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California assisted suicide bill signed into law, what next?


By: Laura Petrillo, MD @lpetrillz

Governor Jerry Brown signed California bill ABx2-15 into law today. The law will give California doctors the ability to prescribe lethal medication to competent, terminally ill patients so that they may end their lives. California is not the first state to enact such a law (Oregon, Washington and Vermont have laws in place), but it is the first since Brittany Maynard, the 29 year-old California woman with a fatal brain tumor, moved to Oregon last year to use the Death with Dignity Act and re-invigorated the decades-old legalization movement. Other states are likely to follow.

What next? If there is one message that all healthcare providers should hear, it is this: a request for assisted suicide is an opportunity to learn more about the individual’s experience, and to partner with the patient to create a plan that addresses her needs. This should include an evaluation of decision-making capacity, mood, symptoms and psychosocial support, followed by a trial of intensified treatment of reversible causes of suffering, possibly including referral to mental health specialists for additional care, and almost always enlisting palliative care support. Timothy Quill’s Fast Facts #156 and #159 provide an excellent starting point for going through this process. After thorough evaluation and treatment, and learning about other options such as hospice care and withdrawal of life-prolonging therapies, if the patient persists in her request, assisted suicide should be considered as a last resort.

The reason to go through all of this is not to prolong life at all costs, but because the vast majority of people will actually achieve a better quality of life through supportive care, and will not persist in their request for hastened death once their needs are met. If the goal of assisted suicide is truly to relieve suffering, anything that could achieve that goal while someone is still alive should be pursued. In Oregon and Washington, the number of people who use assisted suicide is incredibly low, about 0.3% of all deaths, most likely because there is excellent access to hospice and palliative services in those states (as demonstrated in last week’s CAPC report card), as well as appropriate evaluation of eligible patients.

As palliative care and geriatrics providers, we need to lead the way in spreading the message that every assisted suicide request is an opportunity to help our patients achieve a dignified death, but not necessarily through assisted suicide— it should be a last resort. Whether you plan to prescribe or not, it is important to create your own plan for how to respond, and if you can, educate others about primary palliative care skills (“Tell me more about your suffering”; “What are you worried about?”) and how to find more support for people contemplating assisted suicide.


Photo courtesy of Nancy Lundeberg ©2014

Comments

George Handzo said…
This is a helpful and positive take on the new CA legislation. As a certified chaplain, I do note the omission of good assessment and engagement with spiritual/religious/existential suffering. Even though the research increasingly points to unmet spiritual needs as a major correlate of how patients make health care decisions, we still too rarely even assess it let alone integrate it into the plan of care. Health care providers need better training in how to engage this dimension of care and professional chaplains need to be better integrated into palliative care teams to make sure this dimension of a patient's suffering is fully evaluated and attended to.
Jordan said…
I really enjoy this blog but continue to find its approach to this subject misguided.

Assisted dying is not just something people cry out for when they get substandard hospice and palliative care. The evidence does not bear that premise out. Nor should it be viewed merely as an "opportunity to learn more about the patient's experience." After a mentally competent dying person repeatedly asks for assisted dying, it is inappropriate to view that request as a medical provider's exploratory project.

Please consider, in the least, not calling it "assisted suicide," as that is disrespectful to the process and people who are involved with it.

Legally, the states that protect this process, including California, clearly distinguish it from "assisted suicide." Assisted suicide -- is still illegal in these states. (It's usually done by violent means to someone in mental distress or disease who's not in the dying process.) If a citizen of one of these states lawfully participates in the process, the coroner lists the terminal illness -- not suicide -- as the cause of death. And insurance companies do not consider these deaths as suicides when determining whether to pay out benefits under an insurance policy.

More importantly for this blog, from a psychological and medical standpoint, calling the process suicide hurts patients and their families and does not reflect best medical practice. Major organizations in the fields of psychology and medicine support this view -- including the American Academy of Hospice and Palliative Medicine, the American Psychological Association, the American Medical Student Association, the American Medical Women's Association, the American College of Legal Medicine, and the American Public Health Association.

Thank you for considering this comment. With much respect and appreciation, Jordan
Eric Widera said…
Jordan,

I actually see Dr. Petrillo's argument as a very fair description of the next steps. It would be a huge disservice to patients if we did not explore the meaning of their request and also did not explore whether they are making an informed decisions (as Dr. Petrillo pointed out this includes evaluating decision-making capacity, mood, etc). It is not only the medically and ethically correct thing to do, it also appears to be part of the new law (https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB128) as well as a part that leaders promoting this bill have said we should do (and those at a national level like Dr. Quill who Dr. Petrillo references). Your comment seems to suggest that we don't explore this, which I'm guessing that you are not advocating for. Can you clarify?

Eric

PS. Also note GeriPal has published posts on both sides of this issue. See an example here http://www.geripal.org/2013/08/a-hospice-nurses-experience-of-assisted.html

Eric Widera said…
One other thing. I actually completely agree with you on the importance of wording, although I have not yet found a term better than Physician Assisted Suicide as it is the most technically specific wording out there that I have seen. While I originally thought Physician Assisted Death was appropriate, I started noticing in the medical literature that this also refers to euthanasia (which makes sense as it is also physician assisted death for some individuals). See my post here:

http://www.geripal.org/2015/06/what-should-we-call-physician-assisted-suicide.html

Overall I think most physicians are like me, struggling to make sense of PAS/PAD and how it fits in to our practice (if at all). I think discussion like this is one way to help inform us of a way forward.

Eric
Loretta Downs said…
PAD is a matter of choice--which we all expect and demand--in the way to be at the end of our life. 70% of Americans want this choice, whether or not a request is made for PAD. For protection of the ethical use of the law, the process to get the mediation is long, and the cost of the drugs--in Oregon $1500 out of pocket--makes taking advantage of the choice impossible for many who want and need it.
Regardless of your ultimate position on the bill, is there anyone out there who can defend Jerry Brown's defense o the bill talking about"prolonged and excruciating pain?" Yes there are arguments about existential pain and dignity that clearly support the passage of this bill, but is there any evidence that "prolonged and excruciating pain"(understood my most people as physical pain) is something that is a realistic risk with good palliative care?

I am cnncerned that this bill was passed by reference to unrealistic fears and a fallacious argument. The disturbing result may be people who choose death in fear of outcomes that they need not fear with good care.
Patrice Villars said…
Thanks to Dr. Petrillo for this excellent post and for the opportunity to have another discussion. I, too, hope that requests for aid-in-dying result in thoughtful responses from medical and mental health professionals, referrals to Palliative experts, and all other supportive measures to minimize suffering without an attachment to whether or not the individual chooses to follow through with self-administering medications to end her/his life. With regard to terminology - I also don't like the stigmatization of the word "suicide". I also don't like having "Physician" as the first word. It implies control/responsibility on the prescribing doctor, rather than the broader understanding that this is a collaborative decision between an individual with an endstage illness, her/his doctor and (in hopefully many cases) other health care professionals. How about using the term "Aid-in-Dying"? This seems straight forward and is the language used in the bill.

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