Physician-Assisted Death Scanning the Landscape: Proceedings of a Workshop (2018) / Chapter Skim
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5 Implementation and Practice of Physician-Assisted Death
5 Implementation and Practice of Physician-Assisted Death
Pages 75-98
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From page 75... ...
(Pope) • Institutional responses to the newly legalized physician aid-in dying option in California have been challenging to design and implement, and these responses require significant resources, including clearly identified patient navigators.
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From page 76... ...
SAFEGUARDS Thaddeus Pope Director, Health Law Institute Mitchell Hamline School of Law At the time of the workshop, five states (California, Colorado, Oregon, Vermont, and Washington) and the District of Columbia had approved medical aid-in-dying laws,1 and more than half of the remaining states had 1 A 2009 Montana Supreme Court decision ruled that state law protects Montana physicians from prosecution for helping terminally ill patients die.
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From page 77... ...
In response, Pope said, some institutions now require a mental health screening for everyone who seeks to receive a prescription for lethal medication, and some jurisdictions have sought to include mandatory screening in their laws. Scotland included mandatory screening in its proposed law, which did not pass, and Belgian law includes mandatory screening for some categories, such as for individuals who are not terminally ill and for mature minors (Boring, 2014; Scottish Parliament, 2010)
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From page 78... ...
. Current laws in Belgium and the Netherlands allow minors to access assisted death.
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From page 79... ...
This requirement can cause a serious access problem when it comes to finding two available and willing physicians, Pope said, adding that there is a growing literature on whether nurse practitioners should be included in the list of eligible providers, just as they are now with physician order for life-sustaining treatment forms (Stokes, 2017)
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From page 80... ...
Notify attending Death < 10 NO Submit OHA report Medication days Death and notify Disposal attending physician FIGURE 5-1 Potential patient navigator system for physician-assisted death. NOTE: MD = medical doctor; PAD = physician-assisted death; RX = prescription.
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From page 81... ...
This way, he said, physicians and pharmacists do not have to make quality-of-life assessments about extraordinary suffering or directly administer a lethal agent into the patient's body, but simply are responsible for determinations of capacity. Similarly, because the Oregon law imposes no legal duty on any health care professional to participate in prescribing lethal medication, the provision acts as a safeguard against involuntary participation by physicians or pharmacists, who can choose to participate or not with moral integrity.
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From page 82... ...
Hospice care is based on a team philosophy, and hospice best practices could ensure that patient requests for physicianassisted death are voluntary, informed, and not motivated by uncontrolled pain or financial concerns. PHYSICIAN PERSPECTIVES Anthony Back Professor of Medicine University of Washington Anthony Back told the workshop that from his perspective as a medical oncologist and palliative care physician, thinking about physicianassisted dying is no longer just for social pioneers.
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From page 83... ...
Back said that he sees something of a "gift exchange" between patients who consider physician-assisted death and their loved ones -- that is, the patient gives his or her loved ones a new perspective on approaching death, while receiving the gift of a "good" death in return. Back clarified that this concept of a "gift exchange" is complicated and not well described or understood and therefore an area for further research.
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From page 84... ...
based on a similar program implemented at Oregon Health & Science University. He has also worked with a large health system in California to teach its physicians that physician-assisted death is not about the law, but rather about the patient's goals for end-of-life care.
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From page 85... ...
He said he supports Oregon's law, particularly because of the enhanced potential for communication it creates with patients and families. He noted that after 20 years and some 1,500 cases of aid-in-dying in Oregon, there has not been a single complaint of misuse filed with the Oregon medical board and almost no unexpected complications (Oregon Health Authority, 2018)
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From page 86... ...
According to Reagan, about 20 percent of oral aid-in-dying patients in the Netherlands received some form of intravenous euthanasia 2 or so hours after ingestion.6 In Oregon, when a dying process goes on for more than 8 to 12 hours, or when vital signs appear to be strengthening, buccal morphine or topical fentanyl patches are sometimes used. Reagan spoke of the value of discussing a prolonged dying process with the patient and family in advance, and he questioned whether legally, intentionally, and publicly ingesting a lethal prescription constitutes a form of consent for palliative sedation if that lethal medication fails to work as intended.
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From page 87... ...
Currently, a patient requesting assisted death would need to have all of the medical records based on his or her state of residence in order to access the law. Erik Fromme Director, Serious Illness Care Program, Ariadne Labs Dana-Farber Cancer Institute Erik Fromme, the director of the Serious Illness Care Program at Ariadne Labs, recently left a position as the director of palliative care at Oregon Health & Science University, where for 15 years he chose not to prescribe lethal medications for patients requesting physician-assisted death.
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From page 88... ...
Three faith-based health systems and the Veterans Affairs medical center, which together account for the majority of health care services in the city, along with many smaller physician groups adopted policies that forbade their physicians to prescribe lethal medications or to discuss physician-assisted death with patients. This forced patients to either abandon their request or to seek care from one of two health systems that had not forbidden physicians to prescribe.
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From page 89... ...
Access to specialty palliative care is limited or non-existent in rural areas. He reported that many hospice organizations decided not to participate in physician aidin-dying requests and that many rural physicians said they did not want to become involved in assisted deaths for fear it would alienate some in their communities.
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From page 90... ...
Koenig said that an institution must consider a number of issues when determining how to respond to a law such as EOLOA. These consideration include • Whether to allow the practice on the premises • Who will participate • How to honor the conscientious objections by providers while respecting patient choice • What will be the role of palliative care • How often will mental health evaluations be conducted • How to determine if a patient should be referred for an ethics consultations For example, while most hospitals do not allow the lethal medications to be ingested onsite, patients at a large long-term care institution often have nowhere else to go because the institution is their home.
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From page 91... ...
The data collection efforts surrounding "final attestation" forms are not yet adequate, and therefore it is unknown whether the concept of documenting final ingestion of the lethal medication serves the purpose for which it was intended. One unique issue that arose at the second stakeholder engagement meeting was that interpreters were being asked to sign documentation attesting to the voluntariness of the patient taking the lethal medication, which many interpreters believe is far out of their scope of practice.
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From page 92... ...
"Assisted dying is a low-frequency, high-risk medical procedure," he said. "And we should start treating it like that within the medical profession and stop waiting for government and the state to tell us how to manage this." With that on the table, he said that there are three main sources of data on physicianassisted death: physicians (see Table 5-1)
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From page 93... ...
ü ü ü ü NOTES: EMS = emergency medical services; MD = medical doctor. ECOG is a measurement scale used by physicians to assess how illness or poor health impacts a patient's daily living abilities.
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From page 94... ...
Data from Abbott et al., 2017. TABLE 5-3 Pharmacist-Sourced Data in the Six Jurisdictions Where Physician-Assisted Death Is Legal CO OR WA CA VT DC MT Which medication(s)
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From page 95... ...
As a final comment, Wynia reiterated his earlier statement that assisted dying is a low-frequency, high-risk procedure, and that health professions should start treating it as such. "It is our responsibility and not the responsibility of the government, and not the responsibility of activists, to establish a national registry and to have standard data reporting elements and reporting requirements," he said.
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From page 96... ...
Canada's legislation required that the federal minister of health work with the provinces and territories to develop a regulatory framework that focuses on compliance for transparency and public trust, Jennifer Gibson said. So far, she said, the federal government and Health Canada have issued guidelines on death certificates in order to ensure some consistency across the country on how medically assisted deaths are reported.
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From page 97... ...
Portland: Oregon Health Division. Colorado Department of Public Health and Environment.
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From page 98... ...
:596–603. Oregon Health Authority.
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