Oregon still stands alone: Ten years of physician-assisted suicide

It was 10 springs ago that a Portland woman in her mid-80s sat to talk about her impending death. Doctors guessed the metastatic breast cancer wracking her body would kill her within two months. As the city shook off its winter slumber, the woman -- whose identity is still a secret -- anticipated her eternal rest.

"I'm looking forward to it," she said in a recording later made available to reporters. "I can't see myself living a few more months like this."

Disease set her on the path toward death, but the woman was determined to choose when and how to take her final steps. For that, she needed a doctor's help.

On a Tuesday in 1998, in the presence of her family, she became the first patient to commit suicide with a physician's aid under Oregon's Death With Dignity Act.

A physician prescribed a lethal dose of barbiturates. The woman washed down a mixture of the medication and syrup with a glass of brandy and died shortly thereafter.

Whether the path chosen was a victory for patient autonomy or an ethical tragedy depends upon one's view of this wrenching issue. But what is clear -- and what comes as a surprise given the predictions of supporters and opponents of physician-assisted suicide -- is that it is a path still lightly traveled.

Through the end of last year, only 340 more Oregonians had chosen physician-assisted suicide. And after a decade, Oregon still stands as the lone state to legalize the practice.

There is no tidal wave of patients moving to Oregon to die, and there is no evidence of a slippery slope toward involuntary euthanasia there, as opponents once feared. At the same time, there is no sign that many states will rush to follow Oregon's lead on physician-assisted suicide, as supporters still hope.

Though Oregon's law remains seldom used and unduplicated, its impact on physicians, patients and the movement to improve end-of-life care cannot be overstated.

The 341 reported deaths of terminally ill patients under the law represent three-thousandths of 1% of the 98,942 Oregonians who died of the same diseases in the last decade, said the Oregon Dept. of Human Services' Public Health Division.

Doctors granted one in six requests for lethal prescriptions, and only one in 10 requests resulted in death, according to a survey of more than 2,600 Oregon physicians in the Feb. 24, 2000, New England Journal of Medicine. Of the 221 requests in the survey, 21% were denied because patients had symptoms of depression.

Numerous studies of patients in Oregon and elsewhere found that depressed patients are significantly more likely to seek physician-assisted suicide. Any person seeking a deadly prescription should receive a mental health consultation, according to a health care professionals guidebook prepared by a task force convened by Oregon Health & Science University's Center for Ethics in Health Care.

Only 10% of patients who have died under the law were referred for psychiatric evaluation, which is legally required if the prescribing or consulting physician believes a patient may have depression or another mental illness. In 2007, no patients were referred for consultations.

Patients who use the law are more likely than other Oregonians dying of the same diseases to be white, college-educated and enrolled in hospice care, the state reports. Nearly all inform family of the decision and die at home. Less than 1% are uninsured.

When the Oregon law passed, John Lantos, MD, was filled with "fear and trepidation" about what he saw as a "dangerous experiment in social policy."

Dr. Lantos, the John B. Francis Chair in Bioethics at the Center for Practical Bioethics in Kansas City, Mo., worried vulnerable patients might be pressured "to end their own lives for the convenience of others."

Were Dr. Lantos an Oregon voter, he would have voted against the law. But a decade later, he finds data on how the act has been used "reassuring" and calls the law "a successful experiment."

But use of the Death With Dignity Act has not been flawless. Though 94% of patients died without complications, 19 patients regurgitated the medication before dying. David Pruitt, a lung cancer patient, awakened 65 hours after taking the dose prescribed to kill him.

"What the hell happened?" he reportedly said after waking up. "Why am I not dead?"

Pruitt died of cancer two weeks later.

Changing the conversation

Wherever they stand on the issue, physicians in Oregon say the law has affected their relationships with patients.

Chuck Hofmann, MD, was president of the Oregon Medical Assn. in 1997-98 when the organization supported a ballot initiative to repeal the law first approved by voters in 1994. The Baker City, Ore., internist favors legal access to physician-assisted suicide but refers any patient requesting it to another doctor.

The law has "done more good than harm because it forced the end-of-life discussion to come sooner, and we're more prepared," he said. "We can assure the patient that when there's no hope of being restored to health, they are not going to suffer and will be kept comfortable even if the treatment hastens death. When they understand that, assisted suicide goes way down the list of their concerns."

William L. Toffler, MD, delivers a similar message to patients who ask him about physician-assisted suicide. He said about a dozen patients have brought up the topic.

"I listen to the patients -- that's the first step," said Dr. Toffler, a professor of family medicine at OHSU and national director of Physicians for Compassionate Care Education Foundation, which opposes the Oregon law. "I don't treat people who are labeled terminal any differently than other patients. In my experience, it changes their attitude."

But Dr. Toffler said patient trust in physicians has deteriorated since Oregon legalized doctor-aided dying. He said he gets calls from patients who ask if their physicians have taken the foundation's pledge not to partake in assisted suicide.

"One patient asked if she had 'one of those death doctors,' " Dr. Toffler said. "The questioning of the motives of doctors was never on the radar screen before this law came on the scene. It is now."

Nick Gideonse, MD, also is a member of the OHSU family medicine department. The associate professor has written a dozen prescriptions for lethal medications under Oregon's law, 10 of which were used. He has been at patients' homes in seven deaths.

Dr. Gideonse said only once has a patient expressed concern about physician-assisted suicide. During heated debates over the 1997 ballot initiative, an elderly patient asked, "Are you one of those doctors who would hurt me?" He dismissed the encounter as "a result of fear-mongering."

By contrast, the law "has really enhanced physician-patient communication," Dr. Gideonse said. Doctor-aided dying "is no longer something that patients can't bring up out of fear of asking physicians to do something that could put them in legal jeopardy."

The American Medical Association "strongly opposes any bill to legalize physician-assisted suicide" because the practice is "fundamentally inconsistent with the physician's role as healer."

The rise of palliative care

While physician-assisted suicide in Oregon has remained stable the last decade, changes in end-of-life care have accelerated nationally.

AMA policy says physicians should not abandon their patients once the hope for a cure is gone, and that doctors are obligated to "provide effective palliative treatment even though it may foreseeably hasten death."

The American Hospital Assn. said last month that a third of hospitals have palliative care teams -- more than double the number in 2000. About half of 50-plus-bed facilities now have such teams in place, the AHA said.

Meanwhile, more than a third of all deaths in 2006 occurred under the care of a hospice program, according to the National Hospice and Palliative Care Organization. More than 1.3 million patients received hospice services in 2006, up 61% from 1997.

Also in 2006, 10 medical specialties claimed palliative medicine as a subspecialty for the purposes of accreditation, mainstreaming the emerging field and opening the pipeline of federal dollars for training. Applications for program accreditation will be accepted for the first time starting next month. Although nearly all Americans who die this year, and in the next decade, will do so without the aid of a doctor's lethal prescription, their paths to death still are being transformed.

"The debate about assisted suicide oversimplifies the complexity of the whole new way we have of dying in a world of medical technology that can sustain life long past the point in life when many people would like to have their lives sustained," said Dr. Lantos, of the Center for Practical Bioethics, reflecting on changes since the Oregon law took effect.

"Of the people who die in America, many more die in hospice than used to. Fewer die in hospitals, and fewer get resuscitation at the end of life. There have been dramatic changes in the aggressiveness of treatment and the willingness of both families and patients and physicians to discuss and choose limited treatment plans."