'Death With Dignity' Program Well Accepted by Cancer Patients

Roxanne Nelson

April 12, 2013

The Death with Dignity program in Washington State appears to be well accepted by patients and clinicians, according to a report published in the April 11 issue of the New England Journal of Medicine.

Washington is 1 of only 2 America states with specific laws that allow a "physician-assisted" approach to dying for adults with poor short-term prognoses. The other state is Oregon.

The law in Washington allows terminally ill adult residents of the state who are expected to die within 6 months to request and receive a prescription for a lethal dose of a medication that they can self-administer to end their life.

The laws in Washington and Oregon were approved by voters in statewide referendums. The physician-assisted approach to dying became theoretically legal in a third state, Montana, after a court ruling that protects participating physicians from prosecution. But thus far, no specific state law has been passed by the legislature that specifically addresses the issue or that provides regulations for physicians and terminally ill patients.

After the law in Washington was passed in November 2008, Seattle Cancer Care Alliance — which is an outpatient site of care for cancer patients from the Fred Hutchinson Cancer Research Center, the University of Washington, and Seattle Children's Hospital — developed a Death with Dignity program, which they adapted from programs that were operating in Oregon.

In their report, lead author Elizabeth Trice Loggers, MD, PhD, medical director of palliative care at Seattle Cancer Care Alliance, and colleagues explain that the program "allows patients with cancer who wish to consider this option to do so within the context of their ongoing care." It also accommodates variation in clinicians' willingness to participate, they add.

Of 40 patients who made an initial inquiry and then received a prescription for lethal medication, 24 died after ingesting the medication. There were no unexpected complications, the authors report, and there were no complaints from family members or caregivers about the process or the manner of death.

These 40 patients represent 15.7% of the 255 patients who participated in the Death with Dignity program as of December 2011.

Lessons Learned

The program ensures that all patients and their families are aware of the options for high-quality end-of-life care, including palliative and hospice care. They also have the opportunity to address any concerns or fears.

From March 5, 2009 to December 31, 2011, 114 patients inquired about the Death with Dignity program at Seattle Cancer Care Alliance. Of this group, 44 (38.6%) did not pursue the program further or were deemed not eligible. So far, the program has refused only 1 patient; that patient was unwilling to ingest the medications privately.

During the study period, 30 patients (26.3%) initiated the process but elected not to pursue the option or died before completing the process (average time from first oral request to death, 16.6 weeks; range, 2.3 to 97.1).

Participants in the program account for 0.02% of annual deaths at Seattle Cancer Center Alliance. Most were white, male, and college-educated, which is consistent with statewide Washington and Oregon data.

A higher percentage of participants in the Seattle program than in statewide programs had both private and Medicare insurance, indicating that they were more likely to be working. When the initial request was made, 54.2% of participants in the Seattle program were enrolled in hospice. At the time of death, 80.9% of participants in Washington State programs and 89.7% in Oregon programs were enrolled in hospice.

For the most part, families anecdotally describe the death as peaceful, even when it took longer than the 35-minute average. Patients and families frequently express gratitude after the prescription is received, whether or not it is ever filled or ingested. This indicates that patients feel "an important sense of control in an uncertain situation," the authors note.

The most common reasons given by patients for wanting to participate in the program are loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%). In the Seattle program, 22.2% of participants reported uncontrolled pain or concerns about future pain, compared with 34.7% of Washington State participants and 22.6% of Oregon participants.

None of the Seattle participants who inquired about the program and who were found to have current or previous issues with depression or who lacked the capacity to make decisions elected to move ahead with the process.

"I would say the lesson learned from the Seattle experience is that our mission hasn't changed," Dr. Loggers told Medscape Medical News. "Our primary goal and responsibility is to cure cancer. But when cure isn't possible, Death with Dignity can be offered as one small part of the broader array of high-quality end-of life-options, which include palliative care and hospice."

She explained that the Seattle program allows patients and their families to maintain a relationship with their long-standing oncology provider and to receive education about their prognosis, the end-of-life experience, and end-of-life options.

"Our study also suggests that Death with Dignity is not becoming more common, nor is it disproportionately affecting vulnerable populations," she added. "More than 80% of Death with Dignity participants die at home with hospice care, and have included their family in the decision. This is the kind of death that most American's say they want, but that studies suggest doesn't always occur."

Physician-Assisted Death

Not surprisingly, the issue of physician-assisted dying for patients with a short-term prognosis is highly controversial; it has been discussed — and dismissed — in several other states.

In Massachusetts, a ballot proposition that would have legalized the practice was narrowly defeated (51% to 49%) in November 2012. In late September, polls had shown the proposition leading by a 3-to-1 margin. Supporters attribute the turnaround to a last-minute flurry of ads by opponents of the measure, who outspent them roughly 5 to 1.

"We are pleased that the majority of voters agree that a physician's role is to heal and comfort, not to aid in death," said Richard Aghababian, MD, president of the Massachusetts Medical Society, at the time in a press release.

Although there is no law specifically prohibiting physician-assisted suicide in Montana, the state Supreme Court ruled in 2009 that there is "no indication in Montana law that physician aid in dying provided to terminally ill, mentally competent adult patients is against public policy." Thus, physicians who assist are protected from criminal liability by the patient's consent.

But that court fell short of ruling whether the practice is a constitutionally protected right. Although this decision made Montana the third state to allow assisted suicide, the court left it up to the state legislature to create laws to regulate it.

However, the Montana Senate is expected to approve a House-passed bill that will imprison doctors for up to 10 years if they provide aid in dying to terminally ill patients. If enacted, House Bill 505 would overturn the 2009 ruling. This is despite the fact that a recent poll conducted by Global Strategy Group found that 82% of Montana residents believe that end-of-life choices are private decisions that should be made without government interference.

Currently, 39 states have laws prohibiting assisted suicide, 4 states (Alabama, Massachusetts, Vermont, and West Virginia) and the District of Columbia prohibit assisted suicide by common law, and 4 (Nevada, North Carolina, Utah, and Wyoming) do not have specific laws regarding assisted suicide, do not recognize common law, or are otherwise unclear on the legality of the issue.

N Engl J Med. 2013;368:1417-1424. Abstract

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