JAMA Highlights Euthanasia Issues
This week's issue of the Journal of the American Medical Association profiles a variety of issues related to euthanasia and physician-assisted suicide, including patient perceptions and opinions on the measures, communication between physicians and terminally ill patients and legal barriers to end-of-life care. Here are some highlights from a few of the studies and their findings.
While a majority of patients support euthanasia and
physician-assisted suicide, only a "small proportion" would actually consider the procedure for themselves, a new study finds. The study, which was funded by the Commonwealth Fund and the Nathan Cummings Foundation, is the "first study ... to assess the attitudes and experiences regarding euthanasia and physician-assisted suicide of patients deemed terminally ill by their physicians and to follow up with the patients until death," the study's authors wrote. The researchers interviewed 988 terminally ill patients and 893 individuals designated by the patients to be their primary caregivers. Of the patient respondents, 60.2% supported euthanasia or physician-assisted suicide in a hypothetical situation, while only 10.6% said they were "seriously considering" either practice for themselves. Of the patients who supported euthanasia or physician-assisted suicide in a hypothetical situation, only 14.3% considered either practice for themselves. Among caregivers, 58.7% supported euthanasia for patients "in pain," while 29.1% supported the procedure for patients "who believed they were a burden." Fully 54.8% of patients who survived and were reinterviewed supported euthanasia for a terminally ill patient experiencing "unremitting pain," while 32.7% supported the procedure for "terminally ill patients without pain who felt they were a burden." In addition, researchers found that patients' opinions regarding euthanasia and physician-assisted suicide "appear to be quite unstable," with about half of those who had initially considered the measures for themselves changing their minds at a follow-up interview, and an almost equal number of patients who had not considered the measures for themselves at first did so at a follow-up interview.
Study results indicated that psychological factors such as "depressive symptoms" were "important determinants" of both patients' personal interest in euthanasia or physician-assisted suicide and their changing opinions on whether or not they wished to undergo the measures. Patients who were "feeling appreciated" were "less likely" to consider euthanasia or physician-assisted suicide, while patients with "depressive symptoms," were more likely to consider those measures. In addition, patients with depressive symptoms were "more likely to change their minds to consider euthanasia or physician-assisted suicide," the study noted. The study revealed that terminally ill patients "whose physical functioning or pain worsened were not more likely to have newly considered euthanasia or physician-assisted suicide for themselves." The researchers found that "most of the key determinants of interest in euthanasia and physician-assisted suicide relate not to physical symptoms but to psychological distress and care needs," suggesting "a tension between ... the reason people find euthanasia and physician-assisted suicide acceptable -- predominantly pain -- and the main factor motivating interest in euthanasia or physician-assisted suicide -- patient depression." The "instability" in patients' opinions regarding euthanasia or physician-assisted suicide for themselves suggests that "the waiting period before a patient is given the prescription for physician-assisted suicide mandated in Oregon and included in many proposals for legalization is an important safeguard," the authors stated. "[W]hen physicians are confronted by a patient's request for euthanasia or physician-assisted suicide, they should attend to the possibility of depression and other psychological stressors," the authors conclude (Emanuel et al., "Attitudes and Desires Related to Euthanasia and Physician-Assisted Suicide Among Terminally Ill Patients and Their Caregivers," Journal of the American Medical Association, 11/15). Lead author Dr. Ezekiel Emanuel, chair of the Department of Bioethics at the National Institutes of Health, said, "Improving end-of-life care has often been framed as a question of permitting either physician-assisted suicide or euthanasia. But these issues are largely irrelevant and distract us from attending to the real issues of the dying: depression and meeting patients' needs for all kinds of help in their everyday lives" (Commonwealth-Cummings release, 11/14). Dr. Harold Schwartz, vice president of behavioral health at Hartford Hospital, cited "lack of training in end-of-life issues, time pressures and the specialized nature of modern medicine" as reasons for why physicians "undertreat" depression in patients. Stating that depression among patients is "underdiagnosed," Schwartz added that clinicians need to "address the possibility of depression before taking so extreme a step as to help a patient take his or her life" (Julien, Hartford Courant, 11/15). To view the JAMA study, go to http://jama.ama-assn.org/issues/current/rfull/joc01512.html
Discussions with patients concerning end-of-life issues are "difficult for clinicians to initiate," a study by Dr. Timothy Quill of the University of Rochester writes. Patients, their families and clinicians "avoid mentioning death or dying, even when the patient's suffering is severe and prognosis is poor," he adds. "There is a collusion of silence when death is in the room," Quill said (Quill, "Initiating End-of-Life Discussions With Seriously Ill Patients," JAMA, 11/15). Another study found that physicians treating children with cancer knew that death was "inevitable" for their patients about 101 days before they told the family this prognosis (Davis,
USA Today, 11/15). Besides being "doubly reluctant to be candid" with parents of terminally ill children, physicians also tend to be "overly optimistic" when discussing prognoses with their patients, Quill said. He added that physicians often hesitate on initiating dialogue about end-of-life issues because there is "always some uncertainty" concerning a prognosis and because they do not want to be seen as "giving up" if they discuss death. When patients are aware of their situation, Quill stated, they can "get their affairs in order" by signing papers about what care they want in their final days or by seeking religious counseling (MacDonald, Hartford Courant, 11/15). "Initiating end-of-life discussions earlier and more systematically could allow patients to make more informed choices, achieve better palliation of symptoms, and have more opportunity to work on issues of life closure," Quill concluded ("Initiating End-of-Life-Discussions With Seriously Ill Patients, JAMA, 11/15). To view the study, go to
Despite physicians' fears of lawsuits concerning physician-assisted suicide, doctors are "rarely" sued over end-of-life treatment, a new study finds. "The risks of sanctions are exceedingly small," study author Alan Meisel, director of University of Pittsburgh's Center for Bioethics and Health Law, said. Over the last 25 years, only about a dozen doctors have been sued for damages, and in those cases they were "more likely to be sued for being too aggressive in extending life, rather than the opposite," the Pittsburgh Post-Gazette reports. Meisel addresses seven "myths" surrounding end-of-life care:
- evidence of a patient's wishes is necessary before withdrawing life-sustaining treatment;
- withholding food and water is illegal;
- consulting a hospital's risk management office is necessary before halting life-sustaining treatment;
- living wills and other advanced directives must be in writing;
- doctors can be criminally prosecuted if high doses of pain medication cause a patient's death;
- no legal option is available for a patient requesting a "quick death;" and,
- the Supreme Court has "outlawed physician-assisted suicide"
Pittsburgh Post-Gazette, 11/15). "Legal myths about end-of-life care can undermine good care and ethical medical practice," Meisel and his colleagues concluded (Meisel et al., "Seven Legal Barriers to End-of-Life Care," JAMA, 11/15). To view the study, go to http://jama.ama-assn.org/issues/current/rfull/jlm00010.html.
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