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Programs Schwartz Center Rounds Clinical Pastoral Education Compassionate Caregiver Award Patient Initiative CarePages Partnership Speaker Series |
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Case of the Month To access an archive of past "Case of the Months", click here. March 2008 "Coping with A Patient's Request for Hastened Death " The Schwartz Center Rounds is a multidisciplinary forum where caregivers discuss challenging emotional and social issues that arise in caring for patients. Names and clinical details have been altered to protect confidentiality. Presenters: Attending Oncologist (Dr. A), Medical Oncology Fellow (Dr. B), Palliative Care Nurse Practitioner (Nurse C), Psychiatric Psycho-oncologist (Dr. D) Abstract A palliative care patient plans to seek physician-assisted suicide but becomes incapacitated before the plan is implemented. Caregivers grapple with feelings of guilt about not satisfying the patient’s desires. Clinical Summary Issues Raised Ethical Dilemma: Physician-Assisted Suicide vs. Physician-Assisted Palliation From the onset, Mrs. E worried about suffering. She had seen her father endure terrible pain during the period leading up to his cancer-related death. At the onset of treatment, Mrs. E told her providers that she wanted to be warned when she had six months left to live so that she could terminate treatment and avoid agony by moving to Oregon to pursue physician-assisted suicide. Mrs. E had shared her plan with her husband but not with the rest of her family. Mrs. E’s plan was partly driven by her desire to prevent her family from watching another loved one suffer. Mrs. E discussed her options intellectually, rationally and was open about her thoughts. Dr. A, the oncology attending, thought that Mrs. E was trying to be protective of her caregivers by bringing this issue up so openly and did not feel that Mrs. E was a real suicide risk. Dr. A reported that Mrs. E discussed suicide only as part of her plan for the future; it never felt like an imminent threat. However, when Mrs. E became incapacitated, it was too late as she lacked the capacity to enact her plan.End-of-Life Depression Dr. D, the psycho-oncologist, reported that according to the literature, 60% of cancer patients with suicidal ideation have significant treatable depression. He advised that careful diagnosis and treatment of the underlying depression improves quality of life and once treated, many patients change their minds about hastening death. Though this caregiver team had a low level of concern that Mrs. E would harm herself, they did seek input from psychiatry. Mrs. E was evaluated by Dr. D who did not see any evidence of depression. Patient Empowerment Dr. D explained that thinking about ending life and wanting “an out” is very common among cancer patients. Dr. D further reported that for the 40% of cancer patients with suicidal ideation who are not depressed, the request for a hastened death is often closely tied to the need for control and/or anxiety about losing independence. Even though, as a new fellow in oncology, this was Dr. B’s first experience with a patient interested in physician-assisted suicide, he perceived Mrs. E’s plan as her way of feeling in control of her vulnerable situation. He felt Mrs. E presented the plan as a way to ask: “If I had to, could I control the ending [of my life]?” Nurse C first met Mrs. E when she began palliative treatment. Mrs. E told Nurse C immediately that she had been evaluated by psychiatry due to her physician-assisted suicide plan. Nurse C recalls Mrs. E explaining her desire to avoid suffering as she had seen her father die “by inches and in pain”. Nurse C felt that Mrs. E was asking the caregiver team to help her avoid pain and to help ease her death. Pain control was a constant theme for Mrs. E; even while pain was controlled, Mrs. E worried about future pain. Mrs. E also expressed concern about losing her independence. Nurse C felt that sharing this plan of seeking physician-assisted suicide in Oregon was really Mrs. E’s way of saying “Be with me, don’t let me die alone, don’t let me die in pain”. Though Mrs. E had a plan, she pursued aggressive treatment, only refusing those medications which caused intolerable side effects. Given these actions, Dr. D viewed Mrs. E as ambivalent about implementing her plan. Mrs. E continued with extensive treatment even after Nurse C indicated Mrs. E had less than 6 months left to live. In addition, Mrs. E was aware that she had access to enough medication to end her life if she chose to and she did not. Dr. D commented that having access to medications can give terminally ill patients a feeling of control; it can be comforting to know there is an “opt-out option”.Communication/Facilitating a Good Death Though many patients express thoughts about controlling or assisting their deaths, the underlying need may be to find someone to talk to them about dying. Dr. D stated that rather than act, many patients who have the means to choose suicide instead bring the issue to a professional caregiver. By requesting to be informed of the appropriate time to terminate their lives, they are seeking reassurance and support for getting through the process of dying. An audience clinician pointed out the distinction between taking an active role in hastening death and what caregivers can offer to quell pain and suffering. Another clinician in the audience commented that patients generally expect that physicians aim to keep patients alive by all possible means for as long as possible. Caregivers can support a patient’s option to terminate treatment if the treatment itself becomes too burdensome and diminishes quality of life. Dying patients can experience enormous relief when a doctor says “I am here to help you die without pain.” It is comforting to patients to learn that this is not a battle they have to take on alone. Though Mrs. E planned to go to Oregon, as her disease progressed, she learned more about hospice and palliative sedation. Mrs. E found it comforting that there was a way to avoid awareness of pain. Legal Liability In Mrs. E’s home state, physician-assisted suicide is illegal; physicians can be arrested for murder. It is illegal for a physician to write a prescription for a patient with the intention that the patient will use it to commit suicide. If a physician discovers that a patient has a suicide plan and the means to carry it out, s/he is expected to have the patient evaluated, and if necessary, hospitalized against their will. However, there is some recognition in the legal system that many judges would not prosecute someone for failing to report the suicidal ideation of a dying patient with decision-making capacity. Dr. D was not aware of any cases in which a physician was prosecuted for failing to stop the suicide of a dying patient though he emphasized the importance for such patients to be evaluated by psychiatry to rule out treatable depression. The law in Oregon allows physicians to write a prescription for large doses of barbiturates with the plan that a patient can take them if/when ending life is desired. However, Oregon law requires patients to establish residency in order to partake in this plan, though there is no requirement as to residency duration. Mrs. E was aware of these legal requirements. She intended to rent a room to establish residency and yet, she did not proceed. Her caregivers on the panel wondered if perhaps this was because she did not think it was time yet. Caregiver Reactions to Suicides of Dying Patients Several audience clinicians shared stories they carry with them of terminally ill patients who ended their own lives. Though some were surprises, in most cases, these patients had shared their thoughts and had been evaluated by psychiatry. The caregivers attributed the decisions to one or more of the following factors: fear of becoming dependent; difficulty managing pain or other symptoms; or need for control. One clinician in the audience shared a different perspective, opining that suicide of a dying patient is not necessarily a failure. Her view was that suicide may be a viable option and an appropriate choice for a dying patient who wants to maintain control. This professional caregiver understood this choice, made by two of her patients in the past, despite the anger these actions evoked among the patients’ family members.Professional Caregiver Guilt/Feelings of Failure When Nurse C visited the hospice, she found Mrs. E cachectic and curled up in bed. Mrs. E reported feeling comfortable and safe at the hospice, though she then told Nurse C “It wasn’t supposed to be like this.” These were her parting words, which Nurse C interpreted as an expression of remorse by Mrs. E, indicating that she was not “supposed to” end her life dependent and in pain. Upon leaving the hospice, Nurse C felt enormously guilty that she was not able to do what the patient wanted. Regarding these feelings of guilt, Dr. D reminded Nurse C that Mrs. E’s plan was not very well formulated and that Mrs. E made the choice not to exercise her options. When asked about resources to support professional caregivers similarly burdened with guilt, the panel indicated that in addition to external counseling offered by the employee assistance program, the palliative care team processes these feelings during team meetings. Mrs. E died peacefully in the hospice. Lessons Learned
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