End-of-Life Choice, Palliative Care and Counseling

Posts TaggedMontana

The Evolving State of Physician-Assisted Suicide

By Jaime Joyce
The Atlantic
July 16, 2012

Should terminally ill patients have the right to kill themselves? Voters in Massachusetts will soon decide. Last Wednesday, the Secretary of the Commonwealth announced that on November 6, 2012, when Bay State voters go to the polls to pick the next President, they will also have their say on a ballot measure called the Death with Dignity Act. If passed, the law would make Massachusetts the third state to give adults diagnosed with six months or less to live the option to end their lives using a lethal dose of doctor-prescribed medication.

Last year, volunteers from across the state began a petition drive to collect the 68,911 signatures needed to introduce the act for consideration by the state legislature; by the time they were done, they’d gotten more than 86,000 voters to sign on to show their support. Lawmakers had until the beginning of May to address the issue, but they declined to do so. In response, volunteers fanned out for a second wave of signature gathering. An additional 21,000 people from the state’s 14 counties signed on to support the Act. That’s nearly double the number needed to bypass the statehouse and bring the issue directly to voters via ballot measure.

Oregon and Washington were the first states to enact Death with Dignity laws. (In Montana, the state’s Supreme Court ruled in 2009 that physician-assisted suicide was legal, but Montana has no guidelines in place to regulate and monitor the practice.) Since 1997, when Oregon’s Death with Dignity Act went into effect, more than 900 people have received prescriptions to their end their lives. Not all have used the drugs. The Oregon Public Heath Division reports that more than 600 individuals have taken the dose, while the remainder either decided against using the prescription, or succumbed to their diagnosed illness.

In Oregon and Washington, patients must first make two requests of their doctor for medication, fifteen days apart. The patient then has to make the request in writing. In order to prevent potential abuses, patients are required to sign consent forms in the presence of two witnesses to whom they are not related. Once approved, patients must self-administer the drugs. Typically, it’s a deadly dose of Seconal, a barbiturate often prescribed by doctors to treat insomnia or to calm patients before surgery. The contents of the capsules are stirred into a glass of water or a serving of applesauce, to dull the taste. Statistics compiled and released annually by the Oregon Department of Health show that in the majority of cases, people lose consciousness within five minutes of swallowing the drugs. It can take anywhere between one minute and four days to die, but for most people death comes in just 25 minutes.

Ninety-eight percent of people who have made use of the law in Oregon are white. Eighty-one percent had cancer. Fifty-two percent were men. The median age of those who died using the law was 71. Most patients were enrolled in hospice and privately insured. They cited loss of autonomy, loss of dignity and the fact that they were “less able to engage in activities making life enjoyable” as the top three end-of-life concerns. In Washington State, where a Death with Dignity Act was approved by ballot initiative in 2008, and went into effect the following year, patients fit a similar profile. According to the latest figures released by the state, 135 people have died from the lethal prescription. The Death with Dignity Act that will go before Massachusetts’s voters this fall is modeled after laws in place in Oregon and Washington.

A survey conducted in May by Western New England Polling Institute showed that 60 percent of Massachusetts’s voters supported the rights of terminally ill patients to legally obtain and ingest life-ending drugs. Still, the measure faces tough challenges from powerful factions within and beyond the state. The Massachusetts Medical Society opposes the Act. The American Medical Association does too. “Physician-assisted suicide is fundamentally incompatible with the physician’s role as a healer,” the AMA states in its Code of Medical Ethics. “Patients should not be abandoned once it is determined that cure is impossible.”

Disability-rights activists have also spoken out against physician-assisted suicide. So has the Catholic Church. Noting a resurgence of interest in the topic and a renewed push by advocates of physician-assisted suicide to extend the practice beyond Oregon and Washington, the United States Conference of Catholic Bishops last year issued an impassioned statement against the practice. In Massachusetts, the Roman Catholic Archdiocese of Boston, anticipating the ballot measure, created a website, suicideisalwaysatragedy.org. “Our society will be judged by how we treat those who are ill and infirm,” Archbishop of Boston, Cardinal Sean O’Malley, says in a video address that appears on the site. “They need our care and protection, not lethal drugs.”

But it’s the people of Massachusetts who will ultimately decide the law’s fate, not religious leaders, lawmakers or medical professionals. Dr. Marcia Angell, former editor of Massachusetts Medical Society’s New England Journal of Medicine, and one of the Act’s lead sponsors, puts little stock in what physicians have to say about the matter.

“I am less concerned with what doctors want than with what patients want,” Angell said in an interview that aired on WGBH, in Boston. She continued, “I think doctors sometimes have a too-narrow idea of what their own obligations are. They feel they have an obligation to extend life even when it can’t be extended significantly. And even if you have that situation, then it seems to me they have two obligations. One is to support the autonomy, the self-determination of their patients. And the other is to relieve suffering. If you can’t extend life significantly, then you must relieve suffering.”

A study released by the Health Research and Education Trust shows that Americans are living longer lives than ever before. As a result, more individuals and families will face difficult questions about end-of-life care. In 2011, the oldest Baby Boomers turned 65. By 2030, the number of Boomers between 66 and 84 years old will climb to 61 million, and six out of 10 will be managing chronic health conditions. For the elderly and others facing terminal illness, doctors have numerous ways to prolong life. Palliative and hospice care are available to help patients find peace and comfort in their final days. But there are some people who want another option, which is the right to end suffering by taking their own life at a time and place of their choosing.

Death with Dignity

by David Atkins (“thereisnospoon”)

A friend sent along this deeply touching blog post by the husband of a woman with brain cancer who chose the time and manner of her own death. After losing control of one side of her body due to the terminal illness, she was allowed to take control of her own destiny in a painless fashion surrounded by family, friends and relatives because of Washington’s Death with Dignity law. In most other states across America, she would have been forced to linger increasingly painfully and helplessly without recourse despite her wishes.

Vermont and Massachusetts are working on their own versions of this law as well, and I am pushing legislators in California to get the ball rolling again on this as well.

The principle involved here is that people with terminal illnesses should be able to choose the time and place of their passing. They shouldn’t be forced to allow their illness choose it for them. Obviously, safeguards need to be put in place to prevent the terminally ill from being pushed into the decision. But those safeguards are written into any decent version of the law.

With the graying of the U.S. population, this is increasingly a major issue of social justice. The wealthy, as they do now, will have personal physicians who will “accidentally” allow their patients to administer morphine overdoses. But the poor will be forced to suffer needlessly. Nobody should be forced to extend their life wracked with pain because the State told them it was illegal to do otherwise.

Despite my young age, this is an important subject for me. I am very goal-oriented in my own life, and I don’t take well to incapacitation through illness or otherwise. I don’t drink alcohol or do drugs not because of moral concerns, but because I don’t like not being in control of my mental faculties. My priorities in life are 1) to make the world a better place; 2) to take care of my family and friends; 3) to see and experience as much of the world as possible during my brief stay on the planet; and 4) to do it all with as much autonomy as I can.

If I’m lucky enough to live a long life and die from a slow illness such as cancer, I would hope to be able to be in control of that process. If I’m mentally incapacitated, it will be difficult for me to help make the world a better place; my family and friends would be taking care of me, rather than the reverse; I wouldn’t be able to see or experience much while laid out in bed; and the illness itself will have removed much of my autonomy. A few more debilitating and painful weeks or months of life will not be valuable to me. What will be valuable is the ability to say goodbye to my family and my friends in a dignified and compassionate way as I prepare to take that final journey toward a destination unknown.

The idea that so-called “freedom-loving” conservatives would take that freedom from me is infuriating, and part of the struggle to which I have devoted my life includes stopping them from forcing their misguided authoritarian priorities on the rest of society.

Hawaii: The latest state where doctors can provide aid in dying

A mile high and ten miles northeast of Lincoln, Montana, melting snow and mountain springs form the headwaters of the Blackfoot, made famous in the novella and film A River Runs Through It. Stand at the source, running icy and fast, and try to picture Hawaii. This water flows to the Pacific and could ultimately wash onto the red sand beach at Hana Bay.

Today, in Hawaii, a panel of experts convened at the state capitol. Legal, medical, elder care, legislative and end-of-life authorities concluded Hawaii law permits physicians to provide aid in dying subject to professional best-practice standards. How did they reach this conclusion? The journey begins in Montana.

The Montana Supreme Court’s ruling in Baxter v. Montana created a watershed between previous assisted-dying advocacy typified by Oregon’s Death with Dignity Act and the new era, in which patient choice becomes integral to the scope of medical practice at the end of life. Today the liberty springing from that Montana decision flows through Hawaii as newly affirmed choice at life’s end.

The Montana court recognized that requests for aid in dying were akin to other already-permissible end-of-life choices, as contemplated in the autonomy protected under the state’s Rights of the Terminally Ill Act. Hawaii law includes a version of this Uniform Health-Care Decisions Act, which allows patients to specify if and when they wish to refuse or withdraw life-sustaining medical care. Additionally, in 2004 Hawaii enacted the Pain Patient’s Bill of Rights, and in doing so recognized that inadequate treatment of pain is a significant health problem.

James Pietsch, a professor at the University of Hawaii’s Law School writing in 2004 for The Journal of Legal Medicine, noted a unique Hawaii law:

“[W]hen a duly licensed physician or osteopathic physician pronounces a person affected with any disease hopeless and beyond recovery and gives a written certificate to that effect to the person affected or the person’s attendant nothing herein shall forbid any person from giving or furnishing any remedial agent or measure when so requested by or on behalf of the affected person.”

Added in 1909, this provision aimed to give terminally ill patients the option to obtain treatment that had not yet been approved by the government. The 1909 provision, the Pain Patient’s Bill of Rights and the Uniform Health-Care Decision Act together give terminally ill patients significant freedom of choice to determine their course of medical care at the end of life and protection to physicians who provide that chosen care.

As in Montana, new law explicitly governing aid in dying was not necessary to enable dying patients to openly ask their physicians for aid in dying and for physicians to openly provide it. Most medical care is not governed by law, but by professional standards. Doctors may discontinue life-sustaining treatment such as respiratory support, pacemakers, dialysis and medication at the request of their patients.

Physicians in Hawaii have already witnessed an emerging standard of care that respects a patient’s autonomy and accepts life-ending practices.

The Hawaii Public Health Association (HPHA) along with the American Public Health Association (APHA) assert that people in Hawaii deserve a full range of options for palliative care and end of life, including aid in dying. That’s why the HPHA co-sponsored the panel discussion today. HPHA President Deborah Zysman says, “With proper safeguards in place, we believe that aid in dying poses no public-health risk, and that a mentally competent, terminally ill adult should be allowed to control the time, place and manner of his or her impending death.” Other major medical organizations also support open access to aid in dying: the American Medical Women’s Association (AMWA), the American Medical Student Association (AMSA) and the American College of Legal Medicine (ACLM). The American Academy of Hospice and Palliative Medicine (AAHPM) has shifted its stand from oppositional to neutral.

The lawyers and legislators on today’s panel concurred nothing in Hawaii law currently prohibits aid in dying. Patients and their doctors may make decisions governed by best medical practice, allowing them the opportunity to explore a range of patient-directed end-of-life choices. This is the model set by the Montana court in its watershed ruling. The liberty epitomized by the clear-flowing Blackfoot River gives hope to Hawaii residents facing their final days. They will soon have the same broad spectrum of end-of-life choices enjoyed by the people in Montana, Oregon and Washington.

Dignified Dying

Guest Essay
by Dustin Hankinson

Disability Rights Advocate Dustin Hankinson
Disability Rights Advocate Dustin Hankinson
The recent essay “Only Dignified When Dead?” by Stephen Mikochick of the Ave Maria School of Law makes a number of false claims and inaccurate assessments about aid in dying that I, an American living with a disability and supporter of Death with Dignity, take issue with.

Mikochick refers to the recent statement by the U.S. Catholic bishops opposing end-of-life choice in his assertion that it hinders patient autonomy, threatens disabled people and vulnerable populations such as the chronically or mentally ill, and carries the risk of involuntary administration.

This view contradicts the support of most Catholics and Americans for patients’ rights at the end of life, and the rationale is flawed.

The Death with Dignity law sets out a detailed process under which only terminally ill patients, meaning those with a diagnosis of less than six months to live, qualify. Furthermore, those individuals must be deemed mentally and psychologically competent by two separate physicians.

There is no room for error or slope-slipping, as it is the patient who has to pursue this option for themselves.

No one is forced to die, just as no one should be forced to stay alive longer than their body is able and their mind is willing.

I support the right of terminally ill adults — of any religion or no religion at all — to make their own end-of-life decisions.

It’s one thing to state your position based on religious beliefs, but quite another to falsify facts and impose those beliefs on every adult in the country.

We all deserve the autonomous decision to live a comfortable, dignified life right up until the end, whenever that may be for each of us. Artificially eating, artificially breathing, and enduring other painful and futile procedures to extend a terminal existence will not bring us closer to God; only living as compassionate, caring people can do that.

Hankinson has been a disability-rights advocate for over a decade. He has lived with Duchenne muscular dystrophy for 36 years.

Montanans’ right to ‘aid in dying’ reaffirmed

By Anders Blewett and Dick Barrett
Great Falls Tribune
May 11, 2011

Last week we celebrated the Legislature’s adjournment with great satisfaction that Montanans’ access to aid in dying had been reaffirmed. Two bills introduced in the state Senate threatened to outlaw physician aid in dying, as established by the Montana Supreme Court. A bipartisan majority of the Senate Judiciary Committee, and the full Senate, rejected the bills, thus preserving the right of terminally ill patients to make their own end-of-life decisions..

On Feb. 16, the committee voted 7 to 5 to table defeat SB116, which would have revoked the right of terminally ill patients to request aid in dying from their physicians.

Doctors, patients, family members, clergy, hospice nurses and doctors — including the Montana Medical Association and the National Association of Social Workers Montana Chapter — testified against the bill repealing physician aid in dying.

And when the sponsor of SB116 tried to bring the bill before the full Senate for consideration, lawmakers of both parties opposed it, 35 to 15.

The Judiciary Committee also defeated SB169, increasing penalties for “suicide predators,” because its ambiguous language could have created a backdoor deterrent to aid in dying.

Most of us have experienced loved ones’ deaths that were not in harmony with how they lived their lives. We think every Montanan, when approaching the end of life, should have the right to choose his or her own path.

The defeat of this these bills was a victory for individual rights over government control. These are decisions that should be — and now can continue to be — made by the terminally ill patients whose lives, deaths and suffering are at stake, based on their own religious, spiritual and family beliefs.

It now falls to Montana physicians to develop the standard of care to respect and protect their patients’ end-of-life decisions. Montana’s medical community is certainly up to the task of including aid in dying as one of the options available for patients with end-stage cancer and other terminal diseases.

Also tabled by the Senate Judiciary Committee was SB167, which would have provided specific practice guidance and immunities for physicians who honor their terminally ill patient’s’ end-of-life medical decisions.

“It is unfortunate that the Legislature did not go further to codify the court’s decision, providing physicians with additional protections for honoring patients’ decisions,” said Dr. Stephen Speckart, an oncologist from Missoula. “However, Montana’s medical community can rest assured the Senate examined this issue closely, and concluded that it is proper public policy for physicians to respect a dying patient’s decisions.”

The Montana Supreme Court Dec. 31, 2009, in Baxter vs. Montana, recognized that the statutes empowering patients to direct their end-of-life care, even when decisions may advance the time of death, reflect public policy in favor of patient autonomy.

The court recognized that Montana public policy allows competent dying patients to choose aid in dying, and established that physicians who provide aid in dying at the behest of their terminally ill patients are acting with the consent of their patients and are protected from prosecution.