Oregon's Death with Dignity Act

[Jump_Nurse]

I'm interested to hear what hospice nurses' opinions are about the Oregon Death with Dignity Act.

This piece of legislation was passed in 1997, and essentially allows a terminally ill patient to self-administer medications prescribed by a physician in order to end their life. Obviously, the patient has to seek out this service, it is not done solely on the whim of the prescribing physician.

Last year 85 patients utilized this option to end their own suffering. There are strict criteria a patient must meet in order to be eligible for this.

More information and a general overview is available on the state of Oregon's website here:

http://www.oregon.gov/DHS/ph/pas/faqs.shtml

As for myself?

I absolutely support it. I have seen it, and I KNOW that I would not want to live in such a state. I KNOW that several of my family members and friends have expressed the same desire, should they end up in a similar situation. I don't feel like anyone who is not suffering should be able to tell someone who is that they don't have the right to make this choice.

That said, I don't feel like this should be a patient's first, or even second or third alternative. The criterion for inclusion exist for a reason, and if followed I see no reason why this should not exist in every state. Nobody is going to make you, the terminally ill patient, participate if you don't want to. No one is going to make a physician prescribe these medications if he or she feels uncomfortable doing so. But for those patients who do elect to take this route, and find a physician willing to cooperate, it could save them a lot of needless suffering.

How do you feel?

[aimeee, BSN, RN]

I'm personally uncomfortable with it but I support self-determination. My father is a member of the hemlock society and I would want to be able to support him.

[rngolfer53]

My concern with this and similar legislation is the potential for abuse r/t families, etc putting pressure on relatives to end their lives before they are ready.

Autonomy, imho, should be the guiding principle, and that can be abused on both sides of this subject.

I am surprised at the relatively small number of people who have acted under this legislation, which seems to be evidence that my concern is perhaps overblown.

[aimeee, BSN, RN]

The small numbers may reflect that while few people actually MAKE the choice, they want to be able free to make it. It may reflect that we have deep taboos in our society and makeup about taking our own lives that keep us from doing that even when we have the means and the freedom.

[marachne]

i am a hospice & palliative nurse from oregon, as well as a nurse researcher who has studied the issue, done research on the issue, and have presented on the issue. so, you could say i have a bit of background and knowledge about the subject.

first of all, physician assisted death is now available in 2 states -- washington just passed a measure that is identical to oregon's law.

next, not only has there only been 341 deaths from pad in the 10 years it has been law.

third -- what all research, as well as the annual reports from proscribing physicians points to it that it has little to do w/physical pain, but almost overwhelmingly about control. when you go to the site cited by the op, if you click through to the "annual report" you will see:

"as in previous years, the most frequently mentioned end-of-life concerns were: loss of autonomy (100%), decreasing ability to participate in activities that made life enjoyable (86%), and loss of dignity (86%). during 2007, more participants were concerned about inadequate pain control (33%) than in previous years (26%)."

and while the issue of pain control has a fairly high prevalence, when current pain is separated from concern about future pain, it is the concern about future pain that is more of an issue.

if you look at the annual report, you will see that the number of people who use their prescription is much lower than the number of prescriptions written (85 rx, 46 deaths in 2007) -- the ops numbers are a bit off as they described the number of rx's not the number of people who died from ingesting the prescription. in the past, many have assumed that just having the prescription was enough for many people, but newer research seems to indicate that it is actually an issue of timing -- the process to aquire an rx is fairly lenghty, for one thing, you must request 3x -- 2x orally, 15 days apart, and once in writing, plus 2 physicians must agree that your prognosis is 6 months or less and that you are capable of making and communicating a health care decision (a psych consult is not required unless felt necessary by the physicians). once you get the rx, you must then be able to ingest the medication -- if you no longer are able to swallow (and we're talking 9 grams of secobarbital -- 90 caps or 9-10 grams of pentobarbital -- 90-100 caps). there are liquid forms sometimes available, but the cost is significantly higher

speaking of costs the medication is not inexpensive. while these are drugs that are traditionally cheap, a perscription costs between $800-$2400 -- and not covered by insurance.

as to concerns about family pressure, there is no evidence that famiies exert any pressure to take advantage of this law. actually, it is more a matter of families sometimes not being in agreement w/the patient in their desire to pursue pad.

so what do i think? i won't talk to the rightness or wrongness of the law: as a researcher, i must stay neutral in order to maintain my credibility. i do think the law is well written and that the fears regarding vulnerable populations have not been borne out -- the majority of recipients of prescriptions have been older, highly educated, insured, and with intact social support networks. the one concern that has been raised is that the prevalence of clinical depression may be higher than previously thought to be the case, and that may, at some times influence someone's decision-making capacity.

if you are interested in the topic, i have listed a few articles that specifically relate to hospice and the law. i highly recommend doing more reading, including the (very short, 2 page) annual report.

dilemmas encountered by hospice workers when patients wish to hasten death. by: harvath theresa a.; miller, lois l.; smith, kathryn a.; clark, lisa d.; jackson, ann; ganzini, linda. journal of hospice & palliative nursing, jul/aug2006, vol. 8 issue 4, p200-209

attitudes and experiences of oregon hospice nurses and social workers regarding assisted suicide. by: miller, lois l.; harvath, theresa a.; ganzini, linda; goy, elizabeth r.; delorit, molly a.; jackson, ann. palliative medicine, dec2004, vol. 18 issue 8, p685-691

nurses' experiences with hospice patients who refuse food and fluids to hasten death. by: ganzini, linda; goy, elizabeth r.; miller, lois l.; harvath, theresa a.; jackson, ann; delorit, molly a.. new england journal of medicine, 7/24/2003, vol. 349 issue 4, p359-365

[finn11707]

Yes, I believe the law in Oregon is a good one. Both of my parents were in an Oregon hospice at end of life, and did not choose to use this law and end their own life, though both voiced a wish for acceleration of their end. Other member of my family had difficulty finding within themselves ability to accept and support Hospice goals of comfort care - use of morphine and ativan to ease symptoms. My sister, who is a ER nurse especially had difficulty with the hospice philosophy. Though both of my parents expressed a strong wish to hasten their death, neither had the capacity to seek this out on their own, let alone the family support which would have been needed for them to feel comfortable with such a choice. Watching the struggle within my own family as my parents prepared to die opened my eyes further to the full responsibility and nature of our work with patients and families facing death. It is their journey, their end. We must look deeply within ourselves to find the capacity to support the full scope of the work. We are not just nurses. Each nursing visit to patients and families struggling to cope with approaching death, necessitates we possess strong ability in other areas more akin to social worker, chaplain and friend. In a perfect world, the MSW or Chaplain would be there or be available to go as needed to such visits. We know, this is not, in actuality the way most hospices function.

[katwoman7755]

Excellent post Marachne!! Very informative presentation of the data.

Thanks!

Kathryn

[prowlingMA]

As an MA I work for the doctors who are writing some of these RX.

We had one case where the man did not ask the doctor for an RX , did not share his wish to die, was depressed and, desided to end his life by suicide with his own gun.

So I have to ask would you rather someone ask for Rx to end pain in their own way or someone to end it in suicide.

So much harder on the surviving family of the suicide case.

The doctor even stated if he had asked he would have written the Rx for him.