Thursday, June 4, 2015

What should we call the physician-assisted act of intentionally killing oneself near the end of life

By: Eric Widera (@ewidera)

It was a big day in California today. The California Senate passed SB 128 which would permit a doctor to provide a terminally ill patient a lethal dose of a drug with the explicit intention that the terminally ill patient make take this drug to shorten his or her life.

So here is the problem that I have when trying to put my head around this issue and write about this for GeriPal. It all starts with what to call it when a physician prescribes a lethal dose of a drug for a terminally ill patient with the intent that the patient may choose to self-administer this drug to bring about his or her death. For obvious reasons, it would be hard to say this over and over again in a paragraph (as I just did), so what should we call it when we right or talk about it?

Here are the leading options:
  • Death with Dignity: I know what I’m about to say will be taken as a great offense to some who read this blog, but come on. This is just pandering. The term is vague and value laden that offers nothing to the debate over the topic except spin. It also makes it seem like this is the only road to go if you want dignity at death. 
  • Physician-aid in dying (PAD): I’m not loving this one either mainly because of a loss of specificity. Are we providing people aid that are dying by focusing on their comfort or are we aiding them to die by giving them medications with the intent to end their lives? Only the latter is correct but people may confuse the former with it 
  • Aid in Dying: I’m not even sure what to do with this one. Who is aiding who with what again
  • Physician Assisted Death (another PAD): I'll talk more about this below, but this makes it unclear if we are including euthanasia
  • Physician Assisted Suicide (PAS): this is probably the most specific term for the physician assisted act of killing oneself intentionally. However I do realize that many criticize this definition as suicide is linked with mental illness and lack of decision-making capacity (both of which may I add shouldn't be stigmatized either)

With all of this said, I feel the most technically correct phrase to use is Physician Assisted Suicide (sui: of oneself + caedere: kill).

Physician Assisted Death probably comes in at a close second for best term to use, although another worry is that it is vague enough that I don't know if it encompasses euthanasia and/or assisted suicide (this is also true of aid-in-dying as it doesn't state who is doing what to whom). For example, a recent NEJM article defined Physician Assisted Death as the administration of drugs with the explicit intention of shorting of life that both encompassed euthanasia or PAS. As I don't think most people would argue for endorsing euthanasia, I think specificity is important.

So with that said, I’d love to know what term you use and why. Take my poll and leave comments below.

What should the physician-assisted act of killing oneself intentionally near the end of life be called?


Bruce Scott said...

I generally agree with your feelings about the terms, although likely with less vigor.

I'm not sure what you intend to do with the results of this survey, but I think you should use caution.

Since you made arguments in the post leading up to the poll, you probably can't make much of the results. (It has a bit of the elements of a push-poll)

Eric Widera said...

Thank Bruce. I did not create this poll to be an academically rigorous study into the beliefs of health care providers. Rather, just an informal way to judge the mood of the readership. Also, didn't know I had that much vigor in my writing - must be the cold medicine...

Bruce Scott said...

I didn't really mean that you were overly vigorous...more that I'm fairly ambivalent. (About the name. I'm a partisan on the topic itself.) More a matter of indicating that my views on naming seemed to be diluted compared to yours. My answer really would have been more like: "I don't really much care that much, but I suppose I'd pick PAS".

I don't particularly love DwD, since I think that is something we can and should be shooting for in general.

Niamh van Meines said...

If the physician did not administer the drug, was not present at the death, and did not physically do anything to cause the death, then I don't believe that they assisted. Suicide is suicide. PAD or PAS implies an active role in the patient's act of killing themselves. I think, it would be more appropriate to just focus on the act of prescribing the medication, which is a pre-cursor to the suicide to describe the physician's role. So what to call the act of prescribing the medication and what the prescription is called. We admit patients to hospices / hospitals for "terminal sedation", so something along those lines would be palatable. In hospice, many patients are prescribed a comfort pack for pain and symptom if we merge them.....Terminal comfort pack prescriber / or suicide pack prescriber still doesn't feel right, but it's removed from the suicide act.

Ann Broderick said...

None of these names describe patient control--which is the overwhelming reason that patient want this option I think. How about:
Patient-controlled death by physician prescription (is it always a physician--not clinician).

Pam Campbell said...

I vote for the name - "Choice at the end of life". That would be "Doctor Assisted Choice" at the end of life. DAC

My argument for 'Choice' is two-fold. For one thing it is just plain honest - which is always the best policy - and carries no judgment or attitude. We all have choice, all the time. My argument is also shaped by a significant bout with cancer, and all the accompanying accouterments of chemical and radiation therapies, etc. This has given me great pause and consideration of this subject.

I am not saying everyone ought to cut out the last part of their inevitable journey to death, I'm just stating the obvious - we have the choice, and we ought to be able to make it without shame and judgment. And to receive assistance from our care providers so we don't need to resort to extreme measures. Of course I am referring to the time when additional interventions would be futile, adding little to no quality of life.

To the doctors who have respect for the patient's carefully considered choice to end their own suffering, and who are willing to assist in the relief of that suffering - I say thank you.

Anonymous said...

How about The Right to Die

Ronald said...

A terminal diagnosis isn't a certainty that one will die when predicted. Many of us know people who were suppose to die within months of a diagnosis but instead lived for years. We already have palliative care with pain management and hospices for the those with actual terminal diagnosis within a few months.
Physician Assisted suicide laws are vulnerable to deadly abuses especially for the elderly and disabled. State oversight depends almost entirely on self-reporting. The death certificate does not require that physician assisted death be entered on it only the underlying terminal illness and many times the MDs are under the direction of corporate managers.
Who are the corporate interests that stand to gain under physician assisted suicide laws? Big profit Wall Street medical insurance companies stand to be big winners as they would no longer be paying for medical care when patients die early.
Physician assisted suicide is a slippery slope. Corporate interests aleady have lead to a mandatory Russian Roulette drug use in hospitals. The clot-buster drug for heart and lung blood clots has proven test trial and community hospital use results but for a non-life threathening ischemic clot stroke it's just the deadly opposite. Mandatory stroke TPA in the ER has a history of deadly failed test trials and controversial if any benefit modest benefit. Search: AAEM TPA position, The NNT TPA stroke, or in ER emergency blogs or for the stroke TPA drug controversy.
The Maynard family might consider being advocates on public awareness for the increased risk of brain cancer from placing a wireless transmitting device next to one's head. The brain cancer risk for cell phone use is especially increased for those who start using it as a child, Search: BioInitiative, Lennart Hardell and EU Interphone studies on cell phone risks.

Amy Getter said...

None of the dozen or so patients I have cared for on hospice, (that did in fact use their prescription to end their life prematurely), had a physician present. I have had a problem with all the terms, because none of them are truly precise. Can you say the physician actually assisted in the suicide because he wrote a prescription? That term unfortunately is why so many people confuse DWD or PAS with euthanasia. It would be more accurate to remove the physician part in the title. We don’t say “pharmacist assisted death”, “chaplain assisted death” or “volunteer assisted death” to describe the other people who have assisted, indirectly, with someone taking a lethal dose of medication to end their life. Let’s call it patient hastened death, because that is what it is.

Andre said...

Do we speak of physician assisted life when a doctor prescribes a medication or a treatment. Key thing to emphasise here is the decision of the person to end their pain rather than the physician. Assisted suicide/death places which infers a doctor intervening in the process - a slippery slope. Voluntary euthanasia is a commonly used term in Australia and places some of the power back in the hands of the person.

Anonymous said...

SAD....Self Arranged Death

Scott Irwin said...

If passed, why not just another tool for end-of-life care? We use lots of things at our disposal without naming them controversially. A whole host of things fall under withdrawing or withholding care. How is palliative sedation to death different (and I think it is), what about agitation control?

I do believe suicide should be a term used for something motivated by mental illness, which in many, if not most cases, PAS, DWD, whatever, is not.

We will have a lot more time to debate, as they postponed the bill today for about a year . . .