In March, Washington State became one of only two states that allow lethal ingestions in terminally ill individuals. In a surprising show of support, nearly 60% of voters approved I-1000. This law permits physicians to write prescriptions for patients who have less than six months of life remaining, and choose to end it early. As you can imagine, the medical community has been abuzz with discussions about how to respond to this directive from our citizens. However, doctors, hospitals, clinics, nursing homes, and others do not have to reinvent this wheel. Oregonians have essentially had the same law for 10 years now, so fortunately we can study and learn from their experiences.
The obvious question has to be why do people elect to take a lethal drug dose, and why would so many Washingtonians vote affirmatively for this initiative. Many people think that the fear of pain is the reason most dying patients would access this law, but Oregon residents using this option disproved that. They found that most feared loss of control or autonomy, loss of enjoyment of lifes pleasures, loss of dignity and control of bodily functions, and becoming a burden on their families. In actuality, only one in four people were fearful of the pain.
Americans are fiercely independent people, and our need for control to the very end might be the most important lesson to be learned in the passage of this piece of legislation. Oregonians taught us another important lesson, this being options. Of the terminal patients who ask for lethal prescriptions from their physicians, only one in 25 (4%) actually ingests the drug. The law requires two oral requests, a written request, and a 15-day waiting period. The doctor must also provide information about alternatives including hospice, comfort care, and palliative care. In addition, the patient must visit a second physician to confirm terminality and mental competency. If mental health or depression is questioned, a trip to a psychiatrist or psychologist becomes part of the process. Once patients go through this process and understand about modern pain and symptom management, they understand there are other ways to control our end-of-life fears. In turn, they seek the support of a hospice team that focuses on the alleviation of suffering, and they elect to die naturally; 96% of those considering PAD elect not to use it.
Whenever a terminally ill patient is referred to hospice, all members of our interdisciplinary team are notified and spring to action. This is particularly true for someone considering ending his or her life early. A registered nurse would make a visit and be sure that the patient is not suffering physical pain, or other unpleasant symptoms like nausea or breathlessness. Our hospice physicians are experts in pain and symptom management (palliative care). A medical social worker would discuss advanced directives, finances, interpersonal issues, family concerns, or any other issue that might be troubling. A chaplain would also stop by to discuss spiritual and existential concerns, from which many dying patients suffer. Hospice has bath aides who help with personal hygiene, dietitians, grief counselors, and volunteers. Some patients receive music therapy, massage, alternative medicine treatments, and perhaps a friendly volunteer to help out.
When dying patients become aware of this holistic support system, and that the hospice team will work to alleviate pain and suffering regardless of the source, nearly all patients change their minds. They realize that with help from hospice, they can be in control and comfortable until the end. Instead, they use each day they have left to interact with friends and family, as well as with their supportive hospice team to do life closure work. I have been trying to get the message out that this life closure work takes different amounts of time for different people. It is very hard to do in a day, or even a week. The process can often take weeks or months. In the last few days of life we are often too weak to get out of bed, fully concentrate, or actively participate in wrapping up a lifetime. Please do not wait to call hospice until its too late. Hospice can often be added to traditional medical care. Patients do not necessarily have to stop treatments, or quit seeing their own physicians to take advantage of hospice services.
The Medicare Hospice Benefit was designed to be used for at least six months. Washingtons new Death with Dignity law, or Physician Aid in Dying, gives Washington state residents another alternative to control how their lives will end. After being fully informed of other options, Hospice NW would support a patients decision to use this law. However, after going through the PAD process, and facing their fears, I think that Washington residents will discover there are alternatives to pain management in their last few weeks of life. At Hospice NW we will always strive to make every day of life good, comfortable, controlled, and filled with the love of family and friends.
Paul D. Johnson, M.D. is the Hospice N W Medical Director. For more information you can contact Paul at 800-894-5877 or visit their website at www.hospicenw.org