death with dignity
Difficult choices
Death with Dignity laws, also known as physician-assisted dying or aid-in-dying laws, stem from the idea that it is terminally ill people, not government, politicians or religious leaders, who should make their own end of life decisions and determine how much pain and suffering they should endure.
Death with Dignity statutes allow mentally competent adult state residents who have a terminal illness with a confirmed prognosis of having six or fewer months to live to voluntarily request and receive a prescription medication to hasten their inevitable, imminent death. By adding a voluntary option to the continuum of end-of-life care, these laws give patients dignity, control and peace of mind during their final days with family and loved ones. States currently having Death with Dignity Acts are Oregon, Washington, Colorado, Montana, Vermont and California.
Existing physician-assisted dying laws mirror Oregon’s Death with Dignity Act, which is widely acclaimed as successful and where independent studies have shown has safeguards to protect patients and prevents misuse. The Death with Dignity process is a thoughtful one not to be undertaken lightly. Two physicians must confirm the patient’s residency, diagnosis, prognosis, mental competence and voluntariness of the request. Two waiting periods, the first between the oral requests and the second between receiving and filling the prescription, are also required.
How do aid-in-dying aka assisted suicide laws protect patients?
Death with Dignity statutes contain a number of safeguards protecting patients from abuse and coercion, including:
Patients must meet stringent eligibility requirements, including being an adult, state resident, mentally competent, and having a terminal diagnosis with a 6-month prognosis as confirmed by two licensed physicians.
Only the patient him or herself can make the oral requests for medication, in person. It is impossible to stipulate the request in an advance directive, living will, or any other end-of-life care document.
The patient must make two oral requests, at least 15 days apart.
The written request must be witnessed by at least two people, who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request. One of the witnesses cannot be a relative of the patient by blood, marriage or adoption; anyone who would be entitled to any portion of the patient’s estate; an owner, operator or employee of a health care facility where the eligible patient is receiving medical treatment or is a resident or the patient’s attending physician.
The patient must be deemed capable to take (self-administer and ingest) the medication themselves, without assistance.
The patient may rescind the request at any time.
Two physicians, one of whom is the patient’s attending physician, familiar with the patient’s case, must confirm the diagnosis. Each physician must be licensed by the state to practice medicine and certified to prescribe medications.
If either physician determines the patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, they must refer the patient for evaluation by a state licensed psychiatrist or psychologist to determine their mental competency. Medication cannot be prescribed until such evaluation determines the patient is mentally competent.
The attending physician must mail or hand-deliver the prescription to the pharmacy.
The patient must wait 48 hours from their written request to fill their prescription.
The request process must be stopped stop immediately if there is any suspicion or evidence of coercion.
The physicians must meet strict reporting requirements for each request.
Anyone who falsifies a request, destroys a rescission of a request or who coerces or exerts undue influence on a patient to request medication under the law or to destroy a rescission of such a request commits a Class A felony. The law also does not limit liability for negligence or intentional misconduct, and criminal penalties also apply for conduct that is inconsistent with it.
Data and studies show these safeguards work as intended, protecting patients and preventing misuse. No evidence of coercion or abuse has been documented in the Oregon since 1998 and Washington since 2009, when these states’ respective laws went into effect.
Pathways to Death
According to New York Times journalist Jane Brody, “There is no one good definition of a good death, just as we have followed different paths in life, each of us must decide for ourselves how we want to be treated when death is near.” Her words remind us of the personalization of death especially for the elderly and infirm, but foreshadow a warning as well for those who are disenfranchised, discouraged or depressed. Each of us knows people who prefer exiting this life on their own terms, regardless of their medical condition, some in hospitals, others at home with friends or family or best yet, peacefully in our sleep.
While for some this form of assisted suicide seems too extreme or is not available as a legal reality in their home state or country, they may instead choose a less high tech plan of action and stop eating and drinking altogether. When hospice nurses in Oregon were asked their opinion of this type of death (which generally works in two to three weeks) the nurses assigned it a median score of 8 on a 0-9 scale where 9 was the “best death experience.” Hospice nurses, Jennifer Sutton Holder and Jann Aldredge-Clanton offer an explanation for this high rating in their book, Parting: A Handbook for Spiritual Care Near the End of Life, “The absence of nutrients and fluids is nature’s way of bringing gentle closure and even pain relief as the body gradually shuts down.” Author Marcia Menter in More Magazine brings her bird’s eye view to the death of her 96-year old friend, Juliette, brought on by Juliette’s decision to stop eating and drinking, asking readers (and herself), “Do I try to talk her out of it? Of course not. It’s quite clear this is what she wants, and she’s almost cheerful at the prospect of taking control of the end of her life.” Though she knew that to stop eating and drinking was what Juliette wanted, it was still hard for Menter to stand by her side for the thirteen days it took her friend to die. Waiting and watching for the body’s internal systems to break down, she came to realize, this approach “…takes a determination and strength of purpose few people possess.” NPR journalist and commentator, Diane Rehm agrees. She, too, had to stand by as her beloved husband of 54 years John, suffering from severe Parkinson’s disease and living for the previous two years in an assisted living facility, chose to refuse all food and drink as well as his medications, because though he had asked, his physician was barred from legally assisting him in ending his life. Ms. Rehm writes, “It was the way John had to die [that] was just totally inexcusable.” Stepping away from her radio show at age 80, she has turned her passion into advocacy for the growing right-to-die movement.
According to a Viewpoint article in the New England Journal of Medicine (Jan. 16, 2016), entitled, Responding to Patients Requesting Physician Assisted Death, authors Doctors Timothy Quill, Anthony Back and Susan Block propose, “Patients can experience substantial benefits that are more apparent under an open legal process. Patients concerned about future distress can gain peace of mind…Others feel an enhanced sense of trust and confidence in their clinician; still others are comforted by decisions that allow them to retain a needed sense of control.” These feelings occur regardless of whether the decision to go forward with physician assisted death is ever made, or if made, ever acted upon. Since in the end, death comes for all of us, bringing the process into the open instead of privately having back door discussions with our physicians, putting physicians in an awkward and tenuous legal position and avoiding death on one’s own should become a kindness, not a felony.
Richard Cohen’s book, Strong at the Broken Places, explains, “The nightmare of unrelenting chronic illness is that pride must yield to survival no matter how you were raised or what you think is expected of you.” Dr. Elizabeth Kubler-Ross who fought her own battle against terminal disease helps us understand, “As you look back at the death, you may see things differently in retrospect. Your loved one was powerful to get through all that he or she did when battling the disease. And they were even more powerful when they finally let go into the unknown, dying into strength, not weakness.” For many this view is a jump shift in thinking, for all of us it is a wake up call to begin to consider our wishes and let them be known.