Background
Suffering near the end of life arises from many sources including loss of sense of self, loss of control, fear of the future, and/or fear of being a burden upon others, as well as refractory physical and non-physical symptoms. Excellent medical care, including state-of-the art palliative care, can address and help alleviate many sources of suffering. On occasion, however, patients seek the assistance of a physician to end their life.
Physician-Assisted Dying (PAD) is defined as a physician providing, at the patient’s request, a prescription for a lethal dose of medication that the patient can self-administer by ingestion, with the explicit intention of ending life. Although PAD has historically not been within the domain of standard medical practice, in recent years it has emerged as both an explicit and covert practice across various legal jurisdictions in the United States. PAD has become a legally sanctioned activity, subject to safeguards, first in Oregon in 1997 and, subsequently, in other states including Washington, Vermont, and California. As of the writing of this document, approximately one-sixth of the U.S. population resides in a jurisdiction where PAD is legally permitted, and its legal status continues to evolve at the state level.
A primary goal of the American Academy of Hospice and Palliative Medicine (AAHPM) is to promote the development, use, and availability of palliative care, including hospice, to relieve patient suffering and to enhance quality of life while upholding respect for patients’ and families’ values and goals. The ending of suffering by ending life has been held as distinct from palliative care, which relieves suffering without intentionally hastening death.
Statement
Situations in which Physician-Assisted Dying (PAD) is requested are challenging for physicians and other healthcare practitioners because they raise significant clinical, ethical, and legal issues. A diversity of positions exists in society, in medicine, and among members of the American Academy of Hospice and Palliative Medicine (AAHPM). AAHPM acknowledges that morally conscientious individuals adhere to a broad range of positions on this issue.
AAHPM takes a position of studied neutrality on the subject of whether PAD should be legally permitted or prohibited. However, as a matter of social policy, the Academy has concerns about a shift to include physician-assisted dying in routine medical practice, including palliative care. Such a change risks unintended long-range consequences that may not yet be discernable, including effects on the relationship between medicine and society, the patient and physician, and the perceived or actual integrity of the medical profession. Any statutes legalizing PAD and related regulations must include safeguards to appropriately address these concerns, such as limiting eligibility to decisionally capable individuals with a limited life expectancy.
Social policy concerns notwithstanding, the Academy recognizes that in particular circumstances some physicians assist patients in ending their lives. Efforts to augment patients’ psychosocial and spiritual resources so that they are better able to manage their suffering may make palliative treatments of physical symptoms more effective and may make these circumstances rarer. Nevertheless, some patients will continue to desire PAD.
Physicians practicing in jurisdictions in which PAD is legally permitted should never be obligated to participate in PAD if they hold moral or professional objections, nor should they be prohibited from participating within parameters defined by relevant statutes and terms of employment. Physicians who affirmatively respond to requests for PAD are obligated to ensure their actions are consistent with best available practices that limit avoidable suffering through end of life.
When a request for PAD is made by a terminally ill patient, medical practitioners should carefully evaluate the patient’s concerns precipitating the inquiry and address the sources. Requests originating from family should not be pursued without direct discussion with the patient. Requests for PAD from surrogates of incapacitated patients should not be considered due to the complexities of the ethics of surrogate decision-making. However, surrogates’ concerns prompting the request should be fully explored.
Evaluating Requests for PAD
Access AAHPM’s Advisory Brief “Guidance on Responding to Requests for Physician-Assisted Dying.”
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