Don’t Confuse FEN Death And Investigation With Aid In Dying

February 28, 2009 at 12:00 pm Leave a comment

The media has recently reported the arrest of individuals associated with a group known as Final Exit Network (FEN) on charges of assisting a suicide in Arizona, and attempting to engage in similar activity in Georgia. The cases reported in the media this week involving FEN ought not be confused with the choice of aid in dying.

Media accounts of the facts suggest that the Arizona decedent was not terminally ill and may have suffered from impaired judgment and/or mental illness.

It is important to recognize the difference between the choice of a mentally competent, terminally ill patient for a peaceful death via self-administering medications prescribed for this purpose, and the act of a distraught individual who is not dying, who may be suffering from impaired judgment or mental illness, to precipitate death. The former is a practice known as aid in dying, which has strong and growing support among the public and among medical and health policy professionals. The latter is suicide. It is essential to recognize the difference between these.

In 2008, four major national medical professional and health policy organizations adopted policy in support of aid in dying, the practice of a physician providing a prescription to a mentally competent, terminally ill patient that brings about a peaceful death. This represents a significant turning point in American society’s evolution to empower terminally ill patients with information and choices about how they will die.

The organizations adopting policy in support of aid in dying include the American Medical Women’s Association (AMWA), the American Medical Students’ Association (AMSA), the American College of Legal Medicine (ACLM), and the American Public Health Association (APHA).

The Oregon Death with Dignity Act (Dignity Act) began implementation in 1998. This law permits mentally competent individuals who have less than six months to live to obtain a prescription for medication that can be self-administered to bring about a peaceful death. It has been implemented without interruption since 1998.

Under the Dignity Act, patients must follow a strict set of procedures to establish eligibility. A physician must determine that the patient has a life expectancy of less than six months; this diagnosis must be confirmed by a second opinion. The patient must make multiple requests, waiting at least fifteen days between the first and last request, must establish capacity to make medical decisions, and must be informed of palliative care options such as hospice, if not already receiving such services. If all of these procedures are followed, and the patient is deemed eligible by the physician to obtain the life-ending medication, an Oregon physician can provide the requested prescription.
During the decade that aid in dying has been legal in Oregon, close to 30 terminally ill individuals each year have gone through the process, obtained and taken the medication, and died peacefully. Those present at these deaths, usually close family members, report that the patient was enormously relieved to be able to make this choice. On a date chosen by the patient, loved ones may gather around for a final goodbye.

The patient consumes the medication, becomes drowsy, falls deeply asleep, and after a short period of time ceases to breathe. The long road from diagnosis to curative treatment to palliative care to death has ended on terms acceptable to the patient. More patients obtain the medication than go on to use it: some fraction each year receive the medication, put it in the medicine cabinet, feel comforted to know it is there, and never take it.

Demographic data about the patients who choose to use the Dignity Act show that most are dying of cancer. The next most common terminal illness is amyotrophic lateral sclerosis (ALS). Those using the law are insured, well educated, and are receiving comprehensive pain and symptom management, typically through hospice services. Opponents of the Dignity Act legislation had argued that such a law would be forced upon the uninsured, the poor, minorities, persons without access to hospice, or disabled persons. The data have disproved this conjecture.

In addition, a number of unexpected but significant developments occurred in Oregon following implementation of the Dignity Act. Referral of patients to hospice care increased dramatically, as did physician enrollment in continuing education courses on how to treat pain and symptoms associated with terminal illness. It is likely that physicians want to ensure that no patient makes use of the Dignity Act due to inadequate pain and symptom management. This galvanized both the increase in hospice referrals and physician efforts to learn more about treating pain and symptoms.

Voters in the state of Washington considered the issue in 2008 and adopted the Washington Death with Dignity Act by the significant margin of 59% to 41%. The Washington measure is virtually identical to Oregon’s and will begin implementation on March 5, 2009.

As a result of a court case, Montana recently recognized that the freedom of its terminally ill citizens to choose aid in dying is a fundamental right protected by its state constitution’s guarantees of privacy and dignity.

Public support for empowering dying patients with the freedom to choose aid in dying is strong. A Harris poll in 2005 found that 70% of U.S. adults favor a law that would “allow doctors to comply with the wishes of a dying patient in severe distress who asks to have his or her life ended.”

When a patient does not feel able to discuss the desire for aid in dying with his or her physician, or cannot find a physician willing to provide it, the patient may seek assistance in hastening death from a family member or loved one. Unfortunately, these incidents often involve a violent means to death, such as gunshot.

A fraction of terminally ill patients – including those who have excellent pain and symptom management – confront a dying process so prolonged and marked by such extreme suffering and deterioration that they decide aid in dying is preferable to the alternatives. Having this option harms no one, and greatly benefits both the relatively few patients in extremis who make use of it and many more who draw comfort from knowing it is available should their dying process become intolerable. The trend in policy among mainstream medical and health policy associations is clearly in favor of supporting this compassionate option.

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