Results From a Survey of American Geriatrics Society Members' Views on Physician-Assisted Suicide

Lisa J. Rosenberg, MD; Jorie M. Butler, PhD; Anthony J. Caprio, MD, AGSF; Ramona L. Rhodes, MD, MPH, MSCS, AGSF; Ursula K. Braun, MD, MPH; Caroline A. Vitale, MD, AGSF; Jacqueline Telonidis, MS; Vyjeyanthi S. Periyakoil, MD; Timothy W. Farrell, MD, AGSF

Disclosures

J Am Geriatr Soc. 2020;68(1):23-30. 

In This Article

Abstract and Introduction

Abstract

Background: Physician-assisted suicide (PAS) is a controversial practice, currently legal in nine states and the District of Columbia. No prior study explores the views of the American Geriatrics Society (AGS) membership on PAS.

Design: We surveyed 1488 randomly selected AGS members via email.

Participants: A total of 369 AGS members completed the survey (24.8% response rate).

Analysis: We conducted bivariate correlation analyses of beliefs related to support for PAS. We also conducted qualitative analysis of open-ended responses.

Results: There was no consensus regarding the acceptability of PAS, with 47% supporting and 52% opposing this practice. PAS being legal in the respondent's state, belief that respect for autonomy alone is sufficient to justify PAS, and intent to prescribe or support requests for PAS if legal in state of practice all correlated with support for PAS. There was no consensus on whether the AGS should oppose, support, or adopt a neutral stance on PAS. Most respondents believed that PAS is more complex among patients with low health literacy, low English proficiency, disability, dependency, or frailty. Most respondents supported mandatory palliative care consultation and independent assessments from two physicians. Themes identified from qualitative analysis include role of the medical profession, uncertainty of the role of professional organizations, potential unintended consequences, autonomy, and ethical and moral considerations.

Conclusion: There was no consensus among respondents regarding the acceptability of PAS. Respondents expressed concern about vulnerable older populations and the need for safeguards when responding to requests for PAS. Ethical, legal, and policy discussions regarding PAS should consider vulnerable populations. J Am Geriatr Soc 68:23–30, 2019

Introduction

End-of-life care is an important issue for patients, families, and caregivers. In its 2014 report, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life," the Institute of Medicine (IOM) indicates that despite considerable progress, important challenges remain in providing end-of-life care for Americans that is high quality, compassionate, and reflective of individuals' care preferences.[1] The IOM report explicitly recommends that end-of-life care be person-centered, family-oriented, available, and covered by insurance. The report further states that patients who receive palliative care and hospice may live longer than similarly ill people who do not receive such care, and that these services eliminate much of the symptom burden and uncertainty often associated with dying. The IOM report does not address the issue of physician-assisted suicide (PAS), but the shift in the patient-physician relationship away from paternalism and toward shared decision making in which patients' preferences and autonomy are more explicitly recognized, the legalization of PAS in several states, and medicine's ability to extend life often without parallel extension of function, make PAS a salient—and controversial—topic.

PAS is defined as the physician providing medication or a prescription to a terminally ill patient at the patient's explicit request with the understanding that the patient intends to use the medication(s) to end his/her life.[2] With advances in medicine and technology, individuals with chronic and terminal diseases are living longer but often face prolonged periods of disability and potential uncertainty related to their conditions. This trend has led to increased attention to PAS as a potential option for patients at the end of life.

PAS in the United States

In recent years, US public opinion shifted toward greater acceptance of PAS as an option for terminally ill patients. A 2017 survey indicated that 67% of US adults supported legalizing PAS.[3] In 2017, 27 states reviewed and rejected legalization of PAS.[4] At least 23 states considered such legislation in 2018, and so far in 2019, 18 states are considering it.[5] By the end of 2018, PAS was legal in seven states (Oregon, Washington, Montana, Vermont, California, Colorado, and Hawaii) and the District of Columbia,[4] and legalized formally in all but Montana and the District of Columbia, where the option of PAS is given to individuals by court decision. In 2019, New Jersey[6] and Maine[7] legalized PAS. PAS remains controversial among health professionals and among lay individuals.

Although there has been increasing interest in surveying the US public regarding their views about PAS, to the best of our knowledge, there have been no surveys of geriatrics healthcare professionals' views about PAS. In particular, little is known about views regarding PAS among members of the American Geriatrics Society (AGS), an organization composed of geriatrics healthcare professionals that develops guidance to support clinicians who care for older people, many of whom are frail or have multiple chronic conditions, with the goal of improving care in advancing age and at the end of life. AGS members' views about PAS are important to elicit given their central roles in both caring for and advocating for older adults. This article reports on the results of a survey of AGS members conducted to better understand their views on PAS.

Terminology

The Hastings Center uses the term "physician-assisted death" (PAD) when referring to the practice described above.[8] Other terms describing PAD include physician aid in dying, patient-directed aid in dying, and patient-administered hastened death. Our survey included one question to determine whether a consensus might be reached about a favored term. Although the medical literature commonly uses the term PAS, it is far from a uniformly accepted term, and the term PAD appears to have since gained greater acceptance. Since we used the term "physician-assisted suicide" (PAS) in the survey that is the focus of this article, we use the term PAS throughout to avoid confusion.

PAS, in which the patient self-administers the lethal intervention, is distinct from voluntary active euthanasia, in which a third party administers, at a patient's request, a medication or other interventions intended to cause death.[9] We included this distinction in the introduction to the survey.

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