In the May 9 issue of the Journal of the American Medical Association, researchers report that Oregon physicians have made a priority of improving their ability to care for dying patients since passage of the Oregon Death with Dignity Act.
"Because Oregon is the only state in which assisted suicide is legal, it offers a rare chance to try to understand how such laws might affect overall medical practice," said first author Linda Ganzini, M.D., director of geriatric psychiatry at the Portland Veterans Affairs Medical Center (VAMC) and an associate professor of psychiatry at Oregon Health & Science University (OHSU). Since legalization of assisted suicide in 1994, Ganzini said, some people have expressed concerns that palliative care options would diminish for patients in Oregon.
"What we actually found was the opposite," Ganzini said. "We found that the majority of physicians who care for dying patients have made efforts to improve their knowledge and skills in palliative care."
In the February 24, 2000 edition of the New England Journal of Medicine, Ganzini and her colleagues reported that Oregon physicians were responding in a careful and prudent manner when patients requested assisted suicide. Physicians reported that they were honoring only one in six requests for lethal prescriptions, with one in 10 requests actually resulting in suicide.
In their new study, researchers looked at Oregon physician attitudes toward and practices around the care of dying patients since passage of the Death with Dignity Act. For both studies, researchers mailed questionnaires to 3,981 physicians eligible to prescribe under the act, receiving 2,641, or 66 percent, of responses.
Thirty percent of responding physicians reported they had increased referrals to hospice care -- 10 times as many as had decreased the referrals, the study found. Thirty-three percent believed that hospice had become more accessible for their patients since passage of the Death with Dignity Act. Sixty-nine percent of physicians reported they had made efforts to improve their ability to recognize treatable psychiatric disorders such as depression, and 79 percent said they had made efforts to improve their knowledge about use of pain medications in the terminally ill.
Study findings also failed to support speculation that legal assisted suicide might set up a situation of distrust between patients and physicians, Ganzini noted, or that requests for lethal prescriptions would reflect a lack of physician knowledge in such areas as pain control and treatable conditions such as depression. Although assisted suicide is rare, the researchers found, many physicians have conversations with patients about it and most patients find those conversations helpful rather than upsetting. Patients were more likely to respond in a negative manner if their physicians opposed assisted suicide rather than supported it, the study found. Most requests for lethal prescriptions came to physicians best equipped to respond knowledgeably -- those who care for many dying patients and who had made attempts to improve their competence in end-of-life care.
The researchers also found, however, that 15 percent of physicians who received a request for a lethal prescription had not sought out information about the Death with Dignity Act from a reliable source, and 27 percent were not confident they could predict a six-month survival. These findings emphasize the importance of continued physician education in end-of-life care, Ganzini stressed, and for expertise on the part of physicians serving for the second consultation required under the law before a lethal prescription request can be granted.
In addition to Ganzini, the research team included Heidi Nelson, M.D., M.P.H., of the VAMC and OHSU; Melinda Lee, M.D., of Providence ElderPlace and OHSU; Terri Schmidt, M.D., and Dale Kraemer, Ph.D., of OHSU; and Molly Delorit of the VAMC. Their work was supported by the Greenwall Foundation, the Gerbode Foundation and the Department of Veterans Affairs.