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Breaking the Mold: Listening to Patients in the Northwest

Death with DignityIn a recent post, we talked about living wills (also known as advance directives) that spell out the type of care a person would prefer to receive at the end-of-life.

Specifically, living wills indicate whether or not a person would want to be placed on a life-support system, or whether she has requested a Do Not Resuscitate (DNR) order, for example.

Even today, there are only a handful of states that recognize living wills as legal documents that carry the weight of a physician’s orders.

Most physicians and family members believe that this is for the best.

Doctors say that patients cannot foresee all of the potential complications that might occur during an illness.   As such, a patient cannot really know what treatment he or she might want in the case of an emergency.

Instead, physicians argue, living wills should really just be used as a guideline for directing care decisions.  The wills should also name a family member to make decisions on a patient’s behalf.

Voters and state legislators in Oregon disagree.

Oregon is one of the few states to recognize a patient’s living will as a legal document that carries significant weight.

This makes sense: Oregonians are deeply respectful of a patient’s wishes at the end of her life. 

Take Oregon’s Death with Dignity Act (DWDA), for example.  In 1997, voters passed a statewide referendum allowing terminally-ill patients with six months left to live to request a physician’s help in committing suicide.

Opponents of the law fought its implementation all the way to the U.S. Supreme Court.  In 2006, the Court upheld the law when it ruled that the states have the power to regulate medical practice, including assisted suicide.

Proponents argue that the law lets terminally ill-patients decide when they wish to put an end to their own pain and suffering.

The law has many safeguards in place to make sure that patients are in-control at all times.

To request a physician’s help in dying, a patient must:

  • Make two verbal requests- separated by 15 days each- to his attending physician.
  • The patient must also sign a written request in the presence of two individuals who are not care givers or family members and then give the request to the attending physician.
  • Finally, the patient must be able to administer the life-ending prescription herself, without the help of a physician.

As of 2007, only 341 people had issued requests from their physicians.  The majority of the patients were white, well-educated cancer patients between the ages of 55 and 84 years old.

Despite the small number of folks who have chosen to die under the DWDA, the law remains incredibly controversial.

  • Doctors and even entire health facilities have opted out of providing the life-ending prescriptions.
  • On the other hand, some argue that the law should be more egalitarian.  For patients to choose this option, they must have insurance coverage so that they can afford the physician visits and prescription medication.
    • Uninsured folks lack access to this end-of-life option as a result.

These concerns didn’t stop voters in Washington from passing similar legislation this past November, 2008.  Washington’s Initiative 1000 passed with 60% of the vote.

While some folks might find a discussion about assisted suicide and other end-of-life choices unsettling, people in Washington and Oregon seem to accept it as a matter of course.

As one Oregonian puts it simply:

“For those of us who have lived in our bodies for 50 plus years and lived with our decisions in life, is it not a just act that we might choose our death as well?”

A unique culture has developed in these and other Northwest states that favors less, rather than more, medical intervention and interference at the end of person’s life.

Medicare records, analyzed by the Dartmouth Atlas Project, back up this cultural phenomenon with hard numbers.

  • Medicare spends $14,106 per chronically-ill patient in Oregon during his or her last six months of life.
  • In contrast, Medicare spends a whopping $22, 945 per chronically-ill patient in New York during his or her last six months of life.
  • And, as we show in our newest As We See It piece, there is evidence that the additional care administered in high-cost regions does not actually produce better results for patients, even though providers may believe otherwise.

Talking about physician-assisted suicide is tough.  It’s a difficult issue that raises important questions such as:

  • “Should a person be required to live even if they are in extreme pain and have no chance of recovery?”
  • “How can we really be sure that a patient is making the decision to die of her own free will?”

What do you think?  Should physician-assisted suicide be available nationwide?  Or, is it an issue that states should tackle one-by-one, on their own?

We encourage you to check out our longer article on end-of-life care options and costs, and to blog your feedback below!

{ 2 comments… add one }
  • John Nagle July 16, 2009, 12:05 pm

    Anyone should have the right to end his life. It is a simple personal freedom. While there can be a negative emotional impact on loved ones if it is done badly, when done well, the emotional impact is positive compared to the alternative of lingering, costly death. The primary material impact is to prevent one’s own pain and to reduce medical costs, so there is no material cost to society that can be used as a counter argument.

    Historically, I think society’s legitimate interest has been to prevent doctors from being used as tools by unsrupulous parties who have an material interest in ending someone else’s life. This has led to a blanket policy which should not be allowed to cover all cases.

  • Michael August 10, 2009, 4:45 pm

    When my dog was approaching the end of his life, and he started to live with obvious pain, it was a difficult, but ultimately loving decision to put him down.

    Why shouldn’t I be able to make the same choice for myself?

    In 40 or 50 years, when my body will be frail and falling apart, it would be much more dignified for me to choose when I go, rather than fight an ultimately losing battle. I would gather up my family, tell each one I loved them, crack one final joke and administer the fatal medication. What’s my other option? — To slowly decay into oblivion under the relentless assault of cancer or stroke or whatever will finally get me. No thank you.

    I want to leave life on my terms.

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