Some of the most difficult decisions faced by patients, families, and physicians arise when a request is made to hasten the death of a dying patient. Physician assisted suicide (PAS) is usually considered an ethical controversy.33,34 Here, I will not discuss the ethics of PAS or attempt to resolve the controversy, but in keeping with the theme of this section, I will offer some suggestions for responding to requests for a hastened death.35,36
Sometimes patients indicate very clearly that they want assistance in hastening their deaths. More often, in my experience, patients toss out very subtle hints that they would like to discuss the issue. Patients may say simply, "I'm tired of all this," or "I wonder how long this dying business is going to take?" Such statements may or may not reflect an interest in discussing PAS. Exploration of such statements may help clarify whether patients are simply tired and asking about prognosis or whether they wish to discuss with you possible hastening of death.
Here, we should pause for definitions. PAS can be defined as the intentional hastening of death performed by a person with decision-making capacity with the assistance of a physician (and other clinicians). Voluntary euthanasia is defined as an act intended to hasten death performed by someone else (usually a physician) with the permission or at the request of the person. (Involuntary euthanasia would be hastening death without the consent of the person.) At the present time in the United States only PAS is legal and only in Oregon under specific circumstances.
No one on either side of the PAS debate worthy of respect advocates a simple yes-no response to questions such as these. Even if you are sure you would never act with the intent of hastening a patient's death, do not start with a response such as, "No, I can't. It's illegal (or wrong)." Do not overreact to inquiries by dying people. I suspect that it is the rare individual who knows he or she is dying who has not at least considered the possibility of "getting the show on the road." Therefore, it is a mistake to assume such inquiries are the equivalent of active suicidal ideation and require an emergency psychiatric consultation and the placement of a hold for "danger to self or others." Neither should you underreact with a response like, "Oh, you don't mean that, you've got plenty to live for" or by ignoring a sometimes subtle, sometimes not so subtle request to discuss the issue.
Most requests I have encountered that might be interpreted as requests for a hastened death incorporate some ambiguity. Some, such as the question, "I want to die, can you give me something," are relatively unambiguous, although it is still not clear what the patient wants in requesting "something." "Will you help me when my time comes" may have nothing to do with a hastened death. The patient may simply be asking will you help me (be there) when my time comes (when I die). Hence, clarification of such ambiguity is helpful. This can be as simple as "What do you mean by 'help you when your time comes,'" but usually it requires deeper exploration of what is being requested and the context and understanding within which such a request is being made.
To the extent that an individual requests a hastened death, an exploration of that person's story is strongly advised. A variety of questions can be asked:
Although posed as a series of questions, in reality the discussion should be a dynamic exchange. The clinician may comment on specifics (such as your bones will not all break) and empathize and respond to questions posed by the patient (or family member). None of these questions will be of much help if you cannot establish a supportive atmosphere and demonstrate real concern and empathy with the person's situation.
The GOOD acronym may help you explore a request for PAS. Key ingredients-identifying stakeholders, determining the person's goals, discussion options (including alternatives to PAS), and exploring values are all relevant. At some point you will have to offer your opinion and, beyond this, clarify your bottom line in terms of what you can and cannot do. However, the reader is cautioned not to jump ahead to his or her bottom line but to see a request for PAS as an opportunity to explore how that person wants to live the rest of his or her life. Such discussions are not so much events or tasks as processes of engagement with patients struggling mightily with very difficult decisions.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.