Two years ago, Colorado voters passed the
End-of-Life Options Act or Medical Aid in Dying. The "death positive
movement" in Colorado has spurred the creation of more than 6,700 "death
cafes" where people can gather to talk positively about death and
end-of-life wishes. The emergence
of "death doulas" has also come around. Who knew?
The law lays out specific requirements for patients, health care
providers, and medical facilities who opt-in. However, the public and private
discourse on the matter has created a tangle of barriers for those who wish to take advantage of the act. For example, not all
hospitals and pharmacies participate in prescribing or stocking these
medications and patients may need to travel extensively to find a willing
physician to assist them. Furthermore, most insurances including federal aid
(Medicaid and Medicare) do not cover these medical-aided death costs.
In order to opt-in, patients must be Colorado residents who are
terminally ill with six months or less to live and who are over the age of
eighteen. They must exhibit the mental capacity to make an informed decision,
act voluntarily, and physically be able to self-administer and ingest the
lethal medications. Every requirement must be documented and confirmed by a
physician who must agree to prescribe the medication. The physician must also
refer the patient to another physician who must (1) agree with the diagnosis
and prognosis and (2) corroborate that the patient is mentally capable, acting
voluntarily, and is not being coerced.
As future practicing
physicians, it is imperative we keep a pulse on the community around us and the
evolving ethics of what defines care. Another difficult skill is learning where we stand and how we can communicate/ defend our positions.
Dr. Rhee,
shared with me his commentary on the matter (posted here). He is a great
example of how important it is for us to professionally create platforms that can
inform the direction of medicine. What do you guys think? Agree or disagree, if people don't voice their platforms,
medicine as a whole becomes less diverse.
Just like voting, if you care,
you should share. Don't you think?
*To throw some physiology in
here, a common drug used is secobarbital, a barbiturate that acts as a CNS
depressant. The drug is an agonist to GABA receptors and at high
concentrations, they also inhibit Ca2++ in the neruotransmission pathway. Too much of this? Trouble aka death.
References:
Rhee, J. Y., Callaghan, K. A., Allen, P.,
Stahl, A., Brown, M. T., Tsoi, A., ... & Dumitru, A. M. G. (2017). A
Medical Student Perspective on Physician-Assisted Suicide. Chest, 152(3),
475-477.
Cordell, K. & Koehler, L., (2018 Oct) “The Art of Dying Well”
5280 Magazine. https://www.5280.com/2018/09/the-art-of-dying-well/
Danielle, I do not know exactly how you feel personally nor am I looking for a debate but in my shadowing and hospital work I have seen the dying process many times. Although I believe strongly in patient autonomy, I believe there are very important aspects of the dying process that are missed (for the patient and family) with physician assisted death. I actually believe a lot of my hesitance to this method of dying has come from seeing death first hand. There is something powerful and actually beautiful about the dying process that I cannot personally understand at this point or possibly ever. I think we must be very careful in the path we take with medicine, it is a powerful entity that can easily cross boundaries and lead to unfortunate circumstances.
ReplyDeleteJake! I agree. As a future practicing physician I would personally not engage in medically assisted death but I believe having options is something that exists as an option for patients. Similar to your exposures, I am actually interested in becoming a palliative care specialist because of the differences in end-of-life care I experienced over the years. I've seen the most horrendous treatment to those at end of life as well as the most caring and beautiful. The purpose of posting this was to start dialogue just like this and make sure that we are aware of options available to us as future physicians and patients.
DeleteVery cool Danielle! I think many physicians lack the ability to deal with death because it can be difficult and truly uncomfortable. There is no way to teach a medical student about death without them experiencing it first hand. I must say my first exposure to death made me as uncomfortable as I have ever been but slowly I have gained confidence in these difficult times and look forward to helping families as they lose their loved ones. I think you have a great personality to lead the way as a palliative care physician and hope we all can continue to improve upon our bedside manner!
ReplyDeleteDanielle, thanks so much for starting this conversation! It makes me happy to see people starting conversations about topics that are often considered taboo in day-to-day American culture. As future physicians, we will have to talk about many uncomfortable and taboo topics and therefore should always be willing to have these conversations now. However, as someone that has spent significantly less time around the dead and dying, I am a supporter of physician assisted suicide. Having read numerous accounts of the horrors one can and often does endure during the last few months of a fight with a fatal illness, I, personally, would like the option of physician assisted suicide. The ability to avoid the unnecessary pain and suffering not only for me, but my family as well, seems like a nice option to have. As for the physician's involvement with the process, this is obviously a much more complicated question. However, to bring in biomedical ethics, I believe that helping with physician assisted suicides would help maintain non-maleficence. Yes, you would effectively be ending someone's life (which one could argue is itself an act of maleficence) but, does the avoidance of future suffering validate these actions? I honestly don't know, but also don't believe this is a white and black argument; all considerations with regard to specific patients must be considered.
ReplyDeleteRamblings aside, I do have a few final points. First, are you aware that in the 38 states that currently allow the death penalty, 17 of them REQUIRE physician participation in the execution? If a physician is legally required for the procedure, how might you handle the decision to participate (and therefore help ensure the least amount of suffering is endured) with the decision to not participate (and the hope that whichever physician does participate cares as much as you do)?
Lastly, I wanted to share an article from Atul Gawande. I have always found Gawande to be an incredible author with an amazing ability to address nearly all sides of a complicated topic and in a manner that is both easy to understand and extremely engaging. I suspect that we was already working on his book, Being Mortal (2014), when this article was published in 2010. Enjoy.
https://www.newyorker.com/magazine/2010/08/02/letting-go-2
https://deathpenaltyinfo.org/node/2264
WILL! I did NOT know that about physicians and the death penalty. Thanks so much for sharing. I also sincerely love Atul Gawande and appreciate this article link.
DeleteMy personal ethics around the death penalty are pretty strong in that ... I don't condone it. This is such an interesting spin on physician assisted death because in the law that is presented to the public, the patient maintains their autonomy and choice to end their life in light of a chronic and terminally ill situation... whereas people on death row were placed on assisted death plans as a form of punishment. Allowing patients the control in their choices is what makes physician assisted end-of-life options a non-coercive system (as much as possible).
But in terms of the death penalty, the physician is not assisting the patient but rather the legal system (justice aside).