Physician Assisted Suicide Deaths

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					An Analysis of Nine Years of
Physician-Assisted Suicide in
          Oregon
 Jerome R. Wernow Ph.D., R.Ph.
            Director
       ncb@teleport.com
Re-visit Take Away Point

The stories used to give meaning to a
 person’s life are the stories used to
 give meaning to a person’s ‘health.’
Human B/b-eing


                  Corporeality

                 Spiritual Illumination

                   Psychofacticity
Defining As Good As It Gets
         Personal ‘Story’
Heavily invested in opposition 1994-1999
Researched
Published academically
Provided legal testimony federal court
Crafted legislative safeguards
Personal ALS and brain cancer contacts
Became uninterested after 2000
              Approach

What was asserted by opponents
What was asserted by proponents
What is the practice found in the reports
             Opponents of PAS
“Pills don’t work”                      “Not family friendly”
“Doctors can’t predict”                 “Killing without
“Mental Health                          consent”
consultation not                        “Duty to die”
required”                               “Terminally ill fear
“Falsified records”                     assisted suicide”
                                        “Unnecessary Law”
Facts about Assisted Suicide under Measure 16 by Physicians for
Compassionate Care (1994)
Proponents for Physician Assisted
             Suicide

Support from people and physicians
Improves care of the terminally ill
Increases death at home not hospitals
Increases pain care
Increases end-of-life care for uninsured
Physician Assisted Suicide Deaths
           1998-2006
                               Physician Assisted Suicide Deaths

            50                                                                   46
            45                                             42
            40                                    38               37     38
            35
            30          27       27
   Deaths




            25                           21
            20   16
            15
            10
             5
             0
                 1998   1999    2000    2001     2002     2003     2004   2005   2006
Death with Dignity Act of
         1994
   “Allows terminally ill adult Oregon
residents voluntary informed choice to
   obtain physician’s prescription for
           drugs to end life.”
“Pills Don’t Work”
             100.00%
             90.00%
             80.00%

             70.00%

             60.00%
   Percent   50.00%           Failures
             40.00%           not reported

             30.00%
             20.00%

             10.00%

              0.00%
                       Year
           Myth and Fact
Myth: “Dutch researcher warns of 25 %
lingering deaths” Keefe, Mark, Oregonian
Fact: About 4% fail in Holland (Kimsma)
Fact: Dutch lethally inject after 6 hours to
end oral administration failure and
lingering death
  Drugs of Choice


Secobarbital used 136 (47%)
Pentobarbital used 152 (52%)
           Oregon Statute

“Nothing in this Act shall be construed
to authorize a physician or any other
person to end a patient’s life by lethal
injection, mercy killing, or active
euthanasia.”
    Onset, Peak, and Duration of
              Activity

Secobarbital               Pentobarbital
  Onset 10-15 minutes        Onset 20-60 minutes
  Peak activity 15 min       Peak activity 15 min
  Duration 3-4 hours (v)     Duration 3-4 hours (v)
           Netherlands’ Standard
   Intravenous route preferred
   IV solution used orally sodium pento- or
   secobarbital 100 ml solution
   If patient fails to ingest entire solution or
   lingers more than 5 hours, administer
   pancuronium or vecuronium bromide 20
   mg intravenously

Gerrit K. Kimsma: “Euthanasia AND euthanizing drugs in The Netherlands,” in
Drug Use in Assisted Suicide and Euthanasia. (Battin and Lipman eds)
Pharmaceutical Products Press, 1996.
        Ingestion to Death
      (Health division report)

Median Time: 25 minutes (n=232)
Range: 4 minutes-48 hours (n=232)
Greater than 6 hrs: 14 (n=232)
Unknown: 17 (232/249 = 7.1%)
Ingestion time until Death
   Reported to Unreported Ingestion until Death

          50
          40
Number of 30
 Patients 20                                     Reported
          10                                     Unreported
           0
               1   2     3    4   5      6   7
                       Years 2000-2006
       “Pills Don’t Work?”

Seem to work in about 94 out 100 cases
Question arises regarding accuracy of
positive outcome due to hard to access
data (59% gives no info on timing)
Is 5-6% failure medically acceptable
standard?
                     Failures
  Approximately six percent known*


*Health division reports 17 cases without reporting of minutes
until death (7.1%)
“Doctors can’t Predict”

               90
               80
               70
               60
   Months 1st
                50
  Request Until                                             Median
                40
     Death                                                  Minimum
                30
                20                                          Maximum
               10
                0
                     1   2   3   4    5     6   7   8   9
                                     Year
       Oregon Statute

 “diagnosed with a terminal illness
that will lead to death within six (6)
               months”
First Request until Death

 Median: 42 days
 Range: 15 days-1009 days


http://oregon.gov/DHS/ph/pas/docs/yr9-tbl-1.pdf
      First Request until Death
             90
             80
             70
             60
 Months 1st
              50
Request Until                                             Median
              40
   Death                                                  Minimum
              30
              20                                          Maximum
             10
              0
                   1   2   3   4    5     6   7   8   9
                                   Year
  “Doctors Seem to Predict”
Median suggests longevity is predictable
Question revolves around skewing of data
Unable to determine longevity of those
using PAS
Unable to weight significance of outlying
data without more detail
“Mental Health consultation
       not required”
                  50

                  40
   Total Physician 30
      Assisted
                   20                                          No Psych Eval
      Suicides
                                                               Psych Eval
                  10

                   0
                        1   2   3   4    5     6   7   8   9
                                        Year
    Capacity And Volition
       Requirements

     127.815 §3.01 (d) Refer the patient to a
consulting physician for medical confirmation
of the diagnosis, and for a determination that
the patient is capable and acting voluntarily;

    127.815 §3.01 (e) Refer the patient for
 counseling if appropriate pursuant to ORS
                  127.825;
       Mental Consult Requirements

If in the opinion of the attending physician or the consulting
physician a patient may be suffering from a psychiatric or
psychological disorder or depression causing impaired
judgment, either physician shall refer the patient for counseling.
No medication to end a patient’s life in a humane and dignified
manner shall be prescribed until the person performing the
counseling determines that the patient is not suffering from a
psychiatric or psychological disorder or depression causing
impaired judgment.


  [OR127.825 §3.03. Counseling referral 1995 c.3 §3.03; 1999 c.423 §4]
  Informed Consent Requirements

127.830 §3.04. Informed decision. “ he or
she has made an informed decision as
defined in ORS 127.800 (7).”

“based on an appreciation of the relevant
facts and after being fully informed by the
attending physician”
  Number of Mental Evaluations

               50

               40
Total Physician 30
   Assisted
                20                                          No Psych Eval
   Suicides
                                                            Psych Eval
               10

                0
                     1   2   3   4    5     6   7   8   9
                                     Year
Mental Health Referrals

   Thirteen percent (36/292) of the
   patients committing suicide were
referred for mental health evaluations
                   Mental Health Referrals
                          Percent
                                Percent


          60
          50
Percent




          40
          30                                              Percent
          20
          10
           0
               1    2   3   4    5        6   7   8   9
                                Year
Physician-Patient Relationship

       6
       5
       4
Months 3
                                                  Median in Months
       2
                                                  Minumum in Months
       1
       0
           1   2   3   4    5     6   7   8   9
                           Year
                        Hospice Care
                                 In Hospice Care


          100
           80
Percent




           60
                                                           In Hospice Care
           40
           20
            0
                1   2   3    4     5    6    7     8   9
                                 Year




                            Median: 86%
     End of Life Concerns
87% Loss of Autonomy
87% Loss of Pleasure
80% Loss of Dignity
57% Loss of Bodily Control
38% Burden on Family
26% Pain Control
2% Finance
 Mental Health consultation not
      required - analysis
Clear decrease in psych referrals
Difficult to determine significance of
minimal physician-patient contact
Psych-socials in hospice care may
diminish referral for psych evaluation
Rationale is subjective and narrative
based
      Cheney Case of Portland
 Female 85 y/o                          Daughter objected
 Dx terminal cancer                     Asserted mother’s desire
 Alzheimer’s dementia                   for PAS
 Psychiatric-diagnosed                  2nd Psych consult found
 diminished capacity                    diminished capacity
 MD recommended                         Concerned about familial
 against PAS                            pressure
 Patient accepted MD                    Psychologist still
 advice                                 determined pt. competent

Wesley J. Smith: “Bioethics: Frontiers and New Challenges. Cf. www.
books.google.com/books?isbn=9728818610...
“Falsified Records” Issue


                70
                60
                50
                40
Scripts Written
                30                                    Rx written
                20                                    Reporting issue
                10
                 0
                     1   2    3    4    5     6   7
                             Year 2000-2006
   Reporting Requirements
ORS127.865 §3.11 (b) The department
shall require any health care provider upon
dispensing medication pursuant to ORS
127.800 to 127.897 to file a copy of the
dispensing record with the department.
     Reporting Requirements
(1) To comply with ORS 127.865(2), within
seven calendar days of writing a prescription for
medication to end the life of a qualified patient
the attending physician shall send the following
completed, signed and dated documentation by
mail to the State Registrar, Center for Health
Statistics, …(6 forms)

  http://arcweb.sos.state.or.us/rules/OARs_300/OAR_333/333_009.html
     Reporting Requirements
(1) (3) To comply with ORS 127.865(1)(b), within
    10 calendar days of dispensing medication
    pursuant to the Death with Dignity Act, the
    dispensing health care provider shall file a
    copy of the "Pharmacy Dispensing Record
    Form" prescribed by the Department with the
    State Registrar, Center for Health Statistics, …
   (ORS 333-009-0010 )
   Reporting Requirements

(2) Within 10 calendar days of a patient's
ingestion of lethal medication obtained
pursuant to the Act, or death from any
other cause, whichever comes first, the
attending physician shall complete the
"Oregon Death with Dignity Act Attending
Physician Interview" form prescribed by
the Department.
Prescriptions cp Deaths




  http://oregon.gov/DHS/ph/pas/docs/year9.pdf
                     Reporting Issues

               70
               60
                50
                40
Scripts Written
                30                                    Rx written
                20                                    Reporting issue
                10
                 0
                     1   2    3    4    5     6   7
                             Year 2000-2006




        No action needed by Board of Medical Examiners
         Reporting Issues
“Cannot detect or collect data on issues of
noncompliance with any accuracy” OHD, 1999
Needed: comparison of DEA records detailing
(1) Pento- and Secobarbital sold with (2) Pento-
with (3) Secobarbitol dispensed with number of
OHD reporting forms
BME reports apparent ‘good faith’ compliance of
100%
     “Killing without consent”


Board of Medical examiners have only
pursued one case
Associated Press raised one other
Occurrences seems rare
Likelihood of prosecution unclear
   Active Involuntary Euthanasia
            March 1996
78 y/o transported to                    Extubated, Morphine,
hospital, intubated,                     Valium ordered prn for
unresponsive                             comfort
Dx: subarachnoid                         Morphine 5-10mg and
hemorrhage by Patient’s                  diazepam 5-10 mg given
MD (6 years) with consult                q 5-10 minutes for 2 hr,
Prognosis for recovery                   no evidence of discomfort
poor                                     Magnet applied to
Daughter and MD                          pacemaker
concurred W/D and W/H                    Succinylcholine 100 mg
tx                                       given causing death
BME Notice of Disciplinary Action, July 18 1996.
       Legal Proceedings
Venue changed to Lane County
District attorney “very difficult to get a
conviction for homicide”
“Injustice to incarcerate”
“Does not need to be on probation”
BME 2 month suspension and $6,371 fine
enough, charges dropped
BME “MD motive – misguided”
     Four nursing home deaths
 Allegation of morphine overdosing
 Nurse determined “mentally unstable and
 unfit for practice”
 Nursing home fined $6,000
 Grand Jury refused to indict RN

Associated Press: Oregon Grand Jury Refuses to Indict Nurse in Euthanasia
Deaths. September 13, 2000
“Terminally ill fear assisted suicide”
             2005 Gallup Poll
When asked if doctors should be allowed
to end the life of a patient who is suffering
from incurable disease and wants to die
"75 percent of respondents said yes”
When asked if doctors should help a
patient commit suicide under the same
circumstances, “only 58 percent said yes”
          http://www.ca-aas.com/pdf/statesidesteps1.pdf
“By using Orwellian ‘doublespeak’ we might be
letting ourselves in for procedures and conclusions
which we do not fully comprehend at the time of
decision-making.

On the other hand, perhaps euphemisms allow
people to come to grips with brutal facts which,
stated another way, would be repugnant.”



Humphry, Derek: What’s in a word? The results of a Roper Poll of Americans on
how they view the importance of language in the debate over the right to choose
to die. (Euthanasia Research and Guidance Organization (ERGO): August,
1993) p. 2.
Compassion & Choices*
   “Suicide” is Inaccurate,
  Biased Term to Describe
    Terminally-Ill Patients’
     End-of-Life Choices”
         (Press Kit Statement)

     *Formerly: Hemlock Society
         Language Games

Compassion & Choices made its case in an
Aug. 22 letter to state official that said
"physician-assisted suicide" "is value-laden
and negatively biased language that
perpetuates misunderstanding of Oregon
law and policy."

         http://www.ca-aas.com/pdf/statesidesteps1.pdf
The Oregon Department of Human
        Services (DHS)
C & C first sent a formal request to the
state agency, suggesting that the terms
“aid-in-dying,” “directed dying,” or
“assisted dying” be used in official state
reports
brought lawyers to a meeting with the DHS
to discuss the language substitution
implied that, if it were not made, litigation
might follow
            http://www.discovery.org/a/3931
The Oregon Public Health Division
Calling it "physician-assisted suicide" was
"perhaps a mistake we made years ago," given
the language of the law, said Dr. Katrina
Hedberg, public health physician with the state
Public Health Division who helps compile the
annual report. But "physician-assisted death"
didn't quite work either.
“The state's Web pages and subsequent annual
reports will refer only to the Death with Dignity
Act.”
         http://www.ca-aas.com/pdf/statesidesteps1.pdf
      American Public Health
           Association
“Urges health educators, policy-makers, journalists
and health care providers to recognize that the
choice of a mentally competent, terminally ill
person to choose to self-administer medications to
bring about a peaceful death is not "suicide," nor is
the prescribing of such medication by a physician
"assisted suicide." Urges terms such as "aid-in-
dying" or "patient-directed dying" be used to
describe such a choice.”
American Academy of Hospice and
  Palliative Medicine Position
            Statement
Physician-assisted Death (PAD) is utilized in
 this document with the belief that it
 captures the essence of the process in a
 more accurately descriptive fashion than
 the more emotionally charged designation
 Physician-assisted Suicide.
 Adopted: February 14, 2007
     “Terminally ill fear assisted
              suicide”
Roper Poll showed euphemisms work
where clear disclosure is less effective
Gallup Poll demonstrates similar finding
Acknowledged as valid by leading medicide
advocates Humphrey and Smith
Politically savvy, medically imprudent
Wernow, JR: “Confronting the Pine Box with the Ballot Box: A
Critical Appraisal of Oregon’s Attempt to ‘do’ Medical Ethics by
Public Ballot” in Ethics and Medicine. (Fall 1997) v. 13/3, pp. 1-4.
“Unnecessary Law?”

7 % covert practice before law
Unwillingness to prosecute
   Conclusion for Oregon
Meaningful data collection
Select committee of proponents and
opponents to weigh data and submit
report
Maintenance of confidentiality
Drop the euphemisms
  The Take Away Point

The stories used to give meaning to a
 person’s life are the stories used to
 give meaning to a person’s ‘health.’
       Two Different Stories
Troy Thompson                         Patrick Matheny
ALS                                   ALS
Storied in faith                      Storied in family
community & family                    Rugged individualist
Committed Christian                   Greatly valued
Greatly valued God’s                  autonomy
will                                  Difficulty swallowing
Died with help of                     lethal draught
hospice palliation                    Brother-in-law helped
                                      die
  Christianity Today, “OR Sever Mercy,” Jn 14, 1999, pp. 66. cf.
  Oregonian, “Man with ALS…Die,” Mrch 11, 1999, section D-1ff.
Final Take Away – In which ghost
      story do you believe?

				
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