Death Be Not Proud
Abstract & commentarySynopsis: Many patients with terminal cancer support policies that would allow them access to euthanasia or physician-assisted suicide. Source: Wilson KG, et al. Arch Intern Med 2000;160:2454-2460.
Wilson and associates carefully recruited a group of patients who were dying of cancer. Because many of the potential patients for this study were too ill or died before they could be interviewed, they were able to offer participation to 150 subjects, 80 of whom declined to be interviewed. Their final sample was 70 patients. This group of 70 had a mean age of 64.5 years, consisted of 32 men, and was highly educated. A total of 41% were Roman Catholic, 41% were Protestant, and 17% were "none" or "other." As would be expected, the leading kind of cancer was lung (21%), followed by GU (19%), female breast (13%), gastrointestinal (13%), and head and neck (10%). The mean survival of this group was 44.5 days after the interview; only 15% lived as long as six months.
The interviews were audiotaped for later content analysis, and were conducted by clinical psychologists, doctoral students in psychology, or research associates in palliative care. Interviewers solicited participants’ views about euthanasia and physician-assisted suicide (PAS), both in general, and with regard to the subject’s personal situation. Euthanasia was defined as a situation in which "a medical doctor gives an overdose of medication to purposely end a patient’s life. This is only done with patients who have asked their doctor to help them die in this way. Usually, the patients involved are very ill with a life-threatening disease." PAS was defined as an action in which "a medical doctor provides drugs and advice, so that a patient could commit suicide. The doctor does not actually inject the drugs, but rather gives the patient the means to end his or her own life."
Seventy-three percent of the patients believed that euthanasia or PAS should be legalized, with pain and the individual’s right to choose as the main reason. Those who thought these actions should not be legalized cited religious or moral reasons. Fifty-eight percent of the articipants said that they might personally request such a procedure if it were legal, particularly if pain or physical symptoms became intolerable. Eight of the 70 participants would have made such a request at the time of the interview: four of these had major depression, two had comorbid anxiety disorders, and one had major depression in remission. Of those who would consider asking for hastened death, euthanasia was preferred to assisted suicide. Comment by Barbara A. Phillips, MD, MSPH Like it or not, this is a hot topic. I found 4812 articles in the National Library of Medicine published since 1966 using the key word "euthanasia," limited to human subjects. I found 487 web sites using the keyword "euthanasia." Euthanasia and PAS are legal in The Netherlands, the
Australian Northern Territory, and Oregon. In a recent national telephone survey, 15.8% of 56 oncologists had performed euthanasia or PAS.1 In six of the patients involved in this report, the patient did not participate in the decision, and in only about one-third of cases did the physicians adhere to all three of the proposed safeguards: 1) having the patient initiate and repeat the request for euthanasia or PAS; 2) ensuring the patient was experiencing extreme physical pain or suffering (although all the patients were receiving narcotic analgesia); and 3) consulting with a colleague. In a mail questionnaire of 1902 physicians, Meier and colleagues found that 11% were willing to hasten a patient’s death even with the current legal constraints, and 18.3% reported having received a request for assistance with suicide from a patient.2 Approximately 3.3% reported writing at least one prescription and 4.7% reported administering at least one lethal injection.
In the current report, patients reported the following reasons that there should be at least limited legal access to euthanasia or PAS: individual’s right to choose, pain, diminished quality of life, suffering, hopeless situation, mental symptoms, burden for others, physical symptoms other than pain, and knowledge of others’ experiences.
In previous reports, pain has been a significant negative factor in studies of end-of-life care.3-5 Bereaved family members cite inadequate pain control (and access to physician’s time!) as significant problems with end-of-life care.4 However, neither a specific nurse intervention3nor patient empowerment and feedback5 improved pain control in clinical trials. I suspect that sometimes physicians balk at giving adequate pain control if they believe that the medicine will hasten death. However, the American Medical Association’s Code of Ethics endorses doing exactly that, if the primary purpose is to relieve pain or suffering. In "official" parlance, "Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care." This includes providing effective palliative treatment even though it may foreseeably hasten death.6 Depression is also a significant and frequent finding in the terminally ill,7-9 and there is some evidence that depression is undertreated in terminal patients.8 In the current study, the eight patients who would have requested PAS/euthanasia at the time of study were significantly more depressed than the other study patients, but there was no difference in their report of pain as a symptom. The article does not include information on antidepressant treatment of this group, though 24% of the 70 patients were on antidepressants.
Fear of being a financial burden is listed as a reason for PAS/euthanasia in some studies of terminal patients.10 However, in the current study, the Canadian patients had access to state-funded palliative care services, at no personal financial cost.
This study and others spotlight the fact that we do not do a very good job with end-of-life care. My reading to prepare this commentary turned up documentation that we are perceived as inaccessible to terminal patients and their families, that we undertreat pain and depression, and that we sometimes expend vast resources for little benefit. As a result, patients and their families feel that they have lost control at the most vulnerable time in their lives. No wonder they request that it be ended! The American Medical Association is attempting to address this problem with a program called Education for Physicians on End-of-Life Care (EPEC). You can learn more about this program by visiting the AMA web site at www.ama-assn.org and clicking on or searching for EPEC. This educational program is divided into 12
Modules and four Plenary Sessions, and includes modules on Pain Management, Physician-Assisted Suicide, and Withholding/Withdrawing Treatment.
References
1. Emanuel EJ, et al. JAMA 1998;280:507-513.
2. Meier DE, et al. N Engl J Med 1998;23:1193-1201.
3. The SUPPORT Principal Investigators. JAMA 1995; 274:1591-1598.
4. Hanson LC, et al. J Am Geriatr Soc 1997;45: 1339-1344.
5. Desbiens NA, et al. Pain 1998;75:237-246.
6. McCarthy EP, et al. J Am Geriatr Soc 2000;48: S110-121.
7. Council on Ethical and Judicial Affairs, American Medical Association. Withholding or withdrawing life-sustaining medical treatment. In: Code of Medical Ethics. Chicago, Ill: AMA press; 1997:40.
8. Kleespies PM, et al. J Clin Psychol 2000;56:1153-1171.
9. Hendin H. J Clin Psychiatry 1999;Suppl 2:46-50.
10. Covinsky KE, et al. Arch Intern Med 1996;156: 1737-1741.
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