Friday, October 24, 2008

Death with Dignity or not?

On the Washington State ballot this year is a compelling initiative, Initiative 1000 which is modeled after Oregon's Death with Dignity act. Since its inception in 1997, the average number of people utilizing this law to procure and use lethal medications is about 40 persons per year. The majority of persons using this law as a means to end their lives are cancer, AIDs and ALS patients.

Working as an oncology nurse in both the outpatient and inpatient setting over the past 5 years, I am no stranger to witnessing death and discussions about the dying process. I have cared for the dying, titrated morphine drips, moistened their mouths, turned them over in bed or just simply sat and held their hand. I have sat with their families and spoken with their loved ones shortly before and after death was near. I have had conversations about hospice and palliative care with patients and families who were struggling with the newly revealed news that death from their cancer was no longer a possibility, but a certainty.

In certain cases, particularly in younger patients with a stronger will to live or older patients with hardier physiques, one can clearly see that the dying process is just as laborious as birth. Every movement, every breath, is purposeful and is fully invested in bringing about an eventuality. The dying process is certainly no less meaningful than that of birth, even if we cannot tangibly evidence why. There is a spiritual realm to all of our daily lives, and this veil thins and becomes transparent at the end of what we experience of life. Even though I am not an especially religious person this is what I feel to be true. Inherent in human life is also death.

I used to think that if ever a law were to be passed in support of patient-assisted death, I could support it. But after seeing how the bottom-line (and certainly not promoting health) is paramount to insurance companies who have the power to deliver or deny treatments that extend (or in some cases, result in cure) of life, there are too many slippery slopes at play. In addition, the manner in which this initiative is written does not allow adequate protection for those who are potentially depressed or otherwise mentally ill. For example, in Oregon's 2007 report, only 36 out of 341 persons were referred for counseling.

The majority of recipients under the Oregon state law were white, educated, and most had private health insurance with about 35% being medi-care or medicaid recipients. So this might weaken my previous 'slippery slope' argument, then again it may not. The more educated population could have placed more value on protecting their hard-earned assets, and part of their decision to seek lethal medications may have subconsciously been financial. The report cites loss of dignity and of autonomy as the most common concerns leading patients to seek medication, but it does not go to any length to qualify what impact treatment decisions or financial situations may have had on their decision.

This initiative is estimated to cost $60,000 for rule-making, and an additional $19,000 per year for statistics tracking and employment of state health department workers. (Yes, I am going to talk about finances) If Washington trends are similar to the Oregon state trends, this would support the deaths of about 40 people a year. It certainly is not a significant source of state funds, but when we're talking health-care dollars, I'd like to ensure that it's money well spent. I'm concerned this is not well-spent, and it does not offer much protection for this vulnerable population of extremely ill persons. It is interesting to note that many disabled rights support groups find this law intimidating.

Consider this (and here is the excerpt which I find most relevant)

Managed care and assisted suicide - a deadly mix.

Perhaps the most significant problem is the deadly mix between assisted suicide and profit-driven managed health care. Again and again, health maintenance organizations (HMOs) and managed care bureaucracies have overruled physicians' treatment decisions. These actions have sometimes hastened patients' deaths. The cost of the lethal medication generally used for assisted suicide is about $35 to $50, far cheaper than the cost of treatment for most long-term medical conditions. The incentive to save money by denying treatment already poses a significant danger. This danger would be far greater if assisted suicide is legal.

Assisted suicide is likely to accelerate the decline in quality of our health care system. A 1998 study from Georgetown University's Center for Clinical Bioethics underscores the link between profit—driven managed health care and assisted suicide. The research found a strong link between cost—cutting pressure on physicians and their willingness to prescribe lethal drugs to patients, were it legal to do so. The study warns that there must be "a sobering degree of caution in legalizing [assisted suicide] in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care" (Sulmasy et al., 1998).

This statement from an accomplished nurse, educator, and wife of a hospice patient states these arguments more eloquently. And this writer offers an interesting position in support of the autonomy of the dying, suggesting that this law with all its safeguards once again places far too much control within the hand of the physician and not of the patient, therefore negating any power of so-called 'freedom' it seems to offer.

Is it possible to write a fail-proof initiative? Maybe not.

But it doesn't mean that we should accept a poorly written and potentially dangerous one where your loved one has to wait an extended period for medication, may not be screened for depression, and is not required to notify anyone (except the physician) of this decision, and saves your insurance plan (or in some cases, the state) a good chunk of cash.

Were the parties responsible for writing this initiative somehow unaware that it is already legal to administer however much sedating medication is needed to relieve pain, even if it hastens death, in the privacy and comfort of your own home? Or were they more aware of the costs of palliative care? Or palliative chemotherapy or radiation treatments for excruciating bone pain for which no other medication is effective? (Yes, such things exist and in some cases are very appropriate.)

No matter your position, you must ask yourself the question: who stands to benefit from such a law? It is clearly not the patient.


Lisa E said...

Thank you for posting this! I've been pretty torn on this one, and I was really hoping to get a detailed healthcare professional's opinion. You make some excellent points, and thank you for the links. I feel much more prepared to cast my vote.

On a much lighter note, that first photo is awesome!

raecatherine said...

Thanks for your comment, Lisa. I was looking for a photo of our state capital and posted this view of the inside of the rotunda instead of a boring ol' outside photo.

Deanna said...

Thanks so much for this informative blog post, Rae. I was feeling very torn on this issue and having your opinion helps confirm my hunches. I hope you don't mind if I link it on my blog?

GeorgeH said...

A good life is worth living, just life is worth nothing.

I weigh my life every day. When I see most days as having more pain than pleasure, I will chose to die.

What is everyone so afraid of?

Anne said...

Although your post is heartfelt, you seem to ignore the fact that the Death with Dignity law has proved both safe and compassionate in Oregon.

After 10 years of experience in Oregon, there has been no slippery slope, no pressure on vulnerable groups, no exploitation by insurance companies, and it costs the state about $20,000 each year.

If price is your primary concern, isn't that a small price to pay to allow end-stage cancer patients who are in pain, suffering, losing their sense of self and their dignity, to allow them to have the choice of whether they want to end their suffering or not?

I hope that this law passes, so if I am ever in that situation, I will be allowed to make my own decision.

Tania said...

Wow...AZ is far from including something like this on the ballot. I didn't know about it until I read the Seattle Times a couple weeks ago. I'm curious to see what the outcome is. I think I'm on the fence about it, though.

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