An Analysis of Nine Years of Physician-Assisted Suicide in Oregon

1. An Analysis of Nine Years of Physician-Assisted Suicide in Oregon Jerome R. Wernow Ph.D., R.Ph. Director ncb@teleport.com

2. Re-visit Take Away Point The stories used to give meaning to a person’s life are the stories used to give meaning to a person’s ‘health.’

3. Human B/b-eing Corporeality Spiritual Illumination Psychofacticity

4. Defining As Good As It Gets

5. Personal ‘Story’ • Heavily invested in opposition 1994-1999 • Researched • Published academically • Provided legal testimony federal court • Crafted legislative safeguards • Personal ALS and brain cancer contacts • Became uninterested after 2000

6. Approach • What was asserted by opponents • What was asserted by proponents • What is the practice found in the reports

7. “Pills don’t work” “Doctors can’t predict” “Mental Health consultation not required” “Falsified records” “Not family friendly” “Killing without consent” “Duty to die” “Terminally ill fear assisted suicide” “Unnecessary Law” Opponents of PAS Facts about Assisted Suicide under Measure 16 byPhysicians for Compassionate Care (1994)

8. Proponents for Physician Assisted Suicide • Support from people and physicians • Improves care of the terminally ill • Increases death at home not hospitals • Increases pain care • Increases end-of-life care for uninsured

9. Physician Assisted Suicide Deaths 1998-2006

10. Death with Dignity Act of1994 “Allows terminally ill adult Oregon residents voluntary informed choice to obtain physician’s prescription for drugs to end life.”

11. “Pills Don’t Work”

12. Myth and Fact • Myth: “Dutch researcher warns of 25 % lingering deaths” Keefe, Mark, Oregonian • Fact: About 4% fail in Holland (Kimsma) • Fact: Dutch lethally inject after 6 hours to end oral administration failure and lingering death

13. Drugs of Choice • Secobarbital used 136 (47%) • Pentobarbital used 152 (52%)

14. Oregon Statute “Nothing in this Act shall be construed to authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing, or active euthanasia.”

15. Secobarbital Onset 10-15 minutes Peak activity 15 min Duration 3-4 hours (v) Pentobarbital Onset 20-60 minutes Peak activity 15 min Duration 3-4 hours (v) Onset, Peak, and Duration of Activity

16. Netherlands’ Standard • Intravenous route preferred • IV solution used orally sodium pento- or secobarbital 100 ml solution • If patient fails to ingest entire solution or lingers more than 5 hours, administer pancuronium or vecuronium bromide 20 mg intravenously Gerrit K. Kimsma: “Euthanasia AND euthanizing drugs in The Netherlands,” in Drug Use in Assisted Suicide and Euthanasia. (Battin and Lipman eds) Pharmaceutical Products Press, 1996.

17. Ingestion to Death(Health division report) • Median Time: 25 minutes (n=232) • Range: 4 minutes-48 hours (n=232) • Greater than 6 hrs: 14 (n=232) • Unknown: 17 (232/249 = 7.1%)

18. Ingestion time until Death

19. “Pills Don’t Work?” • Seem to work in about 94 out 100 cases • Question arises regarding accuracy of positive outcome due to hard to access data (59% gives no info on timing) • Is 5-6% failure medically acceptable standard?

20. Failures Approximately six percent known* *Health division reports 17 cases without reporting of minutes until death (7.1%)

21. “Doctors can’t Predict”

22. Oregon Statute “diagnosed with a terminal illness that will lead to death within six (6) months”

23. First Request until Death • Median: 42 days • Range: 15 days-1009 days http://oregon.gov/DHS/ph/pas/docs/yr9-tbl-1.pdf

24. First Request until Death

25. “Doctors Seem to Predict” • Median suggests longevity is predictable • Question revolves around skewing of data • Unable to determine longevity of those using PAS • Unable to weight significance of outlying data without more detail

26. “Mental Health consultation not required”

27. Capacity And Volition Requirements   127.815 §3.01 (d) Refer the patient to a consulting physician for medical confirmation of the diagnosis, and for a determination that the patient is capable and acting voluntarily;   127.815 §3.01 (e) Refer the patient for counseling if appropriate pursuant to ORS 127.825;

28. Mental Consult Requirements If in the opinion of the attending physician or the consulting physician a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling. No medication to end a patient’s life in a humane and dignified manner shall be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. [OR127.825 §3.03. Counseling referral 1995 c.3 §3.03; 1999 c.423 §4]

29. Informed Consent Requirements 127.830 §3.04. Informed decision. “ he or she has made an informed decision as defined in ORS 127.800 (7).” “based on an appreciation of the relevant facts and after being fully informed by the attending physician”

30. Number of Mental Evaluations

31. Mental Health Referrals Thirteen percent (36/292) of the patients committing suicide were referred for mental health evaluations

32. Mental Health ReferralsPercent

33. Physician-Patient Relationship

34. Hospice Care Median: 86%

35. End of Life Concerns • 87% Loss of Autonomy • 87% Loss of Pleasure • 80% Loss of Dignity • 57% Loss of Bodily Control • 38% Burden on Family • 26% Pain Control • 2% Finance

36. Mental Health consultation not required - analysis • Clear decrease in psych referrals • Difficult to determine significance of minimal physician-patient contact • Psych-socials in hospice care may diminish referral for psych evaluation • Rationale is subjective and narrative based

37. Female 85 y/o Dx terminal cancer Alzheimer’s dementia Psychiatric-diagnosed diminished capacity MD recommended against PAS Patient accepted MD advice Daughter objected Asserted mother’s desire for PAS 2nd Psych consult found diminished capacity Concerned about familial pressure Psychologist still determined pt. competent Cheney Case of Portland Wesley J. Smith: “Bioethics: Frontiers and New Challenges. Cf. www. books.google.com/books?isbn=9728818610...

38. “Falsified Records” Issue

39. Reporting Requirements ORS127.865 §3.11 (b) The department shall require any health care provider upon dispensing medication pursuant to ORS 127.800 to 127.897 to file a copy of the dispensing record with the department.

40. Reporting Requirements (1) To comply with ORS 127.865(2), within seven calendar days of writing a prescription for medication to end the life of a qualified patient the attending physician shall send the following completed, signed and dated documentation by mail to the State Registrar, Center for Health Statistics, …(6 forms) http://arcweb.sos.state.or.us/rules/OARs_300/OAR_333/333_009.html

41. Reporting Requirements (3) To comply with ORS 127.865(1)(b), within 10 calendar days of dispensing medication pursuant to the Death with Dignity Act, the dispensing health care provider shall file a copy of the "Pharmacy Dispensing Record Form" prescribed by the Department with the State Registrar, Center for Health Statistics, … (ORS 333-009-0010 )

42. Reporting Requirements (2) Within 10 calendar days of a patient's ingestion of lethal medication obtained pursuant to the Act, or death from any other cause, whichever comes first, the attending physician shall complete the "Oregon Death with Dignity Act Attending Physician Interview" form prescribed by the Department.

43. Prescriptions cp Deaths http://oregon.gov/DHS/ph/pas/docs/year9.pdf

44. Reporting Issues No action needed by Board of Medical Examiners

45. Reporting Issues • “Cannot detect or collect data on issues of noncompliance with any accuracy” OHD, 1999 • Needed: comparison of DEA records detailing (1) Pento- and Secobarbital sold with (2) Pento- with (3) Secobarbitol dispensed with number of OHD reporting forms • BME reports apparent ‘good faith’ compliance of 100%

46. “Killing without consent” • Board of Medical examiners have only pursued one case • Associated Press raised one other • Occurrences seems rare • Likelihood of prosecution unclear

47. 78 y/o transported to hospital, intubated, unresponsive Dx: subarachnoid hemorrhage by Patient’s MD (6 years) with consult Prognosis for recovery poor Daughter and MD concurred W/D and W/H tx Extubated, Morphine, Valium ordered prn for comfort Morphine 5-10mg and diazepam 5-10 mg given q 5-10 minutes for 2 hr, no evidence of discomfort Magnet applied to pacemaker Succinylcholine 100 mg given causing death Active Involuntary Euthanasia March 1996 BME Notice of Disciplinary Action, July 18 1996.

48. Legal Proceedings • Venue changed to Lane County • District attorney “very difficult to get a conviction for homicide” • “Injustice to incarcerate” • “Does not need to be on probation” • BME 2 month suspension and $6,371 fine enough, charges dropped • BME “MD motive – misguided”

49. Four nursing home deaths • Allegation of morphine overdosing • Nurse determined “mentally unstable and unfit for practice” • Nursing home fined $6,000 • Grand Jury refused to indict RN Associated Press: Oregon Grand Jury Refuses to Indict Nurse in Euthanasia Deaths. September 13, 2000

50. “Terminally ill fear assisted suicide”