Q:There has been a lot of media attention lately around physician aid in dying. Some people seem to associate it with hospice care. It is such an emotional topic. Can you help me understand how hospice care relates to physician aid in dying?
A: Yes. It is understandable why end-of-life issues can become emotional; death involves many emotions and is a uniquely personal experience. Our need to address these issues in a clear way means honoring the emotional side while also working with accurate facts.
To start, it is important to define what physician aid in dying is and what it is not. Similarly, we will define what hospice and palliative care are and what that they are not. Then you will feel informed to develop personal opinions and choices for yourself and loved ones at the end of life.
Physician aid in dying is a practice in which a physician provides a mentally competent, terminally ill patient with a prescription for a lethal dose of medication, upon the patient’s request, which the patient self-administers to end his or her own life.
The requirements involved include:
• Competency. The physician performs many evaluations to assess competency. This can include but is not limited to depression evaluation; tests for mental stability or illness; reasoning for the request (addressing issues such as pain, suffering, hopes and fears); evaluating patient’s physical, mental, social, and spiritual suffering; and exploring alternative options.
• Terminal illness. The physician verifies that the patient has been diagnosed with an illness that has no known cure, and therefore corroborates a limited life expectancy.
• Lethal dose prescription. The physician prescribes medication, commonly in pill form. When taken orally, the medication will painlessly sedate the patient into unconsciousness and then, as breathing and heart rate slowly decline, to death.
• Patient request. The physician is working one-on-one with the patient for this request. Only the patient may request this course; the request may not come from family, loved ones, caregivers or other professionals.
• Patient use. The physician does not administer medication, nor would medical staff, hospital staff, hospice staff, palliative care staff or caregivers. Only the patient is to administer a lethal self-dose of medication if and when they choose.
Interestingly, a majority of patients who go through this rigorous process to access physician aid in dying do not end up taking the lethal medications as prescribed, and instead die naturally without assistance.
Physician aid in dying is not:
• Euthanasia, as no one other than the patient may administer the lethal medication.
• Easy to access. Many patients who request this course are refused as they fail to fulfill the requirements outlined above.
• Pain medication delivered that may hasten death. Some pain medications used at end of life have side effects, such as shortness of breath, which may hasten death. Such medications are only delivered with the primary goal of relieving extreme suffering, and sometimes an expected and accepted secondary side effect is hastened death.
• Palliative sedation. This refers to the practice of sedating a terminally ill patient to the point of unconsciousness to relieve untreatable pain and suffering. These patients are already imminently dying, meaning they are days or hours from death.
• Palliative care. Palliative care specifically relieves a symptom. For example, taking Tylenol for a headache is considered palliative care because you have not “cured” or addressed the cause of the headache, you have simply relieved the symptom: the pain.
• Hospice care. Hospice care is a type and philosophy of care that focuses on the palliative care of a terminally ill or seriously ill patient’s pain and symptoms – attending to their physical, emotional and spiritual needs.
Hospice also is:
• Usually provided in the home. It also can be provided in a skilled nursing facility, assisted or independent living facility, and hospital.
• A program covered by Medicare, Medicaid, and most private insurances.
• Provided for weeks, months and, sometimes, years.
• Palliative care. Again, because hospice is not curative in nature, by definition it is palliative as the program is focused on symptom management.
• Easily accessible.
Hospice is not:
• Permanent. Individuals can choose hospice, then decide to seek curative measures revoking hospice to explore a treatment option, and later return to hospice care if they wish.
• Physician aid in dying. It is possible for someone receiving hospice care to also have access to physician aid in dying. However, these are two different medical options.
• Expensive. Medicare, Medicaid and most private insurance plans cover hospice at 100 percent.
While there are ethical debates surrounding physician aid in dying, many physicians and hospice programs take a stance of studied neutrality. That is, they understand the topic and the process, and evaluate all sides of the debate while maintaining a position of neutrality on the subject. By taking this position, these providers and organizations are able to honor the unique wishes and choices of each patient they care for and remain unbiased.
If you would like more information on this topic or have a question you would like to submit to Life’s End email email@example.com. Additionally, if you would like more information about end of life you are invited to attend Community Conversations on Death and Dying on Thursday, May 16, from 6 to 8 p.m. at The Loft of Missoula, 119 W. Main St. This week the topic is death education in our schools, presented by teacher Gary Stein and facilitated by the Rev. Tom King.
Maurika Wells is administrator of Hospice of Missoula.