Michigan doctors must tell dying their options
State medical society votes to ban assisted suicide
The Michigan legislature has chosen a course it hopes physicians and patients will embrace as a better alternative to physician-assisted suicide: physician-assisted dying.
In April, lawmakers passed the Michigan Dignified Death Act. It specifically requires physicians to inform patients about all options for end-of-life care when they are diagnosed with a disease or illness likely to result in death within six months. The physician is required to give the patient a written brochure containing information about end-of-life choices, including the options regarding palliative care, hospice, and pain management. The bill also creates a narrow immunity from prosecution for physicians who prescribe appropriate pain medication.
The bill’s supporters hope the immunity provision will "make more clear to physicians that they should not hesitate to prescribe whatever doses of narcotics are necessary for terminal pain relief," says Howard Brody, MD, PhD, head of the Michigan State Medical Society’s (MSMS) committee on bioethics and director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University in East Lansing.
Michigan is the first state to grant immunity to physicians in an effort to raise the quality of death and encourage them to provide adequate amounts of pain relief to the dying.
The MSMS initially opposed the law, fearing it would impinge on the doctor/patient relationship. But now the organization supports the legislation, says Greg Aronin, director of government relations for MSMS. "Our intent is to make sure dying patients understand their rights. They should know that all treatment options are available to them and that their pain will be controlled," Aronin adds.
Hospitals and other health care providers in the state say the new bill will not dramatically change the course of dying. "This is an additional responsibility that rests solely on the shoulders of physicians," says Amy Barkholz, JD, manager of legislative issues for the Michigan Health and Hospital Association in Lansing.
Barkholz says hospitals’ compliance with the Patient Self-Determination Act and other staff communications with patients about end-of-life treatment choices will not change. "This measure may open up the lines of communication between the doctor and the patient, but it will ot change hospital policy," she explains.
The hospital association shares the concern of physicians that they will be asked to define terminal illness. "This may well be asking doctors to give information that they cannot give," Barkholz says. The terminal diagnosis will be the hardest element of the law for physicians to follow.
SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) data portray the difficulty in defining terminal illness. "These observations show that there is no well-accepted and clearly desirable definition of the phrase terminally ill’ in our data," says primary investigator Joanne Lynn, MD, director of the Center to Improve Care of the Dying in Washington, DC.1
Rather, Lynn and fellow SUPPORT researchers say that aggressive treatment and comfort care plans may have to exist simultaneously. "The health care professionals will need to develop clinical practices that continue to seek recovery and survival at the same time that we acknowledge the possibility of dying and provide support to families in grieving, in planning, and in concluding a life."
Immunity may improve pain management
Additional provisions of the Dignified Death Act include the following:
• Insurance coverage. Life and health insurers must pay for hospice and palliative care and are precluded from penalizing patients for treatments they choose based on information they receive from physicians. Insurers may not "refuse to provide or continue coverage or benefits. . . limit the amount of coverage or benefits . . . charge the terminally ill patient a different rate . . . consider the terms of the policy or contract to have been breached or modified . . . [or] invoke a suicide or intentional death exemption or exclusion covering the patient."
• Physician immunity. "A physician who, as part of a treatment plan for a terminally ill patient, prescribes drugs, is immune from administrative and civil liability for prescribing such drugs if the prescription is given in good faith with the intention to treat the patient and/or alleviate the patient’s pain and the following criteria are met:
The prescription is for a legitimate legal and professionally recognized therapeutic purpose.
The prescription is within the scope of practice of the physician.
The physician holds a valid license to prescribe controlled substances."
Reference
1. Lynn J, Harrell F, Cohn F, et al. Prognoses of seriously ill hospitalized patients on the days before death: Implications for patient care and public policy. ew Horizons 1997; 5:56-61.
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