficence: The ethical obligation to The ethical obligation to minimize pain and suffering, to reduce minimize pain and suffering, to reduce and remove harms, and to bring about and remove harms, and to bring about benefits to an individual.benefits to an individual.

• NonmaleficenceNonmaleficence: Do no harm: Do no harm

• JusticeJustice: What principles should guide the : What principles should guide the allocation of scarce resources?allocation of scarce resources?

Chronology of Recent Chronology of Recent DevelopmentsDevelopments

• 1991: Washington’s Initiative 1991: Washington’s Initiative 119119

• Shall adult patients who are in a Shall adult patients who are in a medically terminal condition be medically terminal condition be permitted to request and receive permitted to request and receive from a physician aid-in-dying?from a physician aid-in-dying?

• Aid in dyingAid in dying

• ““a medical service, provided in a medical service, provided in person by a physician,person by a physician,

that will end the life of a conscious that will end the life of a conscious and mentally competent and mentally competent qualified patient...qualified patient...

• in a dignified, painless, and in a dignified, painless, and humane manner,humane manner,

• when requested voluntarily by when requested voluntarily by the patient through a written the patient through a written directive.”directive.”

• Defeated: 54-46%Defeated: 54-46%

• 1992: California’s Proposition 1992: California’s Proposition 161161

• Shall adult patients who are in a Shall adult patients who are in a medically terminal condition be medically terminal condition be permitted to request and receive permitted to request and receive from a physician aid-in dying?from a physician aid-in dying?

• Aid in dyingAid in dying

• ““a medical procedure that will a medical procedure that will terminate the life of the qualified terminate the life of the qualified patient patient

• in a painless, humane, and in a painless, humane, and dignified manner,...dignified manner,...

• whether administered by the whether administered by the physician at the patient’s choice physician at the patient’s choice or direction oror direction or

• whether the physician provides whether the physician provides means to the patient for self-means to the patient for self-administration.”administration.”

• Defeated: 54-46%Defeated: 54-46%

• 1994: Oregon’s Ballot Measure 1994: Oregon’s Ballot Measure 16 - The Oregon Death with 16 - The Oregon Death with

Dignity ActDignity Act

• Shall law allow terminally ill Shall law allow terminally ill adult Oregon patients voluntary adult Oregon patients voluntary informed choice to obtain a informed choice to obtain a physician’s prescription for physician’s prescription for drugs to end life?drugs to end life?

The Oregon Death with The Oregon Death with Dignity ActDignity Act

• RequirementsRequirements

• The patient must be 18, terminally The patient must be 18, terminally ill (having less than 6 months to ill (having less than 6 months to live), and an Oregon resident.live), and an Oregon resident.

• The patient must voluntarily make The patient must voluntarily make an oral request...an oral request...

• to the attending physician for a to the attending physician for a prescription for medication to prescription for medication to end his or her life.end his or her life.

• A 15-day waiting period then A 15-day waiting period then begins.begins.

• The attending physician makes The attending physician makes sure the patient understands the sure the patient understands the diagnosis and prognosis.diagnosis and prognosis.

• The patient is informed of all The patient is informed of all options, including pain control, options, including pain control, hospice care, and comfort care.hospice care, and comfort care.

• The attending physician also The attending physician also must inform the patient of the must inform the patient of the risks and expected result of risks and expected result of taking the medication.taking the medication.

• The attending physician…The attending physician…

• determines whether the patient is determines whether the patient is capable of making health care capable of making health care decisions and is acting decisions and is acting voluntarily;voluntarily;

• encourages the patient to notify encourages the patient to notify his or her next of kin;his or her next of kin;

• informs the patient that he or she informs the patient that he or she can withdraw the request for can withdraw the request for medication at any time and in medication at any time and in any manner;any manner;

• refers the patient to a consulting refers the patient to a consulting physician who is asked to physician who is asked to confirm the attending confirm the attending physician’s diagnosis and physician’s diagnosis and prognosis.prognosis.

• The consulting physician also The consulting physician also decides whether the patient is decides whether the patient is capable of making the decision capable of making the decision and is acting voluntarily.and is acting voluntarily.

• If either or both physicians If either or both physicians believe the patient is suffering...believe the patient is suffering...

• from a psychiatric or from a psychiatric or psychological illness or psychological illness or depression that causes impaired depression that causes impaired judgment, the patient will be judgment, the patient will be referred for counseling.referred for counseling.

• Once the preceding steps have Once the preceding steps have been satisfied, the patient been satisfied, the patient voluntarily signs a written voluntarily signs a written request witnessed by two people.request witnessed by two people.

• At least one witness cannot be a At least one witness cannot be a relative or an heir of the patient.relative or an heir of the patient.

• The patient then makes a second The patient then makes a second oral request to the attending oral request to the attending physician for medication to end physician for medication to end his/her life.his/her life.

• The attending physician again The attending physician again informs the patient that he or she informs the patient that he or she can withdraw the request for can withdraw the request for medication at any time and in medication at any time and in any manner.any manner.

• No sooner than 15 days after the No sooner than 15 days after the first oral request and 48 hours first oral request and 48 hours after the written request, the after the written request, the patient may receive a patient may receive a prescription for medication to prescription for medication to end his or her life.end his or her life.

• The attending physician again The attending physician again verifies at this time that the verifies at this time that the patient is making an informed patient is making an informed decision.decision.

• SafeguardsSafeguards

• Immunity: Immunity: Physicians who Physicians who prescribe medication for a prescribe medication for a terminally ill patient to end terminally ill patient to end his or her life would be his or her life would be protected from civil or protected from civil or criminal liability. Physicians criminal liability. Physicians are are notnot obligated to obligated to participate.participate.

• Residency requirementsResidency requirements: Only: Only requests made by Oregon requests made by Oregon residents may be granted.residents may be granted. Physicians must be licensed in Physicians must be licensed in Oregon.Oregon.

• Reporting requirementsReporting requirements: Each : Each year, the Oregon Health Division year, the Oregon Health Division must review a sample of records must review a sample of records of deaths that occur under this of deaths that occur under this law.law.

• Effect on insurance or annuity Effect on insurance or annuity policiespolicies: A qualified patient’s act : A qualified patient’s act of ingesting medication to end his of ingesting medication to end his or her life will not have an effect or her life will not have an effect upon a life, health, or accident upon a life, health, or accident insurance or annuity policy.insurance or annuity policy.

• A qualified person who takes A qualified person who takes medication to end his or her own medication to end his or her own life will life will notnot have his/her have his/her insurance policies affected -- insurance policies affected -- even if those policies specify that even if those policies specify that death by suicide is not covered.death by suicide is not covered.

• LiabilitiesLiabilities: Coercion of a patient, : Coercion of a patient, altering or forging a request for altering or forging a request for medication or concealing a medication or concealing a withdrawal of that request, with withdrawal of that request, with the effect of causing the patient’s the effect of causing the patient’s death, are Class A felonies.death, are Class A felonies.

• Passed 51-49% by a margin of Passed 51-49% by a margin of 32,000 votes on Nov. 4, 1994.32,000 votes on Nov. 4, 1994.

• On Dec. 8, 1994: District Court On Dec. 8, 1994: District Court issues a temporary injunction issues a temporary injunction preventing the law from going preventing the law from going into effect.into effect.

• On Dec. 28, 1994: injunction On Dec. 28, 1994: injunction continuedcontinued

• ““Surely, the first assisted suicide Surely, the first assisted suicide law in this country deserves a law in this country deserves a considered thoughtful considered thoughtful constitutional analysis.”constitutional analysis.”

• Aug. 3, 1995: law ruled Aug. 3, 1995: law ruled unconstitutionalunconstitutional

• ““There is little assurance that There is little assurance that only competent terminally ill only competent terminally ill persons will voluntarily die.persons will voluntarily die.

• Some ‘good results’ cannot Some ‘good results’ cannot outweigh other lives lost due to outweigh other lives lost due to unconstitutional errors and unconstitutional errors and abuses.”abuses.”

• Ruling overturned in Feb., 1997 Ruling overturned in Feb., 1997 by the US Court of Appeals and by the US Court of Appeals and the US Supreme Court on the US Supreme Court on October 14, 1997. October 14, 1997.

• Both courts held that the persons Both courts held that the persons who brought the challenge were who brought the challenge were not in good standing, i.e., were not in good standing, i.e., were not immediately affected or not immediately affected or threatened by the law.threatened by the law.

• Oregon legislature asks voters to Oregon legislature asks voters to vote on the proposed law again.vote on the proposed law again.

• In November, 1997: the original In November, 1997: the original law passed again by a margin of law passed again by a margin of 60% to 40%.60% to 40%.

Oregon’s Physician-Assisted Suicide Law

Update

Legal and Legal and LegislativeChallengesLegislativeChallenges

Pain Relief Promotion ActPain Relief Promotion Act

• June 1999—Introduced in U.S. June 1999—Introduced in U.S. House by Hyde, Stupak, & House by Hyde, Stupak, & NicklesNickles

–Would prohibit use of federally Would prohibit use of federally controlled drugs for PAScontrolled drugs for PAS

Pain Act, cont.Pain Act, cont.

–Encourages aggressive pain Encourages aggressive pain management for dyingmanagement for dying

–Would impede or stop PAS Would impede or stop PAS under Oregon’s lawunder Oregon’s law

PAS Act, cont.PAS Act, cont.• October 27, 1999—U.S. House votes October 27, 1999—U.S. House votes

271–156 to pass the Pain Relief 271–156 to pass the Pain Relief Promotion ActPromotion Act

• Pain Relief Promotion Act has since Pain Relief Promotion Act has since languished in the U.S. Senate and languished in the U.S. Senate and has not been reported out of the has not been reported out of the Committee on Health, Education, Committee on Health, Education, Labor, and PensionsLabor, and Pensions

Attorney General Ashcroft Attorney General Ashcroft

• Nov. 6, 2001Nov. 6, 2001

• Doctors who prescribe drugs to Doctors who prescribe drugs to hasten the death of terminally ill hasten the death of terminally ill patients are in violation of the patients are in violation of the federal Controlled Substances federal Controlled Substances Act.Act.

Court RulingCourt Ruling

• April 17, 2002April 17, 2002

• U.S. District Court Judge Robert U.S. District Court Judge Robert JonesJones

• The 11/6 directive “…is not The 11/6 directive “…is not entitled to deference under any entitled to deference under any standard and is invalid.”standard and is invalid.”

Court Ruling (cont.)Court Ruling (cont.)

• ““The fact that opposition to assisted The fact that opposition to assisted suicide my be fully justified--suicide my be fully justified--morally, ethically, religiously, or morally, ethically, religiously, or otherwise--does not permit a federal otherwise--does not permit a federal statute to be manipulated from its statute to be manipulated from its true meaning to satisfy even a true meaning to satisfy even a worthy goal.”worthy goal.”

PAS So FarPAS So Far

Oregon State StatisticsOregon State Statistics

• PatientsPatients

• 1998-20011998-2001

–91 received and used lethal 91 received and used lethal prescriptionsprescriptions

–out of 117,896 deathsout of 117,896 deaths

–1/1,296 deaths (.08%)1/1,296 deaths (.08%)

Statistics, cont.

• VitalsVitals

–44 Men44 Men

–47 Women47 Women

–97% were white97% were white

–Median age—69Median age—69

Statistics, cont.

• IllnessIllness

–Cancer: 70Cancer: 70

–ALS: 7ALS: 7

–COPD: 7COPD: 7

–Other: 7Other: 7

Statistics, cont.

• Educational LevelEducational Level

–Some high school: 10Some high school: 10

–High school graduate: 42High school graduate: 42

–College graduate: 39College graduate: 39

Statistics, cont.

• Reasons identifiedReasons identified

–Loss of autonomy: 74Loss of autonomy: 74

–Inability to participate: 67Inability to participate: 67

–Loss of bodily control: 55Loss of bodily control: 55

–Burden on others: 30Burden on others: 30

–Inadequate pain control: 18Inadequate pain control: 18

Statistics, cont.• InsuredInsured

–Private: 65

–None: 1

• Place of deathPlace of death

–Home: 82Home: 82

–Hospital: 1Hospital: 1

Statistics, cont.• Minutes between ingestion and Minutes between ingestion and

unconsciousness: median = 5unconsciousness: median = 5

• Minutes between ingestion and Minutes between ingestion and death: median = 30death: median = 30

Vermont Death with Dignity Vermont Death with Dignity ActAct