Doctor-assisted suicide laws pose hospice care dilemmas

Should hospice's role in end-of-life care extend to helping patients who want physician-aided death?

By — Posted Aug. 12, 2013

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Three states now have laws allowing physicians to prescribe lethal doses of medication to terminally ill patients. These laws in Oregon, Vermont and Washington — and similar proposals elsewhere — have generated heated debates about quality end-of-life care, medical ethics, patient autonomy and the sanctity of life.

Most of that conversation has centered on the physician's role, the potential for elder abuse and whether patients seeking doctors' aid in dying are mentally ill. Yet there is another health care setting — hospice care — that plays a central role in how death-with-dignity laws are enacted but that has been largely ignored, said an article in July's Journal of Pain and Symptom Management.

According to the 2012 data from Oregon and Washington, more than 90% of the 160 patients who used the Death With Dignity laws were enrolled in hospice at the time they took their life-ending medication doses. That rate of hospice use among patients using the Death With Dignity laws has been pretty steady since Oregon's first doctor-assisted death in 1998. Vermont enacted its law in May, and there are no figures available on use of the law there.

While the lethal prescription must come from the patient's attending doctor, not a hospice physician, hospices still are affected by these laws, said Courtney S. Campbell, PhD, lead author of the study. He also chairs the ethics committee at Benton Hospice Service and is professor of religion and culture at Oregon State University, both in Corvallis, Ore.

“There's this precept in hospice that the care neither hastens nor prolongs death,” Campbell said. “It's supposed to be the opposite of using all this technology to extend life, as well as being against the idea of euthanasia. I wondered how hospices were reconciling that with the idea of physician-assisted death.”

Campbell and his colleagues obtained the doctor-assisted death policies of 33 hospice programs in Washington. Seven of the programs, or 21%, were opposed, meaning that their staff was not allowed to participate at all in the physician-assisted suicide process, except to say that they would not help patients secure doctor-aided death.

Fifty-four percent of hospice programs were classified as nonparticipating or noninterfering, meaning that their policies called for open discussion of the topic and referral of patients to other organizations that are expert in connecting patients with physicians willing to prescribe lethal medication doses. But these hospice programs drew the line at actually participating in the death by steps such as mixing the lethal medication dose or attending to potential complications after the medication is ingested.

Finally, eight hospice programs, or 24%, were classified as “respecting patient choice.” That means helping patients understand their options under the Death With Dignity Act. It also means that “the hospice responsibility encompasses respecting, honoring and supporting that choice as consonant with the patient's dignity,” the study said.

The figures were similar at Oregon hospice programs, said a study in the September-October 2010 Hastings Center Report. Sixty-five percent of hospice programs in Oregon were classified as noninterfering or nonparticipating, while 18% respected patient choice and 16% were opposed to any participation in doctor-aided death.

Should hospice staff be in the room?

Whatever their broad-stroke policies are on physician-assisted suicide, most hospice programs draw the line at allowing staff to be present when patients take the lethal medication dose. About 80% of Washington hospices bar staff presence, while the rest allow nurses or others to be present at the time of ingestion or just after the dose is taken.

The choice to bar hospice professionals from being present when physician-assisted deaths occur raises questions, Campbell said.

Nearly 1,100 terminally ill U.S. patients have died after taking doctor-prescribed lethal medications since 1998.

“If you don't have a hospice nurse there or a physician there, I wonder about the commitment to nonabandonment to the patient,” he said. “That's a central concern.”

That conception of the obligation to dying patients is ill-founded, said William L. Toffler, MD, national director of the Physicians for Compassionate Care Education Foundation, based in Yakima, Wash., which opposes doctor-assisted suicide. He also is a professor of family medicine at Oregon Health & Science University in Portland.

“It's breathtaking,” Dr. Toffler said. “Charging abandonment because [health professionals] don't want to corrupt hospice with activity that's antithetical to the purpose and intent of the hospice? … It's an absolutely wrongheaded notion of patient abandonment.”

Since 1998, nearly 1,100 terminally ill U.S. patients have died after taking physician-prescribed lethal medications. The National Hospice and Palliative Care Organization opposes the legalization of doctor-assisted suicide, as does the American Medical Association. The AMA says the practice is “fundamentally inconsistent with the physician's role as healer.”

Back to top


How hospices handle death with dignity law

One of many thorny questions to arise in the wake of Washington's Death With Dignity Act is whether hospice nurses, social workers and other professionals in that state should be allowed to be with patients when they ingest the lethal medication.

Hospice policy Hospices
Staff barred from being present 26
Staff presence permitted 6
Staff allowed to be present after patient ingests medication 1

Source: “Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death,” Journal of Pain and Symptom Management, posted online July 3 (link)

Back to top

External links

“Hospice and physician-assisted death: collaboration, compliance and complicity,” Hastings Center Report, September-October 2010 (link)

“Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death,” Journal of Pain and Symptom Management, July 3 (link)

“Washington State Department of Health 2012 Death with Dignity Act Report,” Washington State Dept. of Health, June 20 (link)

“Oregon's Death With Dignity Act — 2012,” Oregon Public Health Division, Jan. 16 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn