Oregon Doctors, Patients Defend Threatened Assisted Suicide Law

http://www.washingtonpost.com/wp-dyn/articles/A46684-2001Dec31.html

Tuesday, January 1, 2002; Page A01
By Susan Okie
Washington Post Staff Writer

PORTLAND, Ore. -- Richard Holmes knows he doesn't need a doctor's prescription for a powerful sedative to end his life. He could turn on his car's ignition and sit in his closed garage. Or he could swallow a bottle of the liquid morphine he takes to ease the pain from the cancer that has spread to his liver.

But a solitary and perhaps violent suicide is not the kind of death Holmes wants. Nor does he wish to spend his last days in a painkiller-induced fog, unable to talk with his children and grandchildren.

"That is a bad legacy to leave," said Holmes, 72. "I don't want to die not knowing if it's day or night, not knowing anybody in my family. I want to know what's going on and do it myself if I'm going to do it: Say 'Adios.' "

So, in recent weeks, Holmes filled a prescription for a lethal dose of Nembutal, a fast-acting barbiturate that would put him in a coma in minutes and would likely kill him in hours. Like some other terminally ill Oregonians, he rushed to acquire the drug upon learning of a move last month by Attorney General John D. Ashcroft to block Oregon's four-year-old assisted suicide law.

Although the law remains in force, its future is in doubt. The Justice Department move, which would punish Oregon doctors who help patients end their lives, is on hold for at least four months after a federal judge issued a restraining order. Holmes -- with other patients -- is a plaintiff in a suit challenging the Justice Department directive. By the time the case is decided, he may be dead.

"I've lived my life the way I want to. I should die the way I want to," Holmes said. "I personally think it should be a law in every state in the whole country."

Whatever eventually happens to Oregon's law, the nation's first experiment with physician-assisted suicide has offered new lessons about how people choose to face death. Although many in Oregon and elsewhere consider assisted suicide immoral, the law has not had the dire consequences that some opponents predicted. State officials and researchers say there is no evidence the law has been used to coerce elderly, poor or depressed patients, nor has it caused significant migration of terminally ill people to Oregon. Instead, some data suggest it may have prompted doctors in the state to improve their care of the dying.

"From my point of view, the law has worked smoothly," said cancer specialist Peter Rasmussen of Salem. His patients often bring up assisted suicide, he added, but few want to use the law. Instead, "they're talking about the fact that they think it's good that it's available."

Among people in Oregon who have used the law to end their lives, it appears the most common motive was a desire for autonomy. Holmes's wish to control the time and manner of his death was echoed in interviews with other patients and family members of people who died by assisted suicide, as well as in a survey of Oregon doctors who have cared for such patients. Knowing that assisted suicide is an option, even if they never use it, seems to comfort some sick people by offering a measure of personal choice in the face of terrifying illnesses that may rob them of control over pain, sleep, movement, awareness, breathing and bodily functions.

"I felt reassured after speaking with my doctor" about assisted suicide, said Jim Romney, 56, a former school superintendent who was diagnosed last June with amyotrophic lateral sclerosis, a fatal neurological disease that causes progressive paralysis. "I felt almost liberated because I now knew how I could die. It was a matter of when."

A survey of more than 2,600 Oregon doctors published last year found about 5 percent had received requests from patients for a prescription for lethal medication since the law took effect.

About 1 out of 6 patients who requested a prescription received one, and 1 out of 10 used it to commit suicide, said Linda Ganzini, a professor of psychiatry at Oregon Health Sciences University who conducted the study.

During the first three years of the law's existence, 96 patients used it to obtain prescriptions and 70 used the medication to end their lives, according to data collected by the state health department.

The law requires that any Oregon resident requesting a prescription for lethal medication must be certified by two doctors as terminally ill with less than six months of life expectancy and as mentally competent to make such a decision. A written request by the patient must be witnessed by two people who are neither family members nor participants in the person's health care. If a doctor suspects depression or mental impairment, the patient must also be evaluated by a psychiatrist or psychologist.

In 68 of 142 cases described in Ganzini's survey, the request for a prescription prompted the doctor to take other measures, such as improving pain treatment, referring the patient to a hospice or prescribing antidepressants. Almost half of those who received such interventions changed their minds about assisted suicide, Ganzini found.

In no case did a doctor prescribe lethal medication for a patient whom the physician considered to be depressed.

Most Oregon residents who have used the assisted suicide law worked with Compassion in Dying of Oregon, a Portland-based nonprofit organization that guides patients and their families through the process.

"When [patients] call, we want to find out what their underlying needs are," said George Eighmey, the group's executive director. In most cases, he said, "if we can address those and improve them, then they change their mind."

The law still has many opponents. In Ganzini's surveys of Oregon doctors, about one-third have consistently said they oppose assisted suicide as morally wrong.

Providence Health System, a Catholic health care organization that operates three hospitals in Portland, prohibits its doctors from participating in the law, said the Rev. John F. Tuohey, the system's medical ethicist. "As public policy, it's wrong to take life, whether it's my taking my own or the state taking a criminal's or somebody else's," Tuohey said.

Some physicians and ethicists argue that suicide may be a valid personal choice, but doctors, as healers, should never hasten death. The traditional philosophy of the hospice movement has been that dying should be neither hastened nor prolonged, said Ann Jackson of the Oregon Hospice Association.

Other critics of the law maintain that the desire to commit suicide is virtually always a sign of depression, a treatable mental condition.

"When people have committed doctors and families to take care of them, they don't have to kill themselves," said N. Gregory Hamilton, a psychiatrist and past president of Physicians for Compassionate Care, a doctors group opposed to assisted suicide. "For a doctor to give a patient a lethal prescription . . . sends with it a message to the patient that the doctor doesn't value their life."

Studies suggest about half of terminally ill people who wish to hasten death are not depressed. Even among psychiatrists, there is disagreement about whether a dying person who is depressed can, nevertheless, make a well-reasoned decision to commit suicide.

"I was trained that anybody who would consider suicide is, by definition, mentally ill," said Rasmussen, the Salem cancer specialist. Rasmussen said he gradually changed his opinion during the debates that led to passage of state referenda on assisted suicide in 1994 and 1997. Since the law took effect, he has written prescriptions for lethal medication for several patients who requested them.

"I have seen depressed patients," he said. "But I have also seen people who seemed to be mentally competent and talked about wishing to die."

Opponents of the law predicted it would be used disproportionately by poor or socially isolated people, the uninsured or those without access to good medical care or hospice services. Some even expressed concerns that managed care organizations would encourage assisted suicide because it costs less than hospice care. But three years of data collected by the state health department have not borne out those predictions.

Oregonians who used the law to obtain lethal prescriptions have tended to be highly educated, well insured and as likely to be married as those who died naturally of similar diseases, said Katrina Hedberg, a medical epidemiologist with the Oregon Health Division. Eighty percent were receiving hospice services. Compared with other Oregonians, they were less likely to be covered by managed care plans or HMOs. The majority had cancer, with heart or lung disease as the next most frequent diagnoses.

"When you talk to doctors, what comes through is, this is an unusual group of people," said Ganzini, who recently surveyed physicians about the personalities of patients who used the law. "They place a high value on control and independence. Compromise is not in their vocabulary. . . . Nobody who knows them is surprised by the request."

Portland resident Peggy Sutherland was diagnosed with lung cancer in January 2000 and underwent surgery to remove the tumor. A few months later, it recurred and spread to her bones.

"She was very insistent on living her life to the fullest as long as she could," recalled her daughter, Julie McMurchie. But despite chemotherapy and an implanted device that pumped a painkiller into her spinal fluid, Sutherland soon was in such severe pain that she could not stand or get out of bed.

In late 2000, Sutherland told her longtime internist and her cancer doctor that she wanted to use the assisted suicide law, McMurchie said. In addition to the pain, she was having trouble breathing and was coughing up blood.

"She was very practical, not hysterical, not depressed," McMurchie said. "She wanted to say goodbye."

Under the law, Sutherland had to wait 15 days before the prescription could be filled. McMurchie said toward the end of the waiting period, her mother fell into a stupor and was difficult to arouse.

But on the 15th day, "she just woke up, clear as a bell."

McMurchie went with Sutherland's doctor to pick up the prescription for secobarbital, a fast-acting barbiturate, at a pharmacy. Then, Sutherland's sister, her five children and their spouses gathered in Sutherland's bedroom with its view of the Willamette River. They talked and read poetry.

"My mom wasn't religious, but she wanted the 23rd Psalm," McMurchie said. "My brother just picked up a Bible and started reading it. She says, 'That's not the right version. I want the King James.' That was just so her."

"We all said goodbye and kissed her," McMurchie said. "She drank the liquid. I think within five minutes she was asleep. Within 20, she passed away." She died last January at age 68.

McMurchie disputes claims that people who choose to use the law are depressed or receiving inadequate care.

"She had the best [care] there was, and it was her choice," she said. "I think she loved her five children an awful lot and wanted to leave them something. After just an awful, wretched several months . . . we were given a gift that morning."

There is some evidence to suggest the assisted suicide law has led to improvements in care of the terminally ill. In a 1999 survey by Ganzini, more than three-quarters of Oregon physicians who had cared for at least one dying patient in the previous year reported they had made efforts to improve their knowledge of pain treatment for such patients. Sixty-nine percent said they had sought to improve their recognition of psychiatric illnesses such as depression and 30 percent said they had increased their hospice referrals.

Physicians' prescribing of morphine has also increased since the assisted-suicide initiative was passed in 1994.

Some experts suggest Oregon voters passed the nation's only assisted suicide law because they have had more personal experience with death than people in other states. More people die at home in Oregon than in any other state. Oregonians are also more likely than people in other states to receive hospice services and less likely to die in the hospital.

"I think people have become empowered to express their wishes and expect that to be respected," Rasmussen said.

Whenever his patients who used the assisted suicide law would permit it, Rasmussen said, he has been present at their deaths.

The experience has been different from attending the deaths of his other cancer patients, where family members have usually been awake many nights coping with the patient's symptoms and are exhausted, he said.

"All that is missing with these planned deaths," he said. "Instead, the focus is on the patient and his or her relationships with other people. And that is a beautiful thing."
 

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