Doctors describe ‘death with dignity’ program for cancer patients

A majority of Americans support the idea of allowing terminally ill patients to end their lives with the help of their doctors. For instance, 55% of people questioned for the NPR-Truven Health Analytics Health Poll last year said they were in favor of legalizing physician-assisted suicide. A BBC World News America/Harris Poll from the year before found that 58% believed that physician-assisted suicide should be a legal option for patients who request it.

It’s one thing to endorse physician-assisted suicide in principle. But how should it be implemented in practice? That’s a difficult question that doctors, social workers and public health experts in Seattle have grappled with as they set up the Death with Dignity Program at the Seattle Cancer Care Alliance, or SCCA. They describe their program in Thursday’s edition of the New England Journal of Medicine.

Washington and Oregon are the only states that allow physician-assisted suicide (though Pennsylvania, Vermont and Hawaii are currently considering it), and cancer patients are among those most likely to seek it. The SCCA -- which serves cancer patients being treated at the Fred Hutchinson Cancer Research Center, the University of Washington and Seattle Children’s -- is the only federally recognized comprehensive cancer center serving those states.

So it was natural for leaders there to consider a death with dignity program after the Washington Legislature passed the Washington Death with Dignity Act in November 2008.

The first step was to poll doctors to see if enough of them would be willing to help patients who wanted to end their lives. Among the 81 who responded to the survey, 50 said they would be comfortable consulting in such cases; among them, 29 were also willing to write the prescriptions for lethal medications. That was enough for the planners to move forward.

After much discussion and debate, the planners set up the following rules:

* Nobody who works at SCCA is required to participate in the Death with Dignity Program.

* The program is only available to patients under the care of the SCCA, and patients may not begin treatment at SCCA just to gain access to the program.

* SCCA does not advertise the program, even in its own buildings.

* Patients are eligible only if they are terminally ill and have no more than six months to live.

* They must pass a psychological assessment to insure they are competent to make a decision of this magnitude.

* All patients who request a lethal prescription are told that palliative care and hospice treatment are available to them (although 54% of Death with Dignity patients are already in hospice care at the time they make their inquiries).

* Patients must agree that if they do take their lethal prescriptions, they do so only in a private place and in a private manner. (One patient was dropped from consideration for failing to agree to this requirement.)

* After patients have met all the requirements, they must wait at least 15 days before getting a prescription for a lethal dose of secobarbital, a barbiturate.

Between March 5, 2009, and Dec. 31, 2011, 114 SCCA patients made at least initial inquiries about the Death with Dignity Program, according to the report. Among them, 44 -- or 39% -- went no further and 30 -- or 26% -- began working with a social worker but either changed their mind or died before they received a prescription.

That leaves 40 patients who did get a prescription. All of them have died, but only 24 did so as a result of taking secobarbital.

For some patients, simply having the medication on hand and knowing it was available was enough.

“Both patients and families frequently express gratitude after the patient receives the prescription, regardless of whether it is ever filled or ingested, typically referencing an important sense of control in an uncertain situation,� according to the report.

There have been a few hiccups here and there, including one patient who remained alive overnight after taking secobarbital. Considering that the drug is usually lethal in about 35 minutes, the patient’s family became quite distressed. (It kicked in eventually.)

Another hiccup is that 11 patients wound up living for longer than the six months they were expected to have left. In these cases, social workers have opted not to inform physicians out of fear that the doctors will wait until their patients are closer to death before they have a frank conversation about their prognosis.

Most of the patients who wound up receiving prescriptions for secobarbital were white men who had graduated from college. They were also more likely than Washingtonians in general to have jobs.

When asked why they entered the Death with Dignity Program, 97% of patients surveyed said they feared the “loss of autonomy� that was sure to come as they deteriorated. In addition, 89% cited an “inability to engage in enjoyable activities� and 75% were concerned about “loss of dignity.� Actual pain and fear of future pain were mentioned only 22% of the time, according to the report.

You can read the study, Implementing a Death with Dignity Program at a Comprehensive Cancer Center, on the New England Journal of Medicine website. In addition, two doctors debate the merits of allowing a hypothetical 72-year-old man with metastatic prostate cancer to end his life with the help of his physician on the website here.

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