When medicinal interventions are eventually no longer able to give expected results, the decision to either continue aggressive treatment or transition to hospice care is a major concern and difficulty faced by many terminally ill patients and their families.
Modern medicine, although has great benefits in prolonging life, has limitations in treating the psychological and spiritual pain accompanied with chronic or advanced medical illnesses – risk factors for suicidal ideations. While more Americans are choosing hospice as palliative treatment for their end-of-life care (1), voluntary decision to let go by suicide or assisted death is also considered. Physician-assisted death is currently legal in six states, namely California, Colorado, Montana, Oregon, Vermont, and Washington, and the District of Columbia (2). The controversial act is a great debate whether it is ever justified for people to kill themselves and whether healthcare providers violate the central principle of “first, do no harm” by allowing “death with dignity”, the term that holds the same meaning as “medical aid in dying” and “physician-assisted death” (2). To many, letting go in a peaceful term is acceptable. To others, letting go of life with assistance is not. The decision is a controversy equally faced by patients and healthcare providers who act in the patient’s interests.
According to Reverend Klemstine, human soul is a “life force or energy of consciousness which directs life functions through the vehicles of body and personality during one’s lifetime” (3). Accompanied by physical pain, spiritual distress is often experienced by terminal ill patients, and the needs of the dying are not cured by modern medicine. However, can this spiritual suffering be justified for one to kill oneself? Some religions believe that God creates life and therefore it is not justified for any human to take away life – God’s property. In psychological terms, one may commit suicide as a way to escape emotional and physical suffering. In this situation, the act of killing oneself is considered irrational, because the rationale may be due to anguish and despair instead of logical reasoning. In addition, suicide is criticized as a selfish act because of the insufferable pain that one’s family members have to endure. There are negative consequences such as financial obligations and other intangible costs if the attempts do not actually kill the person. To dying patients, their decision to refuse CPR or to come off the ventilator may result in tremendous pain to their families. Suicide is immoral and unjustifiable in the eyes of the public, who advocate that one’s life should be more valuable over anything else. There are no logical rationales to validate suicidal ideations.
On the contrary, suicide may be seen as an honorable act in certain situations in some countries. For instance, Japan has a long history of suicide, where military figures may commit the act when faced with defeat. Tibetan monks have burned themselves in protest against the Chinese government. There are also stories of U.S. army snipers who sacrificed themselves for injured comrades, with one example being Army Sgt. 1st Class Randy Shughart. All of the above are examples of honorable suicides, where killing oneself is not merely a way to escape personal suffering. That is considered altruistic suicide and not morally wrong. Other debate includes the idea of “My Body, My Choice”: in the right mind, one should not be stopped if he or she decides to commit suicide because it is their body. The decision for their existence is theirs. This concept is similar to a simple case of smoking cessation, where pharmacists can provide support in every step of the process, but the decision to quit smoking ultimately depends on the will of the smokers. In addition, when the physical and psychological pain is unbearable, such as the case of dying patients or abductees, letting go peacefully is a solution rather than hanging on to life with suffering. To dying patients, the reasoning is often because the patients do not want to suffer any longer, or they do not want to hold their family accountable for the healthcare and intangible costs, or both. In these cases, suicide is considered justified and unselfish. In terms of laws, whether committing suicide is illegal depends on the state law codes. Virginia, for example, rules that suicide is an “immoral and illegal act” if the person is of sound mind (4). Maryland, however, only criminalizes assisting another to commit or attempt suicide in section 3-102 (5). Suicide rates in the U.S have increased steadily between 2006-2015, with the highest rate among 45-64 years of age (19.6%) and second highest rate among 85 years and older (19.4%) in 2015 (6).
According to the U.S. News article, a majority of cancer patients who chose medically assisted death, and many of U.S. patients were in hospice or palliative care (2). For certain terminally ill patients, Death with Dignity is an end-of-life option if they are eligible for a prescription: a resident of California, Colorado, District of Columbia, Oregon, Vermont, or Washington; 18 years of age or older; mentally competent to make decisions; and diagnosed with a terminal illness that may lead to death within six months based on reasonable medical judgment (7). In addition, the patients must be able to self-administer the prescribed medication, not qualify under aid-in-dying laws solely because of age or disability, and deemed qualified by two physicians (7). Of the states mentioned above, physician-assisted dying is by State Supreme Court ruling in Montana while the others have their own statutes. The steps for the application process are first oral request which can be rescinded any time, first waiting period after the first oral request is authorized, second oral request 15 days after the waiting period, a written request at anything following the first oral request (after the first and before the second oral request in the District of Columbia), second waiting period of 48 hours from the time of receiving the written request to writing the prescription (District of Columbia, Oregon, Vermont, and Washington only), and finally the prescription ordering (7). The term physician-assisted suicide (PAS), suicide, and euthanasia are no longer use and are replaced by Death with Dignity, physician-assisted death or physician-assisted dying, aid in dying, physician aid in dying, or medical aid-in-dying (7). Physician participation in Death with Dignity is voluntary and has to be either a doctor of medicine or osteopathy licensed to practice medicine in these states. The prescription is usually written for an oral dosage of pentobarbital or secobarbital or compounds containing morphine beginning in 2015 (7). Once the medication is obtained, patients can choose the location to self-administer, as long as it is within one of these the states and not in public places. For those who are not eligible for the physician-aid in dying, they can either voluntarily stop eating and drinking, stop treatment or not start treatment at all, or use palliative sedation (7).
Oregon was the first state in the U.S. that legalized the physician-aid dying law in 1997. Since then, 1545 patients have received prescriptions in Oregon and 991 had died from the lethal medications by the end of 2016 (8). The majority of these patients had cancer and chose death not only because of pain; quality of life, autonomy, and dignity were major reasons as well. These numbers are not nearly as high as the number of euthanasia in the Netherlands, which allowed the program in 2002. The Netherlands’ laws permit euthanasia that is not limited to only terminally ill patients. A 2015 survey found that 1288 patients received continuous deep sedation with 11% of the cases overlapped with other end-of-life measures; 829 patients underwent euthanasia; 22 underwent physician-assisted suicide; and 18 patients underwent “ending of life without an explicit patient request” (8). This finding indicated that for 2015 alone, the Netherlands had a high number of deaths related to the program, although there were cases of assisted dying prior to legalization (8).
In states where medical aid in dying is legal, there are no legal ramifications for spouses or other family members who honor a family member’s request for assisted death. However, the law requires that the patient must submit the request if they meet all the eligibility criteria. Because the aid in dying laws require that patients must be able to communicate and make their own decision, physician-assisted death laws cannot be used with advanced directives, which are legal documents that describe the patients’ wishes when they can no longer communicate. In addition, patients can change residency to a state with “Death with Dignity” in order to participate in the law (7).
As pharmacists, although we do not have the authority to prescribe medications for assisted death, there are issues concerning patient counseling, morality and ethics, and consequences of refusing to dispense the medications. In the 2000 Pharmaceutical Journal (9), Marjorie Weiss raised several questions regarding the role of pharmacist in assisted death: (1) “Would the attending physician have to indicate what the prescription was intended for?” (2) “Since the pharmacists are not listed in the immunities granted in the Act, what liability does the pharmacist have if the patient does not die, but ends up in persistent vegetative state?” (3) “Is there a duty to counsel the patient who intends to die?” (4) “Could employee pharmacists be required to dispense lethal doses for use in PAS as a term of employment?” One of the pharmacist’s duties is to assure optimal drug therapy outcomes to relieve suffering, but what should a pharmacist do when a terminally ill patient is enduring insufferable physical and spiritual pain that drug therapies will not work? Although medically assisted death is currently illegal in Maryland, pharmacists should be trained for when the question comes up from a patient. They should ensure that barriers to care be addressed and resolved in order to provide optimal outcomes. As part of a healthcare team, they should communicate with team members about any medication concerns and appropriateness. They should ensure that information about legally available options be conveyed to patients and caregivers. Finally they should be adequately trained in the care of dying patients.
Personally, as a student pharmacist, I value the work that pharmacists contribute to patient care. We have come a long way to get to where we are now: being able to dispense birth controls in several states, being able to dispense and administer naloxone to an opioid overdosed patient, working on achieving the provider status that most of us feel we have already done the work of a provider. To other providers, we have proved to be an essential part of any interdisciplinary healthcare team to show that our duties are beyond dispensing. To patients, we are the communication bridge to physicians. We are trained to be drug therapy experts, but we can only help alleviate the physical pain as much as a medication can do. We must treat their total pain, which also includes the psychological, social, and spiritual aspects. Moreover, pain is not the only cause to their deteriorating health; terminally ill patients suffer from numerous conditions related to cardiorespiratory, neuropsychiatric, and gastrointestinal, and other symptoms.
Building a trusting relationship with families and caregivers is also essential as part of a pharmacist’s duties. Most of us have encountered a death, whether friends, neighbors, or in the family. We were taught to have sympathy and provide support during the grieving process. We were taught about advanced directives and Five Wishes. We were asked to compile our bucket list and eulogy, and plan our own funeral. These class activities were certainly not easy to complete, as most of us are focusing on school and work at the moment. However, they were eye-opening and had us think and sympathize with terminally ill patients as they are going through the end-of-life stage. The hardest part was to write my own eulogy while evaluating what kind of person I wanted family and friends to remember.
For patients who prefer Death with Dignity, they perhaps have gone through the same process of spiritual distress before deciding to choose death over suffering. We, as pharmacists, cannot influence their decisions; we can only provide them with comfort and support up to the last stage of dying. However, plan of care does not end upon a patient’s death. We may share our grieving with families and caregivers by attending the funeral, maintaining contact, and providing bereavement support. At the end, death of a patient impacts both family members and healthcare providers. By sharing our deepest sympathy, we are giving ourselves closure every time a patient passes, regardless if it is medically assisted death.