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

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. Opponents of PAS �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�

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 of 1994 �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. Onset, Peak, and Duration of Activity 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)

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

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*

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

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. Cheney Case of Portland 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

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)

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

44. Reporting Issues

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. Active Involuntary Euthanasia March 1996 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

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

50. �Terminally ill fear assisted suicide�

51. 2005 Gallup Poll When asked if doctors should be allowed to end the life of a patient who is suffering from incurable disease and wants to die "75 percent of respondents said yes� When asked if doctors should help a patient commit suicide under the same circumstances, �only 58 percent said yes�

52. �By using Orwellian �doublespeak� we might be letting ourselves in for procedures and conclusions which we do not fully comprehend at the time of decision-making. On the other hand, perhaps euphemisms allow people to come to grips with brutal facts which, stated another way, would be repugnant.�

53. Compassion & Choices* �Suicide� is Inaccurate, Biased Term to Describe Terminally-Ill Patients� End-of-Life Choices� (Press Kit Statement)

54. Language Games Compassion & Choices made its case in an Aug. 22 letter to state official that said "physician-assisted suicide" "is value-laden and negatively biased language that perpetuates misunderstanding of Oregon law and policy."

55. The Oregon Department of Human Services (DHS) C & C first sent a formal request to the state agency, suggesting that the terms �aid-in-dying,� �directed dying,� or �assisted dying� be used in official state reports brought lawyers to a meeting with the DHS to discuss the language substitution implied that, if it were not made, litigation might follow

56. The Oregon Public Health Division Calling it "physician-assisted suicide" was "perhaps a mistake we made years ago," given the language of the law, said Dr. Katrina Hedberg, public health physician with the state Public Health Division who helps compile the annual report. But "physician-assisted death" didn't quite work either. �The state's Web pages and subsequent annual reports will refer only to the Death with Dignity Act.�

57. American Public Health Association �Urges health educators, policy-makers, journalists and health care providers to recognize that the choice of a mentally competent, terminally ill person to choose to self-administer medications to bring about a peaceful death is not "suicide," nor is the prescribing of such medication by a physician "assisted suicide." Urges terms such as "aid-in-dying" or "patient-directed dying" be used to describe such a choice.�

58. American Academy of Hospice and Palliative Medicine Position Statement Physician-assisted Death (PAD) is utilized in this document with the belief that it captures the essence of the process in a more accurately descriptive fashion than the more emotionally charged designation Physician-assisted Suicide.

59. �Terminally ill fear assisted suicide� Roper Poll showed euphemisms work where clear disclosure is less effective Gallup Poll demonstrates similar finding Acknowledged as valid by leading medicide advocates Humphrey and Smith Politically savvy, medically imprudent

60. �Unnecessary Law?� 7 % covert practice before law Unwillingness to prosecute

61. Conclusion for Oregon Meaningful data collection Select committee of proponents and opponents to weigh data and submit report Maintenance of confidentiality Drop the euphemisms

62. The 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.�

63. Two Different Stories Troy Thompson ALS Storied in faith community & family Committed Christian Greatly valued God�s will Died with help of hospice palliation Patrick Matheny ALS Storied in family Rugged individualist Greatly valued autonomy Difficulty swallowing lethal draught Brother-in-law helped die

64. Final Take Away � In which ghost story do you believe?