Physician-Assisted Death in the United States: Are the Existing "Last Resorts" Enough?
- Physician-Assisted Death in the United States:Are the Existing "Last Resorts" Enough?
Although there has been relatively little activity in the last ten years with regard to legal access to physician-assisted death, this fall a citizens' initiative in the state of Washington is proposing an Oregon-style law that would allow legal access to potentially lethal medication for terminally ill patients, subject to defined safeguards. As the rhetoric inevitably heats up, this seems like a good time to review areas of progress in palliative and end-of-life care and to consider whether laws like the one on the table in Washington are either needed or desirable.
Several things are clear: (1) Palliative care and hospice have improved in terms of access and delivery, and they remain the standards of care for addressing the suffering of seriously ill patients. (2) Despite state-of-the-art palliative measures, there will remain a relatively small number of patients whose suffering is insufficiently relieved. (3) Several "last resort" options, including aggressive pain management, forgoing life-sustaining therapies, voluntarily stopping eating and drinking, and sedation to unconsciousness to relieve otherwise intractable suffering, could address many of these cases.1 The question remains as to whether physician-assisted death—that is, providing terminally ill patients with a potentially lethal prescription that they could ingest on their own to relieve otherwise intractable suffering by directly hastening death—should be one of these last resort options.
My own answer to this last question is a cautious "yes": open access to physician-assisted death, subject to the safeguards of excellent palliative care and access to other last resort options, gives patients an important additional option, and the benefits of legalization outweigh the risks.
Progress in the Last Decade
Perhaps the most dramatic sign of progress has been the coming of age of the palliative care movement, which allows fully informed decision-making and the provision of treatments to maximize quality of life for all seriously ill patients alongside any and all disease-directed treatment that patients want to continue. Almost all major medical centers now have inpatient palliative care consultation services, and similar services are spreading into community hospitals. Consultation possibilities are also spreading into the outpatient and home settings, although the gaps between need and availability are much wider in these contexts. The American Board of Medical Specialties has recently given palliative care the status of being a board-certified subspecialty, and fellowship programs are sprouting up across the country.
There remain serious challenges. There are not enough skilled palliative care clinicians to meet the growing needs, and reimbursement for palliative care services—which rely heavily on counseling and coordination of care rather than expensive procedures—remains problematic. Similar gaps exist in providing basic palliative care education for all clinicians who care for seriously ill patients, and in generating an evidence base for the field. Nonetheless, palliative care seems to have passed [End Page 17] the "tipping point" as a field; most patients and families can find the treatments that they need regardless of their stage of disease.
When patients become terminally ill, access to palliative care is facilitated by the proliferation of hospice programs. Hospice remains our premiere program to provide palliative care for terminally ill patients who are willing to forgo further treatment of their underlying disease, as it provides, pays for, and coordinates comprehensive quality-of-life-oriented treatments for terminally ill patients. Hospice has expanded considerably in the last ten years, primarily in two domains: the inclusion of terminally ill patients with diseases other than cancer—congestive heart failure, dementia, and chronic lung disease, for example—and the ability to supplement the palliative aspects of care for terminally ill patients who reside in skilled nursing homes.
Despite this progress, the majority of patients who die in the United States are never transitioned to hospice, mostly because of a requirement that once they are in hospice they will forgo disease-directed therapy. Some larger hospices are experimenting with loosening these restrictions through "bridge" programs that let patients continue active treatments that are important to them and have some potential for helping while at the same time receiving the...
