Sunday, June 30, 2013

Aid in Dying - Vermont's Unique Path

Vermont recently became the first state to enact a law authorizing physician-assisted suicide through the legislative process.  "As the governor signed the bill, Jean Mallary watched carefully over his shoulder. She’s the widow of the late Dick Mallary, a former speaker of the House and U.S. Congressman.  Mallary was in pain and suffered from terminal cancer when he chose to end his life over a year ago. Jean Mallary’s story about her husband’s choice – and that he had to die alone without his family at his side – was compelling personal testimony that pushed the bill forward."

I happen to live in one of the other two States which passed a "Death with Dignity" (DWD) law through the voter initiative process.  It's been pretty much a non-issue here in Washington State with no blaring media articles.  Only about one in 500 deaths are a result of utilizing our State's law.  The individuals I've talked to who have witnessed the deaths, have found the process humane and comforting.  A recent report in the April 11th issue of the New England Journal of Medicine gives the most recent data on the quite rare use of physician assisted suicide. "Washington's Death With Dignity Act hasn't lead to scores of terminally ill people seeking lethal prescriptions, the researchers report: Almost three years after the law was enacted, just 255 people had obtained a lethal prescription from a physician. Of those 255 prescriptions, 40 were written for terminal cancer patients at the Seattle Cancer Care Alliance. And, in the new study, doctors there found that only 60 percent (24 people) of their patients chose to use their prescription to hasten their death."

I must admit, however, that I still have some qualms about the potential for abuse of the Death with Dignity (DWD) laws.  So I've stayed neutral in my own stance, waiting to see how it plays out and trying to stay vigilant for the potential of abuse.  As more and more of us reach advanced age and the pressure to conserve health resources mounts, we need to make sure that the individual is making an autonomous well informed choice.  Also, we need widely available affordable health care for these very ill patients, plus superb hospice and palliative care.  The DWD option needs to be a "last resort" when very good care has failed to relieve or address the individual's concerns.

Fortunately the DWD laws in Oregon and Washington have been carefully crafted, monitored, and transparently reported.  To maintain their good record, it will require on-going funding and oversight particularly if the financial burden of health issues continues to weigh heavily on patients, families, medical institutions, and governments.

I have three areas of concern about Advance Care Planning.  First is the continuing lack of Medicare payment for end of life discussions with an individual's physician.  There is some hope that progress will be made by the United States Senate Special Committee on Aging.  It's certainly worth viewing this special Senate Hearing and reading reports from very the engaged Senators, plus representatives from Five Wishes, the Conversation Project, and the POLST Paradigm.

The second area of concern are media reports of abuses related to England's Liverpool Care Pathway where, at times, physicians may have written "do not resuscitate" without the consent of the patient.  Other abuses are under investigation as well.  The pathway, though well intentioned, has proven to be an area of controversy in its uneven application and implementation.

Thirdly, there is evidence for the misapplication and misuse of Washington State's POLST (Physician's Orders for Life Sustaining Treatment).  Some retirement communities in our area are "requiring" that all residents, even those in independent living, have a completed POLST form.  This is not the intent of POLST forms which are applicable as active medical orders for those in the last six months of life or the very frail elderly who are clear about their wishes.  So there are unintended consequences from some important efforts that need monitoring and updating to prevent misunderstanding or abuses. 

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