Portland, Ore.

Report highlights missed opportunities to reduce suffering when physicians avoid extended conversation on end-of-life issues

According to an article in the July 3 edition of the Journal of the American Medical Association, open discussions between physicians and patients often provide alternatives to those considering physician-assisted suicide (PAS). That's the conclusion of a real-life case study reported by researchers at the Center for Ethics in Health Care at Oregon Health & Science University. The researchers documented the case of an Oregon patient with amyotrophic lateral sclerosis (ALS) or Lou Gehrig's disease, who initially requested PAS. However, following a more detailed discussion with a second physician, the patient decided not to go through with the process. To protect the privacy of the patient and his caregivers, their names are not listed in the article. Paul Bascom, M.D., assistant professor in the OHSU School of Medicine; and Susan Tolle, M.D., director of the Center for Ethics on Health Care, authored the article. It was written on request of the journal and is the sixth in a series on end-of life care from a patient's perspective sponsored by The Robert Wood Johnson Foundation.

The authors do not debate the moral issue of PAS, instead they focus on the obligation of all physicians to provide comfort and put patients' needs for deeper dialogue first. The Center for Ethics in Health Care at OHSU remains neutral on the Oregon Death with Dignity Act, neither supporting nor opposing the option.

In summary, the case involves a 47-year-old patient, referred to as "Mr. G" in the paper. Mr. G initially asks the house physician at his nursing facility to assist him in ending his life. The physician, "Dr. R," does not explore the motivation behind the patient's request and refers his patient to hospice care. Dr. R is opposed to PAS and discontinues his care of Mr. G. In response, the hospice medical director, "Dr. L," begins caring for the patient. Dr. L and Mr. G then take part in patient-physician discussions about end-of-life issues. Their conversations include what Mr. G can expect to face in the final stages of ALS, how these symptoms can be treated and the various life-sustaining treatment options. Based on information gathered from these discussions, Mr. G decides to die without the aid of PAS. Instead his life ends comfortably under a treatment plan he and his physician designed.

"The case study is a perfect example of what can and does occur in health care settings," said Bascom. "At times, communication can break down, causing additional stress to dying patients and their families. More importantly, however, this case demonstrates the importance of in-depth, open, patient-physician conversations about end-of-life issues to identify concerns, put patients at ease and help them make informed decisions. While Oregon is the only state where physician-assisted suicide is legal, we believe this message of communication can be of value to physicians and patients throughout the U.S. and around the world. If we are afraid to talk about tough issues, our patients suffer."

In reality, relatively few patients take part in the actions legalized by Oregon's Death With Dignity Act. While about half of dying patients say they would like the option, studies show that only 10 percent seriously consider ending their lives through the assistance of a physician. About 1 percent of patients request PAS, and one in 10 of those patients receive and take the lethal prescription.

"Most patients' concerns and fears can be met without PAS," adds Bascom. " Ultimately, less than one in a thousand Oregonians takes a lethal prescription. In other words while legal, the option is not commonly used in this state."

Like the public, professional opinions on PAS also vary. A 1995 statewide survey of Oregon physicians showed that 60 percent of respondents agreed that PAS should be legal. However, less than half (46 percent) said they would be willing to write a prescription for lethal medication.

Nationally, approximately 25,000 terminally ill people ask their doctors for lethal prescriptions each year. The authors advise physicians to focus on an exploration of the patient's request first, rather than responding according to their own support of or opposition to PAS.

"Many patients are not afraid of death, but of the process of dying," said Bascom. "Some worry that they will suffer in their final weeks or days, or have witnessed the painful death of a loved one when palliative care measures were not as advanced as they are now. This story illustrates the benefits of an open dialogue about death regardless of whether the patient lives in a state where PAS is legal or not."