Transcript Physician Assisted Suicide Deaths 1998-2006

An Analysis of Nine Years of
Physician-Assisted Suicide in
Oregon
Jerome R. Wernow Ph.D., R.Ph.
Director
[email protected]
Re-visit Take Away Point
The stories used to give meaning to a
person’s life are the stories used to
give meaning to a person’s ‘health.’
Human B/b-eing
Corporeality
Spiritual Illumination
Psychofacticity
Defining As Good As It Gets
Personal ‘Story’
Heavily invested in opposition 1994-1999
Researched
Published academically
Provided legal testimony federal court
Crafted legislative safeguards
Personal ALS and brain cancer contacts
Became uninterested after 2000
Approach
What was asserted by opponents
What was asserted by proponents
What is the practice found in the reports
Opponents of PAS
“Pills don’t work”
“Doctors can’t predict”
“Mental Health
consultation not
required”
“Falsified records”
“Not family friendly”
“Killing without
consent”
“Duty to die”
“Terminally ill fear
assisted suicide”
“Unnecessary Law”
Facts about Assisted Suicide under Measure 16 by Physicians for
Compassionate Care (1994)
Proponents for Physician Assisted
Suicide
Support from people and physicians
Improves care of the terminally ill
Increases death at home not hospitals
Increases pain care
Increases end-of-life care for uninsured
Physician Assisted Suicide Deaths
1998-2006
Deaths
Physician Assisted Suicide Deaths
50
45
40
35
30
25
20
15
10
5
0
46
42
38
27
37
38
2004
2005
27
21
16
1998
1999
2000
2001
2002
2003
2006
Death with Dignity Act of
1994
“Allows terminally ill adult Oregon
residents voluntary informed choice to
obtain physician’s prescription for
drugs to end life.”
“Pills Don’t Work”
100.00%
90.00%
80.00%
70.00%
60.00%
Percent
50.00%
Failures
40.00%
not reported
30.00%
20.00%
10.00%
0.00%
Year
Myth and Fact
Myth: “Dutch researcher warns of 25 %
lingering deaths” Keefe, Mark, Oregonian
Fact: About 4% fail in Holland (Kimsma)
Fact: Dutch lethally inject after 6 hours to
end oral administration failure and
lingering death
Drugs of Choice
Secobarbital used 136 (47%)
Pentobarbital used 152 (52%)
Oregon Statute
“Nothing in this Act shall be construed
to authorize a physician or any other
person to end a patient’s life by lethal
injection, mercy killing, or active
euthanasia.”
Onset, Peak, and Duration of
Activity
Secobarbital
Onset 10-15 minutes
Peak activity 15 min
Duration 3-4 hours (v)
Pentobarbital
Onset 20-60 minutes
Peak activity 15 min
Duration 3-4 hours (v)
Netherlands’ Standard
Intravenous route preferred
IV solution used orally sodium pento- or
secobarbital 100 ml solution
If patient fails to ingest entire solution or
lingers more than 5 hours, administer
pancuronium or vecuronium bromide 20
mg intravenously
Gerrit K. Kimsma: “Euthanasia AND euthanizing drugs in The Netherlands,” in
Drug Use in Assisted Suicide and Euthanasia. (Battin and Lipman eds)
Pharmaceutical Products Press, 1996.
Ingestion to Death
(Health division report)
Median Time: 25 minutes (n=232)
Range: 4 minutes-48 hours (n=232)
Greater than 6 hrs: 14 (n=232)
Unknown: 17 (232/249 = 7.1%)
Ingestion time until Death
Reported to Unreported Ingestion until Death
50
40
Number of 30
Patients 20
10
0
Reported
Unreported
1
2
3
4
5
Years 2000-2006
6
7
“Pills Don’t Work?”
Seem to work in about 94 out 100 cases
Question arises regarding accuracy of
positive outcome due to hard to access
data (59% gives no info on timing)
Is 5-6% failure medically acceptable
standard?
Failures
Approximately six percent known*
*Health division reports 17 cases without reporting of minutes
until death (7.1%)
“Doctors can’t Predict”
90
80
70
60
Months 1st
50
Request Until
40
Death
30
20
Median
Minimum
Maximum
10
0
1
2
3
4
5
Year
6
7
8
9
Oregon Statute
“diagnosed with a terminal illness
that will lead to death within six (6)
months”
First Request until Death
Median: 42 days
Range: 15 days-1009 days
http://oregon.gov/DHS/ph/pas/docs/yr9-tbl-1.pdf
First Request until Death
90
80
70
60
Months 1st
50
Request Until
40
Death
30
20
Median
Minimum
Maximum
10
0
1
2
3
4
5
Year
6
7
8
9
“Doctors Seem to Predict”
Median suggests longevity is predictable
Question revolves around skewing of data
Unable to determine longevity of those
using PAS
Unable to weight significance of outlying
data without more detail
“Mental Health consultation
not required”
50
40
Total Physician 30
Assisted
20
Suicides
No Psych Eval
Psych Eval
10
0
1
2
3
4
5
Year
6
7
8
9
Capacity And Volition
Requirements
127.815 §3.01 (d) Refer the patient to a
consulting physician for medical confirmation
of the diagnosis, and for a determination that
the patient is capable and acting voluntarily;
127.815 §3.01 (e) Refer the patient for
counseling if appropriate pursuant to ORS
127.825;
Mental Consult Requirements
If in the opinion of the attending physician or the consulting
physician a patient may be suffering from a psychiatric or
psychological disorder or depression causing impaired
judgment, either physician shall refer the patient for counseling.
No medication to end a patient’s life in a humane and dignified
manner shall be prescribed until the person performing the
counseling determines that the patient is not suffering from a
psychiatric or psychological disorder or depression causing
impaired judgment.
[OR127.825 §3.03. Counseling referral 1995 c.3 §3.03; 1999 c.423 §4]
Informed Consent Requirements
127.830 §3.04. Informed decision. “ he or
she has made an informed decision as
defined in ORS 127.800 (7).”
“based on an appreciation of the relevant
facts and after being fully informed by the
attending physician”
Number of Mental Evaluations
50
40
Total Physician 30
Assisted
20
Suicides
No Psych Eval
Psych Eval
10
0
1
2
3
4
5
Year
6
7
8
9
Mental Health Referrals
Thirteen percent (36/292) of the
patients committing suicide were
referred for mental health evaluations
Mental Health Referrals
Percent
Percent
Percent
60
50
40
30
20
10
0
Percent
1
2
3
4
5
Year
6
7
8
9
Physician-Patient Relationship
6
5
4
Months 3
Median in Months
2
Minumum in Months
1
0
1
2
3
4
5
Year
6
7
8
9
Hospice Care
In Hospice Care
100
Percent
80
60
In Hospice Care
40
20
0
1
2
3
4
5
6
7
Year
Median: 86%
8
9
End of Life Concerns
87% Loss of Autonomy
87% Loss of Pleasure
80% Loss of Dignity
57% Loss of Bodily Control
38% Burden on Family
26% Pain Control
2% Finance
Mental Health consultation not
required - analysis
Clear decrease in psych referrals
Difficult to determine significance of
minimal physician-patient contact
Psych-socials in hospice care may
diminish referral for psych evaluation
Rationale is subjective and narrative
based
Cheney Case of Portland
Female 85 y/o
Dx terminal cancer
Alzheimer’s dementia
Psychiatric-diagnosed
diminished capacity
MD recommended
against PAS
Patient accepted MD
advice
Daughter objected
Asserted mother’s desire
for PAS
2nd Psych consult found
diminished capacity
Concerned about familial
pressure
Psychologist still
determined pt. competent
Wesley J. Smith: “Bioethics: Frontiers and New Challenges. Cf. www.
books.google.com/books?isbn=9728818610...
“Falsified Records” Issue
70
60
50
40
Scripts Written
30
20
10
0
Rx written
Reporting issue
1
2
3
4
5
Year 2000-2006
6
7
Reporting Requirements
ORS127.865 §3.11 (b) The department
shall require any health care provider upon
dispensing medication pursuant to ORS
127.800 to 127.897 to file a copy of the
dispensing record with the department.
Reporting Requirements
(1) To comply with ORS 127.865(2), within seven
calendar days of writing a prescription for
medication to end the life of a qualified patient
the attending physician shall send the following
completed, signed and dated documentation by
mail to the State Registrar, Center for Health
Statistics, …(6 forms)
http://arcweb.sos.state.or.us/rules/OARs_300/OAR_333/333_009.html
Reporting Requirements
(1) (3) To comply with ORS 127.865(1)(b), within
10 calendar days of dispensing medication
pursuant to the Death with Dignity Act, the
dispensing health care provider shall file a
copy of the "Pharmacy Dispensing Record
Form" prescribed by the Department with the
State Registrar, Center for Health Statistics, …
(ORS 333-009-0010 )
Reporting Requirements
(2) Within 10 calendar days of a patient's
ingestion of lethal medication obtained
pursuant to the Act, or death from any
other cause, whichever comes first, the
attending physician shall complete the
"Oregon Death with Dignity Act Attending
Physician Interview" form prescribed by
the Department.
Prescriptions cp Deaths
http://oregon.gov/DHS/ph/pas/docs/year9.pdf
Reporting Issues
70
60
50
40
Scripts Written
30
Rx written
20
10
0
Reporting issue
1
2
3
4
5
6
7
Year 2000-2006
No action needed by Board of Medical Examiners
Reporting Issues
“Cannot detect or collect data on issues of
noncompliance with any accuracy” OHD, 1999
Needed: comparison of DEA records detailing
(1) Pento- and Secobarbital sold with (2) Pentowith (3) Secobarbitol dispensed with number of
OHD reporting forms
BME reports apparent ‘good faith’ compliance of
100%
“Killing without consent”
Board of Medical examiners have only
pursued one case
Associated Press raised one other
Occurrences seems rare
Likelihood of prosecution unclear
Active Involuntary Euthanasia
March 1996
78 y/o transported to
hospital, intubated,
unresponsive
Dx: subarachnoid
hemorrhage by Patient’s
MD (6 years) with consult
Prognosis for recovery
poor
Daughter and MD
concurred W/D and W/H
tx
Extubated, Morphine,
Valium ordered prn for
comfort
Morphine 5-10mg and
diazepam 5-10 mg given
q 5-10 minutes for 2 hr,
no evidence of discomfort
Magnet applied to
pacemaker
Succinylcholine 100 mg
given causing death
BME Notice of Disciplinary Action, July 18 1996.
Legal Proceedings
Venue changed to Lane County
District attorney “very difficult to get a
conviction for homicide”
“Injustice to incarcerate”
“Does not need to be on probation”
BME 2 month suspension and $6,371 fine
enough, charges dropped
BME “MD motive – misguided”
Four nursing home deaths
Allegation of morphine overdosing
Nurse determined “mentally unstable and
unfit for practice”
Nursing home fined $6,000
Grand Jury refused to indict RN
Associated Press: Oregon Grand Jury Refuses to Indict Nurse in Euthanasia
Deaths. September 13, 2000
“Terminally ill fear assisted suicide”
2005 Gallup Poll
When asked if doctors should be allowed
to end the life of a patient who is suffering
from incurable disease and wants to die
"75 percent of respondents said yes”
When asked if doctors should help a
patient commit suicide under the same
circumstances, “only 58 percent said yes”
http://www.ca-aas.com/pdf/statesidesteps1.pdf
“By using Orwellian ‘doublespeak’ we might be
letting ourselves in for procedures and conclusions
which we do not fully comprehend at the time of
decision-making.
On the other hand, perhaps euphemisms allow
people to come to grips with brutal facts which,
stated another way, would be repugnant.”
Humphry, Derek: What’s in a word? The results of a Roper Poll of Americans on
how they view the importance of language in the debate over the right to choose
to die. (Euthanasia Research and Guidance Organization (ERGO): August,
1993) p. 2.
Compassion & Choices*
“Suicide” is Inaccurate,
Biased Term to Describe
Terminally-Ill Patients’
End-of-Life Choices”
(Press Kit Statement)
*Formerly: Hemlock Society
Language Games
Compassion & Choices made its case in an
Aug. 22 letter to state official that said
"physician-assisted suicide" "is value-laden
and negatively biased language that
perpetuates misunderstanding of Oregon
law and policy."
http://www.ca-aas.com/pdf/statesidesteps1.pdf
The Oregon Department of Human
Services (DHS)
C & C first sent a formal request to the
state agency, suggesting that the terms
“aid-in-dying,” “directed dying,” or
“assisted dying” be used in official state
reports
brought lawyers to a meeting with the DHS
to discuss the language substitution
implied that, if it were not made, litigation
might follow
http://www.discovery.org/a/3931
The Oregon Public Health Division
Calling it "physician-assisted suicide" was
"perhaps a mistake we made years ago," given
the language of the law, said Dr. Katrina
Hedberg, public health physician with the state
Public Health Division who helps compile the
annual report. But "physician-assisted death"
didn't quite work either.
“The state's Web pages and subsequent annual
reports will refer only to the Death with Dignity
Act.”
http://www.ca-aas.com/pdf/statesidesteps1.pdf
American Public Health
Association
“Urges health educators, policy-makers, journalists
and health care providers to recognize that the
choice of a mentally competent, terminally ill
person to choose to self-administer medications to
bring about a peaceful death is not "suicide," nor is
the prescribing of such medication by a physician
"assisted suicide." Urges terms such as "aid-indying" or "patient-directed dying" be used to
describe such a choice.”
American Academy of Hospice and
Palliative Medicine Position
Statement
Physician-assisted Death (PAD) is utilized in
this document with the belief that it
captures the essence of the process in a
more accurately descriptive fashion than
the more emotionally charged designation
Physician-assisted Suicide.
Adopted: February 14, 2007
“Terminally ill fear assisted
suicide”
Roper Poll showed euphemisms work
where clear disclosure is less effective
Gallup Poll demonstrates similar finding
Acknowledged as valid by leading medicide
advocates Humphrey and Smith
Politically savvy, medically imprudent
Wernow, JR: “Confronting the Pine Box with the Ballot Box: A
Critical Appraisal of Oregon’s Attempt to ‘do’ Medical Ethics by
Public Ballot” in Ethics and Medicine. (Fall 1997) v. 13/3, pp. 1-4.
“Unnecessary Law?”
7 % covert practice before law
Unwillingness to prosecute
Conclusion for Oregon
Meaningful data collection
Select committee of proponents and
opponents to weigh data and submit
report
Maintenance of confidentiality
Drop the euphemisms
The Take Away Point
The stories used to give meaning to a
person’s life are the stories used to
give meaning to a person’s ‘health.’
Two Different Stories
Troy Thompson
ALS
Storied in faith
community & family
Committed Christian
Greatly valued God’s
will
Died with help of
hospice palliation
Patrick Matheny
ALS
Storied in family
Rugged individualist
Greatly valued
autonomy
Difficulty swallowing
lethal draught
Brother-in-law helped
die
Christianity Today, “OR Sever Mercy,” Jn 14, 1999, pp. 66. cf.
Oregonian, “Man with ALS…Die,” Mrch 11, 1999, section D-1ff.
Final Take Away – In which ghost
story do you believe?