Palliative Care

Understanding Quality of Care Well Enough to Treat Symptoms, Relieve Suffering and Facilitate Good Dying

University of Washington
South Campus Center Room 246 - Seattle
Tuesday, May 2, 2006
Noon - 1:00 p.m.

Students and Faculty Encouraged to Participate
Lunch will be Provided

Robert A. Pearlman, MD, MPH, will describe the elements of patient quality of life and how these change with time and illness, characterize how health care providers often fail to understand the patient’s perspective, and provide examples of how these misperceptions influence provider behavior. The presentation will focus on advance care planning, relief of suffering, and the motivation for foregoing life-sustaining treatment and physician-assisted dying.  These topics will be explored to demonstrate the importance of quality of life near the end of life. In addition, the social and cultural contexts for these decisions and choices in the United States will be addressed.

Robert A. Pearlman, MD, MPH, is University of Washington Professor of Medicine, Health Services and Medical History and Ethics. Dr. Pearlman is a noted author and expert researcher in clinical ethics and end-of-life care. His research has explored euthanasia, the role of quality of life in decision-making, the validity of life-sustaining treatment preferences, medical futility, advance care planning, physician-assisted suicide, and relief of patient suffering. He is the author of two books and more than 100 publications in medical journals and book chapters; and his most recent book, Your Life, Your Choices, is an interactive workbook that helps patients and loved ones with advance care planning. Dr. Pearlman has mentored countless junior faculty throughout the United States in the technique of combining empirical research methods and ethics.

Students and faculty interested in emerging developments in palliative and end-of-life care for terminally-ill patients are encouraged toattend this important presentation and Q&A session.

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Tough Conversations About the End of Life

Seattle expert Anthony Back, MD, speaks with Stanford medical students about how physicians communicate with patients with terminal illness.

Anthony Back, MD,  is a medical oncologist and director of Palliative Care at the Seattle Cancer Care Alliance / Fred Hutchison Cancer Research Center. On April 20, 2006, Dr. back spoke with students about the difficult conversations physicians face in caring for patients with life-threatening illnesses – both the challenges and rewards. Dr. Back’s research focuses on patient-doctor communication and palliative care, and he is currently principal investigator on a large study funded by the National Cancer Institute designed to teach communication skills to oncologists.

Back qualified as a physician from Harvard Medical School in 1984 and returned to his home state of Washington to begin his medical career. He has been affiliated with the University of Washington for 18 years and has held faculty positions as Associate Professor in the Division of Oncology and Adjunct Associate Professor in the Division of Medical History and Ethics. Back is also a member of the Clinical Research Division at Fred Hutchison Cancer Research Center. Back is also a staff physician and director of Palliative Care Service at the VA Puget Sound Health Care System in Seattle. In addition, Back is an attending physician at the Seattle Cancer Care Alliance. During the last decade, Back has specialized in physician-patient communication. At ASCO’s annual meeting in 2001, Back was a member of the Communication Task Force and a faculty member of the education session “Communication at the End of Life.” One of Back’s current research projects is the development and implementation of a national communication skills workshop for medical oncology fellows.

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Voices Behind the Choice

The views of Oregon physicians, hospice nurses and social workers on Physician-Assisted Dying and their experience with patients who request lethal prescriptions.

Researchers at Oregon Health Sciences University have extensively studied and reported on dying Oregonians’ attitudes toward physician-assisted suicide – providing valuable data well beyond the Oregon Department of Human Services annual PAS reports.

This landmark research (Linda Ganzini, MD, MPH, Principal Investigator) began with surveys of Oregon physicians and hospice care specialists and now includes in-depth survey interviewing and mental health and personality assessment of Oregonians with terminal illness who are considering their options for requesting a lethal prescription.

On November 17, 2005, Elizabeth Goy, PhD, presented an overview of the surveys of Oregon physicians, hospice nurses and social workers on physician-assisted suicide, as well as preliminary findings from current research on patient and family caregiver views and experiences with Oregon’s law. These presentations and open forums are invaluable for any medical student whose work will include providing palliative and end-of-life care for patients in Oregon and throughout the United States.

Goy is a licensed clinical geropsychologist who completed Internship training and a Geropsychology Postdoctoral Fellowship at the Portland VA Medical Center. She is currently a researcher at the PVAMC, serving as co-investigator in the VA Research Program on End of Life Care, established by Linda Ganzini, MD, MPH. Dr. Goy holds joint appointments as Assistant Professor in Psychiatry and Geriatric Psychiatry at the OHSU School of Medicine. She is the recipient of a Medical Research Foundation grant supporting her research on the end-of-life trajectory of Parkinson’s Disease. She is also the research psychologist for a variety of related studies on Oregon’s Death with Dignity Act. Dr. Goy is a supervisor of older adult cognitive assessments at Lifeworks Northwest (formerly Tualatin Valley Mental Health Centers). Through Lifeworks Northwest, Dr. Goy has also provided consultation to Washington County care facilities on cognitive impairment, dementia, depression, anxiety, behavioral disturbance and end-of-life concerns.

Access Dr. Goy's PowerPoint presentation.

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Hastings Center Charts New Course for Dying Patients

Hastings Center's research says new laws aren't needed and urges shift from treating patients in isolation to embracing patients' and families' collective needs.

On Thursday, November 10, 2005, The Hastings Center released the conclusions of its recent research project on end-of-life care at a Congressional briefing in the Rayburn House Office Building. The project described the progress made in the past decade on improving end-of-life care and identified challenges that remain.

Less than a year after Terri Schiavo’s death exposed a deep divide about care at the end of life, this report concludes that too many Americans still receive poor end-of-life care and that improvements will occur only when whole families take collective responsibility at life’s end. The conclusions run counter to the prevailing perspective that focuses primarily on patients and makes little room for involvement of doctors and families.

At the briefing, the research project co-directors Thomas H. Murray and Bruce Jennings outlined where the movement to reform end-of-life care should head, what challenges must be overcome to meet those goals, and what role there is for policymakers in the process. They were joined by Hastings Center Fellows Dr. Joanne Lynn and Alan Meisel, who offered perspectives on health care system reform and the role of law in end-of-life care.

Published as a special supplement to the November/December 2005 Hastings Center Report, the study lays out ideas for a new strategy to improve care for the dying. With the goal of building a better system of care, the authors recognize the collective needs of patients and families, suggest how to overcome the challenge of seeking broader input, and provide examples of ways to revaluate and improve advance directives and surrogate decision-making.

In the closing essay, Murray and Jennings conclude:

“Our understanding of what happens at the end of life has evolved over the past decade, reflecting the spiritual and medical matters most important to the American people. But there is still little knowledge on how end-of-life decisions should be made and the practice of how such decisions actually are made at the bedside. What we need is a system that strengthens the capacity of families and providers to be more effective decisionmakers, especially for patients who have lost the capacity to decide for themselves.”

The authors call for investments over the next decades in public education campaigns that will lead to discussions in communities, at kitchen tables, and in health care settings about end-of-life care issues and decisions. If end-of-life care is to improve, Murray and Jennings say the American public will have to shift the focus away from procedure and process to substantive debates that will help “tell us what to decide, not just how to go about deciding” for dying Americans.

Electronic copies of "Improving End-of-Life Care: Why Has It Been So Difficult?" and of the executive summary of the report are available free.

Individual printed copies may be purchased for $15 each, plus $3.50 shipping (add $.50 for each additional copy). To place an order and inquire about bulk shipping discounts, please contact the Publications Department by phone: (845) 424-4040 ext. 234 or e-mail publications@thehastingscenter.org.

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Research Suggests Doctor-Assisted Suicide
Wouldn’t Undermine Patient Trust

For Immediate Release: December 6, 2005, WINSTON-SALEM, N.C. – There is little evidence to support the argument that legalizing physician-assisted death would reduce patients’ trust in their doctors, according to a researcher from Wake Forest University Baptist Medical Center and colleagues.

“Overall, three times as many people disagree as agree that legalizing physician-assisted death would cause them to trust their personal doctors less,” said Mark Hall, J.D., professor of public health sciences at Wake Forest Baptist and Fred D. and Elizabeth L. Turnage Professor of Law at Wake Forest University.

Hall and colleagues designed a random telephone survey of 1,117 adults in the United States to measure attitudes about physician aid in dying. The results are reported in the current issue of the Journal of Medical Ethics.

Survey participants were asked to use a five-point scale to state their agreement or disagreement with this statement: “Assume for the purpose of this question that euthanasia were legal. If doctors were allowed to help patients die, you would trust your doctor less.” The question did not distinguish between physician-assisted suicide, where the physician helps a patient take his or her own life, and euthanasia, where the physician directly administers the lethal dosage, because prior studies found that attitudes are essentially the same for both.

A majority (58 percent) of participants disagreed with the statement. Only 20 percent said that legalizing euthanasia would cause them to trust their personal physician less. These attitudes were the same in men and women.

Older adults (age 65 or older) and blacks were more likely than other groups to say physician aid in dying would lower trust, but this view was still in the minority. Only 27 percent of older participants and 32 percent of blacks said euthanasia would lower trust.

“Despite the widespread concern that legalizing physician-assisted death would seriously threaten or undermine trust in physicians, the weight of the evidence in the United Sates is to the contrary, although views vary significantly,” said Hall.

The debate over physician-assisted death often includes assertions about the impact on patient trust, yet there has been little data on the subject, Hall said. There are two prior studies on the topic, but they were confined to residents of Massachusetts and Iowa, and they were generally consistent with the findings from this study.

Hall said that public policy advocates often overstate their case when they argue that particular legal or ethical rules are necessary to support trust. Even the U.S. Supreme Court has noted that physician-assisted suicide could “undermine the trust that is essential to the doctor-patient relationship by blurring the time-honored line between healing and harming.”

Hall said that evidence for this argument is weak.

“Our study shows that only about 20 percent of people believe they would trust their physician less if euthanasia were legalized,” he said. “The empirical support is weak for those who confidently assert that legalizing physician-assisted death would undermine trust in physicians for most people in the United States.”

The researchers said, however, that the research doesn’t necessarily support the opposing side, either.

“We should not be cavalier about potential threats to trust because, once it is lost, it is far harder to rebuild than to sustain,” write the authors. Banning physician-assisted suicide or euthanasia could thus still be justified as a measure to avoid any diminution in trust.”

Hall’s co-researchers are Felicia Trachtenberg, Ph.D., from the New England Research Institutes and Elizabeth Dugan, Ph.D., from the University of Massachusetts Medical School. The research was funded by the Robert Wood Johnson Foundation.

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Media Contacts: Karen Richardson, krchrdsn@wfubmc.edu; Shannon Koontz, shkoontz@wfubmc.edu; at 336-716-4587

Wake Forest University Baptist Medical Center is an academic health system comprised of North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university’s School of Medicine. The system comprises 1,187 acute care, psychiatric, rehabilitation and long-term care beds and is consistently ranked as one of “America’s Best Hospitals” by U.S. News & World Report.

Mark A. Hall, JD,is Professor of Law and Public Health at Wake Forest University School of Law and School of Medicine. He is also an Associate in Management at the Babcock School of Management. Prof. Hall received his law degree with highest honors at the University of Chicago and was on the faculty at Arizona State University before assuming his present position. He has also completed a Robert Wood Johnson Foundation Health Finance Fellowship at Johns Hopkins University and has more recently been a visiting Professor at the University of Pennsylvania.

Prof. Hall specializes in health care law and public policy, with a focus on economic, regulatory and corporate issues. His present research interests include doctor/patient trust, managed care regulation, health care rationing, genetics, and insurance market reform. He is the author or editor of ten books on health care law and policy, including the 4-volume series Health Care Corporate Law (Aspen), Making Medical Spending Decisions (Oxford University Press), and Health Care Law and Ethics (5th ed., Aspen).

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Professional Organizations' Position Statements on Physician-Assisted Suicide

A Case for Studied Neutrality

Annals of Internal Medicine, February 4, 2003
Timothy E. Quill, MD and Christine K. Cassel, MD

Position statements opposing legalization of physician-assisted suicide by organizations such as the American College of Physicians–American Society of Internal Medicine rightly emphasize that palliative care should be the standard of care for the dying, and that the inadequacies that exist in its delivery should be remedied. But such position statements generally understate the limitations of palliative care to alleviate some end-of-life suffering, and they do not provide adequate guidance about how physicians should approach patients with intractable suffering who are prepared to die. In this manuscript, we briefly present data about severe suffering before death for terminally ill patients, including those enrolled in hospice programs. We also review some of what is known about requests and responses for physician-assisted suicide in Oregon and in the rest of the United States. Preliminary data from Oregon suggest that legally sanctioned access to physician-assisted suicide is used by a very small number of patients and seems to be associated with improved delivery of hospice and palliative care. Physicians of good will, deep religious convictions, and considerable palliative care experience exist on both sides of the debate about legalization of physician-assisted suicide. In an effort to respect this diversity, and to encourage our profession to continue to struggle with the genuine dilemmas faced by some patients toward the end of their lives and by their families, we argue in favor of medical organizations’ taking a position of studied neutrality on this contentious issue.

Ann Intern Med. 2003;138:208-211. www.annals.org
For author affiliations, see end of text.

The 2001 position statement by American College of Physicians–American Society of Internal Medicine (ACP–ASIM) on physician-assisted suicide (1) was clear about the arguments opposing legalization. We agree that excellent palliative care should be the standard of care for severely ill and dying patients, that the significant inadequacies in its delivery must be remedied, and that legalization has risks (2, 3). Yet the paper was less complete in its presentation of the arguments in favor of legalization, and it was not clear about physicians’ responsibilities to address intractable suffering as part of their commitment not to abandon (4).

Simply prohibiting physician-assisted suicide without giving guidance about how to approach patients experiencing intolerable suffering despite excellent palliative care (5) has several potential adverse consequences: 1) It increases patients’ fears about physicians’ abandonment in the face of severe suffering (6); 2) it reinforces clinicians’ tendencies not to acknowledge the intolerable suffering that some patients experience despite excellent palliative care; 3) it suggests falsely bright lines between physician-assisted suicide and other currently available end-of-life practices that do not resonate with beliefs of many patients, families, and clinicians (7, 8); 4) it may explain some of the variability in access to other last-resort practices; and 5) it may teach patients to be less than forthright with their physicians if they desire a hastened death (9).

People of good will, deep religious conviction, and considerable palliative care experience exist on both sides of the debate about legalization of physician-assisted suicide. As members of ACP–ASIM who believe the position statement (1) was not a balanced description of the clinical and moral issues involved, we write to 1) present clinical data not adequately considered in the article and 2) make a case for organizations to take a position of studied neutrality unless they have empirical knowledge of the views of their members.

INTRACTABLE SUFFERING, REQUESTS, AND PRACTICES
Does Intractable Suffering Exist Despite Excellent Palliative Care?

Terminally ill patients frequently have symptoms such as weakness (39% to 91% of patients), pain (49% to 82%), anorexia (8% to 76%), dyspnea (17% to 51%), nausea and vomiting (9% to 44%), confusion (9% to 24%), and pressure sores (14%) (10, 11). Most experts in pain management believe that they can relieve 95% to 98% of pain using modern methods (12, 13), although other physical symptoms (for example, nausea, vomiting, dyspnea, and open wounds) are more difficult to address. In the last week of life, 2% to 35% of hospice patients report their pain as “severe” or “intolerable” (10, 14, 15), and 35% report their shortness of breath as “unbearable” (16). Survey data from death certificate informants suggest that up to 17% of such patients would have wanted physician-assisted suicide (17). These data speak to a more complex reality of dying patients, even those in hospice, than is ordinarily acknowledged (18).

Are Patients Who Request Physician-Assisted Suicide Depressed?

We must distinguish among contemplations, wishes, general explorations, and explicit requests. For those who receive lethal medication, we must distinguish between those who take it to hasten death and those who still die of their underlying disease (19). Thoughts and wishes about ending one’s life are common in terminally ill patients and may fluctuate over time (20, 21). About half of patients with a persistent desire for physician-assisted suicide have some evidence of clinical depression, but the other half does not (22). Furthermore, many symptoms used to diagnose depression (fatigue, sleep disturbance, thoughts about death) are also symptoms of terminal illness. Without adjusting for such symptoms, depression is diagnosed in 26.1% of terminally ill; with modification for these symptoms, the rate is 13% (22, 23). Some patients with clinical
depression retain the mental capacity to make medical decisions, yet determining this ability can be subtle and complex (24).

How Many Physicians Participate in Physician-Assisted Suicide Outside of Oregon?

The illegality of physician-assisted suicide makes estimation of its frequency difficult. Two well-done studies about the secret practice of physician-assisted suicide report a lifetime physician participation rate of about 5% (25, 26). Subgroups, such as AIDS physicians in San Francisco, California, show participation rates as high as 50% (27).

How Are Other “Last-Resort” Practices Handled?

Supreme Court amicus briefs opposing physician-assisted suicide argued that the practice was not needed because other effective ways can respond to the most challenging cases (28, 29). Patients receiving life-sustaining therapy have the right to stop treatment, even if their intent is to hasten death. About 10% of patients undergoing dialysis die in this way, although there is considerable variation between centers (30, 31). The practice of terminal sedation seemed to be given some legal protection with the Supreme Court decision (32–34), but there is no clear consensus about its moral acceptability or proper role. (Most position statements opposing physician-assisted suicide do not explicitly address this practice.) Access and utilization of other last-resort practices vary widely. For example, terminal sedation is used in 0% to 50% of deaths in different hospice programs (14).

WHAT CAN WE LEARN ABOUT THE EFFECT OF LEGALIZATION FROM OREGON?
Will There Be Many Cases, Particularly from Vulnerable Groups?

Physician-assisted suicide accounted for only 0.1% of all deaths in Oregon (35–37). Of the 70 deaths over the first 3 years, 68 of patients were white (2 were Asian-American), only 1 lacked insurance (insurance status was unknown for 3 patients), only 1 was partially motivated by financial concerns (by physician report), and all had serious chronic progressive illnesses (74% had cancer).

Will Physician-Assisted Suicide Be Viewed as an Alternative to Palliative Care?

In 2000, 85% of patients who died from physician-assisted suicide were enrolled in hospice programs, compared with 38% hospice enrollment for patients who died without physician-assisted suicide. Inadequate pain control was infrequently cited as the reason for physician-assisted suicide (less frequently than cited by matched controls) and was never cited as the sole factor. More commonly cited factors were loss of autonomy, loss of control of bodily functions, feeling a burden on family, and decreased ability
to enjoy life (35).

Will Physicians Evaluate Their Requesting Patients Carefully?

Over the first 3 years of legalized physician-assisted suicide in Oregon, about 5% of physicians received requests; about 1 in 6 requests led to a lethal prescription and 1 in 10 led to a lethal act (38). (Request rates were 21% in 1997, when the legal injunction was in place [39].) Physicians reported evaluating their requesting patients for pain and depression, and many reported that substantive palliative interventions caused some patients to change their minds.

Will Legalization Undermine Efforts To Improve Palliative Care, or Will It Be a Small Part of a Larger Movement To Improve Care of the Dying?

Evidence of concomitant improvements in end-of-life care in Oregon includes increased hospice referrals, morphine prescription per capita among the highest in the United States, the lowest rate of in-hospital deaths in the nation (31%), high levels of do-not-resuscitate orders in nursing home residents (91%), high levels of advance directive completion, and increased physician attendance at palliative care conferences (40, 41).

What Are the Limitations of the Oregon Data?

Oregon has a relatively small, homogeneous population with a history of working proactively and collaboratively on issues of universal access and on restricting treatments of marginal utility. Oregonians pride themselves on being independent thinkers, a quality that has particular resonance with this issue. Furthermore, most studies looking at the first 3 years of practice depend on physician reporting, with inherent risks for underreporting of problems. Nonetheless, Oregon provides the best data available in the United States and is likely to be more reliable than the rest of the country, where physician-assisted suicide is prohibited by law but not aggressively prosecuted.

PSEUDO-CONSENSUS VERSUS STUDIED NEUTRALITY

Many surveys show that physicians, like the rest of the population, are divided about physician-assisted suicide (26, 39, 42–45). A majority of physicians favor legalization (approximately 60%), but only about half of those would be willing to provide such assistance to their patients. A follow-up survey after the American Medical Association issued its position opposing legalization of physician-assisted suicide showed significantly more opposition to legalization in the House of Delegates than in the membership at large (46). Opposition was strongly associated with self-defined politically conservative beliefs, religious affiliation, and the importance of religion to the respondent. Some organizations have explicitly adopted a position of studied neutrality, usually to recognize and respect the diversity of personal and religious views and choices of its members and their patients and to encourage open discussion. Other organizations have made no explicit statement on physician-assisted suicide or its legalization, sometimes to avoid a contentious issue about which there is no consensus and to focus on the broader issue of improving palliative care (2). Neutral positions by the organizations listed in the Appendix show respect for the diversity of views among their memberships and encourage members to struggle with the deep and not easily resolvable issues involved in the question of legalizing physician-assisted suicide.

For example, the Task Force on Care of Terminally-Ill Oregonians’ neutral position on physician-assisted suicide (47) has allowed its members to work to improve palliative care, but also to help physicians and other caregivers with diverse values struggle with how to respond to requests for physician-assisted suicide. These providers were challenged not only to ensure that palliative care was being fully implemented but also to learn how to evaluate such requests, to use them as opportunities to understand and respond to other dimensions of suffering, and to develop a way of working with such patients regardless of whether a particular physician supported or was opposed to physician-assisted suicide.

In our opinion, organizations issuing position statements about the legalization of physician-assisted suicide must address how physicians should respond to the difficult cases. We all agree that inadequacies in the delivery of palliative care must be addressed and that these improvements not be avoided through solutions such as physician-assisted suicide. But predictable, accountable ways of responding to infrequent cases of intractable suffering must also be developed, lest we leave patients and families with the fear that they cannot count on us to work creatively with them to find an acceptable solution. Organizational positions of studied neutrality encourage our profession to continue this discourse and not to leap to overly simplistic policies or prohibitions. Preliminary data from Oregon suggest that these challenges may not be incompatible and in fact may by synergistic and complementary.

CONCLUSION

The question “Would you rather have excellent palliative care or access to physician-assisted suicide?” offers a false dichotomy. A better question might be something like “If you have access to excellent palliative care, and your suffering becomes intolerable, what options should you be able to pursue with your physician?” Or, from a policy point of view, “Is it better to have an open, legally regulated response, or an underground, more idiosyncratic, passively prohibited process?” As our multicultural society seeks to recognize and strengthen respect for different religious and cultural views, patients and physicians will sometimes have diverse opinions on this subject. Reinforcing our duty not to abandon while taking a position of studied neutrality on physician-assisted suicide simultaneously expresses respect for diversity and reinforces the importance of maintaining an ongoing commitment in the face of adversity.

APPENDIX: MEDICAL ORGANIZATIONS WITH NEUTRAL STANCE ON PHYSICIAN-ASSISTED SUICIDE

American Academy of Hospice and Palliative Medicine: www.aahpm.org/pas

American Medical Students Association: www.amsa.org/about/ppp/36.html

American Pharmaceutical Association: www.aphanet.org/

Oncology Nursing Society: www.ons.org/

Oregon Health & Science University: www.ohsu.edu/ethics

Oregon Hospice Association: www.oregonhospice.org/

Oregon Medical Association: www.ormedassoc.org/

Task Force to Improve the Care of Terminally Ill Oregonians: www.ohsu.edu/ethics/guide.htm

Society for Health and Human Values: See reference 48.

From University of Rochester Medical Center, Rochester, New York; and Oregon Health & Science University School of Medicine, Portland, Oregon.

Acknowledgment: The authors thank Daniel Federman for his careful reading and feedback on early drafts of the manuscript.

Requests for Single Reprints: Timothy E. Quill, MD, University of Rochester Medical Center, Box 601, 601 Elmwood Avenue, Rochester, NY 14642.

Current author addresses are available at www.annals.org.

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38. Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians’ experiences with the Oregon Death with Dignity Act. N Engl J Med. 2000; 342:557-63. [PMID: 10684915]
39. Lee MA, Nelson HD, Tilden VP, Ganzini L, Schmidt TA, Tolle SW. Legalizing assisted suicide—views of physicians in Oregon. N Engl J Med. 1996; 334:310-5. [PMID: 8532028]
40. Tolle SW, Rosenfeld AG, Tilden VP, Park Y. Oregon’s low in-hospital death rates: what determines where people die and satisfaction with decisions on place of death? Ann Intern Med. 1999; 130:681-5. [PMID: 10215565]
41. Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA, Delorit MA. Oregon physicians’ attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA. 2001; 285:2363-9.
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42. Cohen JS, Fihn SD, Boyko EJ, Jonsen AR, Wood RW. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med. 1994; 331:89-94. [PMID: 8208272]
43. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet. 1996; 347:1805-10. [PMID: 8667927]
44. Duberstein PR, Conwell Y, Cox C, Podgorski CA, Glazer RS, Caine ED. Attitudes toward self-determined death: a survey of primary care physicians. J Am Geriatr Soc. 1995; 43:395-400. [PMID: 7706630]
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46. Whitney SN, Brown BW, Brody H, Alcser KH, Bachman JG, Greely HT. Views of United States physicians and members of the American Medical Association House of Delegates on physician-assisted suicide. J Gen Intern Med. 2001; 16:290-6. [PMID: 11359546]
47. Task Force to Improve the Care of Terminally-Ill Oregonians. Haley K, Lee M, eds. The Oregon Death with Dignity Act: The Guidebook for Health Care Providers. 2nd ed, revised, online. Portland, OR: Oregon Health Sciences Univ; 2001. Accessed at www.ohsu.edu/ethics/guide.htm on 21 November 2002.
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Current Author Addresses: Dr. Quill: University of Rochester Medical Center, Box 601, 601 Elmwood Avenue, Rochester, NY 14642. Dr. Cassel: Office of the Dean, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.

Timothy E. Quill, MD

TIMOTHY E. QUILL, MD is a board member of the Death with Dignity National Center. Quill is also Professor of Medicine, Psychiatry and Medical Humanities at the University of Rochester (New York) where he directs the Center for Palliative Care and Clinical Ethics and is a practicing palliative care physician. Quill has lectured widely and published numerous articles, including a 1991 New England Journal of Medicine article about “Diane,” a dying patient who requested assistance in dying. Quill is the author of four books, Physician Assisted Dying: The Case for Palliative Care and Patient Choice (Johns Hopkins University Press, co-edited with Margaret Battin), Caring for Patients at the End of Life: Facing an Uncertain Future Together (Oxford University Press), A Midwife Through the Dying Process, Stories of Healing and Hard Choices at the End of Life (Johns Hopkins University Press), and Death and Dignity: Making Choices and Taking Charge (W.W. Norton). He was the lead physician plaintiff in the New York State legal case challenging the law prohibiting physician aid in dying -- Quill v. Vacco.

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Physicians and General Public Support Physician-Assisted Dying

HCD Research, October 11, 2005

FLEMINGTON, N.J. (BUSINESS WIRE) -- Results of a new national survey of 677 physicians and 1,057 members of the general public revealed that the majority of both groups believe that physicians should be permitted to dispense life-ending prescriptions to terminally ill patients who have made a rational decision to die due to unbearable suffering.

The national survey was conducted by HCD Research during October 6-9, in response to the Supreme Court proceedings that are challenging the state of Oregon's Death with Dignity Act. The margin of error in the survey was plus or minus 3% at a 95% confidence level.

The survey indicated that nearly two-thirds of physicians (62%) and the general public (64%) believe that physicians should be permitted to dispense life-ending prescriptions.

Among the findings:

• Over half of physicians (54%) and nearly two thirds of the general public (70%) indicated that federal or state government should not be given the right to decide if physician-assisted suicide is a legitimate medical purpose.
• A majority of physicians (70%) and the general public (66%) believe that Chief Justice Roberts will have some influence on the final decision of the Supreme Court.
• An overwhelming majority of physicians (76%) and slightly more than half of the general public (52%) reported that the justices' personal experiences with serious illnesses will bias their decisions.
• While more than half of physicians (65%) believe that Justice Sandra Day O'Connor's vote would affect the court's decision, less than half of the general public (46%) believe that it would affect the decision.
  Given the choice between Justice O'Connor's vote and Supreme Court Nominee Harriet Miers' vote, a clear majority of physicians (74%) indicated that they would rather see Justice O'Connor's vote count, while only 44% of the general public indicated they would prefer Justice O'Connor's vote, and 40% of the general public reporting that they didn't know.
• "Although the high percentage of physicians who support the ability to prescribe such medications may be somewhat surprising, I believe it is the result of physicians' personal relationships with their patients and the desire to act in the best interest of each patient," commented Craig Alter, M.D., specialist in the Pediatric Endocrinology Division of The Children's Hospital of Philadelphia and a clinical associate professor of Pediatrics at the University of Pennsylvania School of Medicine. "In addition, this survey does not imply that physicians feel there should be uncontrolled access to these medications," he noted.

According to Arthur Kover, Ph.D., a management fellow at the Yale University School of Management and consulting director at HCD Research, while the majority of physicians and the general public support physician-assisted suicide, the debate will become increasingly rancorous. "I believe that those who oppose physician-assisted suicide feel their opinions much more deeply than the majority who support it. Therefore, they will continue to fight despite their shrinking numbers," explained Dr. Kover.

• To view detailed results for the physicians’ poll, please click here.
• To view detailed results of the general public poll, please click here.

Editors/Reporters: For more information on the poll, or to speak with Dr. Craig Alter or Dr. Arthur Kover, please contact Vince McGourty, M&M Communications, Inc., at (908) 638-5555 or vinmcg@earthlink.net.

HCD Research is a marketing and communications research company headquartered in Flemington, NJ. The company's services include traditional and web-based marketing and communications research. HCD Research is also the developer of readmylipz.com, a political ad testing web site for the 2004 Presidential campaign. For additional information on HCD Research, access the company's web site at www.hcdi.net or call HCD Research at 908-788-9393.

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Additional Resources

'The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals,' Patrick Dunn, MD; Bonnie Reagan, MD, RN; Susan W. Tolle, MD; Center for Ethics in Health Care, Oregon Health Sciences University, March 1998 (reprinted 2005).

Additional Books and Articles
Related books and journal articles

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For more information about Next Generation, contact: Robert C. Kenneth by e-mail, or call 503-228-4415.

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