Physicians' responses to patients' requests for physician-assisted suicide

BACKGROUND: Studies show that patient requests for physician-assisted suicide (PAS) are a relatively common clinical occurrence. The purpose of this study was to describe how experienced physicians assess and respond to requests for assisted suicide. METHODS: Focused ethnography in the offices of 11 acquired immunodeficiency syndrome physicians, 8 oncologists, and 1 hospice physician who had received requests for assisted suicide in their practice. Ten had facilitated PAS. RESULTS: Informants had a similar approach to evaluating patients who requested assisted suicide, often asking, "Why do you want to die now?" Reasons for requests fell into 3 broad categories: physical symptoms, psychological issues, and existential suffering. Physicians thought they competently addressed patients' physical symptoms, and this obviated most requests. They treated depression empirically and believed they did not assist depressed patients with assisted suicide. Physicians had difficulty addressing patients' existential suffering, which led to most facilitated requests. Informants rarely talked to colleagues about requests for assisted suicide, suggesting a "professional code of silence." CONCLUSIONS: Regardless of divergent attitudes about PAS, physicians respond similarly to requests for assisted suicide from their patients, creating a common ground for professional dialogue. Our sample addressed physical suffering aggressively, treated depression empirically, but struggled with requests arising from existential suffering. A professional code of silence regarding PAS creates professional isolation. Clinicians do not share knowledge or receive social support from peers about their decisions regarding assisted suicide. Educational strategies drawing on approaches used by experienced clinicians may create an atmosphere that enables physicians with divergent beliefs to discuss this difficult subject.     

Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide

BACKGROUND: The aims of this study were to obtain information about the characteristics of requests for euthanasia and physician-assisted suicide (EAS) and to distinguish among different types of situations that can arise between the request and the physician's decision. METHODS: All general practitioners in 18 of the 23 Dutch general practitioner districts received a written questionnaire in which they were asked to describe the most recent request for EAS they received. RESULTS: A total of 3614 general practitioners responded to the questionnaire (response rate, 60%). Of all explicit requests for EAS, 44% resulted in EAS. In the other cases the patient died before the performance (13%) or finalization of the decision making (13%), the patient withdrew the request (13%), or the physician refused the request (12%). Patients' most prominent symptoms were "feeling bad," "tiredness," and "lack of appetite." The most frequently mentioned reasons for requesting EAS were "pointless suffering," "loss of dignity," and "weakness." The patients' situation met the official requirements for accepted practice best in requests that resulted in EAS and least in refused requests. A lesser degree of competence and less unbearable and hopeless suffering had the strongest associations with the refusal of a request. CONCLUSIONS: The complexity of EAS decision making is reflected in the fact that besides granting and refusing a request, 3 other situations could be distinguished. The decisions physicians make, the reasons they have for their decisions, and the way they arrived at their decisions seem to be based on patient evaluations. Physicians report compliance with the official requirements for accepted practice.     

Motivations for physician-assisted suicide

OBJECTIVE: To obtain detailed narrative accounts of patients' motivations for pursuing physician-assisted suicide (PAS). DESIGN: Longitudinal case studies. PARTICIPANTS: Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors. SETTING: Participants' homes. MEASUREMENTS AND RESULTS: We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS. CONCLUSIONS: Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient's request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients' concerns over time, and tailoring care accordingly.     

Emergency physicians and physician-assisted suicide, Part I: a review of the physician-assisted suicide debate.

Physician-assisted suicide (PAS) has been one of the most hotly debated bioethics and health policy issues of the past decade. Part I of this 2-part article defines key terms in the debate, reviews the history of the debate, and articulates leading arguments for and against legalization of the practice of PAS. Part II of the article will examine the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS.     

Responding to legal requests for physician-assisted suicide. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel

In 1998, 15 terminally ill Oregon residents ended their lives with overdoses of medications supplied legally by their physicians. Many more people consider this possibility. This paper examines the ways in which the physician's response to requests for assisted suicide may change in an era of legalization, articulates some of the resulting conceptual challenges, and provides practical advice to physicians facing such requests. In areas where it is legal, assisted dying becomes one of the many options that can be freely considered for terminally ill patients with extreme suffering. Some patients even view assisted death as a right that can be expected on demand. We consider the ethical implications of disclosing assisted dying to patients as an option of last resort and suggest that physicians working in environments where assisted dying is legal are obliged to do so. However, we conclude that physicians should not encourage patients to hasten death even when practicing in jurisdictions that allow assisted dying. Furthermore, without abandoning the model, we suggest that strict informed consent does not fully address patients' needs at this time. Physicians must also focus on patients' broader biopsychosocial concerns and help them identify solutions through empathic listening and emotional support. We provide a framework and vocabulary for physicians to use when responding to requests for assisted suicide. Physicians should clarify the request, explore and address the patient's concerns, achieve a shared understanding of the goals of treatment, search for less harmful alternatives, express to the patient what they are willing to do, discuss the relevant legal issues, and share their decision making with colleagues.     

Emergency physicians and physician-assisted suicide, Part II: emergency care for patients who have attempted physician-assisted suicide.

Part I of this article reviewed key terms, events, and arguments in the heated national debate regarding physician-assisted suicide (PAS). Part II of the article examines the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS. The article considers the analogous cases of emergency care for other patients who have attempted suicide and care for terminally ill patients who refuse life-sustaining treatment. Morally relevant features of these situations are identified, including the decisionmaking capacity and the choices of the patient, the opinions of the patient's family or other surrogate decisionmakers, the presenting condition and medical history of the patient, the nature of the patient's suicide attempt, and the physician's own moral convictions. The article evaluates the 3 management options: aggressive intervention to preserve life, palliative care only, and assistance in completing the suicide. It concludes with several general recommendations for addressing these situations.     

Support for physician-assisted suicide: exploring the impact of ethnicity and attitudes toward planning for death

The authors interviewed adults in five ethnic groups, used factor analysis to quantify attitudes toward planning for death, and used path analysis to test the relative influence of respondent characteristics, including ethnicity, and attitude factors (Advocacy to Discuss/Document Wishes, Trust in Family and Physician to Make Decisions, Reliance on Religious Guidance, Fears and Anxiety About Life's End, and Fatalism About Death's Timing) on support for physician-assisted suicide (PAS). Findings verified that attitude factors had a direct effect on PAS support but that, contrary to the hypothesis, ethnicity had a direct effect on support for PAS as well.     

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.     

Lipid regulation: a clinician's view of patient management

Practicing physicians now have the capability as well as the responsibility to treat hyperlipidemia. Recent conclusive trials have demonstrated the link between lipid elevations and coronary heart disease, as well as the likelihood of reducing coronary heart disease risk by lowering blood lipids via diet and/or drug intervention. Screening criteria for hyperlipidemia in normal patients and in special patient subgroups are described, and recommendations for treatment are proposed. The diet recommended by the American Heart Association--which limits fat intake to 25% to 30% of all calories in a 1:1:1 ratio of saturated, monounsaturated and polyunsaturated fats, and limits cholesterol to less than 300 mg/day--is discussed. Guidelines are suggested for drug therapy with lipid-lowering agents to reduce abnormal lipid levels when diet alone proves insufficient after 2- to 3-month trial.