Skip to main content
AAHPM Logo
Login
  • Join/Renew
  • Donate
  • Blog
  • Contact
Menu Search Account
  • Membership
    • Join/Renew
      • Member Benefits
    • Diversity, Equity & Inclusion
      • DEI Resources
    • Member Center
    • Getting Involved
    • Communities
      • SIG Instructions
      • Join a SIG
      • Member Councils
    • Mentoring
    • FAAHPM
      • Current Fellows
  • Education & Practice
    • Writing Instructional Objectives
    • Meetings
      • Leadership Forum: Ascend
      • Annual Assembly
        • Back to Meetings
        • Assembly Home
        • About the Assembly
          • Why Attend
        • Registration
        • Special Events
        • Educational Sessions
          • Keynotes
          • Wednesday
          • Thursday
          • Friday
          • Saturday
        • Plan Your Experience
        • CE and MOC
        • Summer Call for Abstracts
        • Fall Call for Abstracts
        • Assembly FAQs
        • Business Meeting
        • Health and Safety
        • Exhibits & Advertising
      • State of the Science
      • State of the Science
        • Back to Meetings
        • State of the Science Home
        • Plan Your Experience
        • Schedule and Pricing
        • SOTS FAQ
        • Virtual State of the Science
      • Intensive Review Course
        • Back to Meetings
        • Home
        • Schedule
        • Plan Your Trip
      • Advanced Course in Pain
        • Back to Meetings
        • Home
        • Plan Your Trip
      • Intensive Board Review Course 2018 Recordings
      • IBRC18 - Additional Management Strategies for Cancer Related Symptoms
      • IBRC18 - Approaches to Care, including Hospice/Medicare
      • IBRC18 - Assessment and Care of the Dying Patient
      • IBRC18 - Communication and Teamwork
      • IBRC18 - Depression/Anxiety & Other Mood Disorders
      • IBRC18 - Ethical and Legal Decision Making
      • IBRC18 - Grief and Bereavement and Spiritual Care
      • IBRC18 - High Yield Pediatrics for the Boards
      • IBRC18 - Non-Pain Symptom Management – GI
      • IBRC18 - Non-Pain Symptom Management – Respiratory
      • IBRC18 - Non-Pain Symptom Management: Pot-Pourri
      • IBRC18 - Pain Management Overview
      • IBRC18 - Palliative Sedation/Physician-Assisted Dying/Discontinuation of Technological Support
      • IBRC18 - Practice Test Question Review Q&A (1)
      • IBRC18 - Practice Test Question Review Q&A (2)
      • IBRC18 - Practice Test Question Review Q&A (3)
      • IBRC18 - Prognostication
      • IBRC18 - Special Topics in Pain Management
      • IBRC18 - Symptom Potpourri
      • IBRC18 - Taking the Test Like a Pro
      • IBRC18 - Urgent Medical Conditions
    • Publications
      • JPSM
        • Members JPSM
      • PC-FACS
        • Members - PC-FACS
      • Quarterly
        • Members Quarterly Full Access
        • Spring 18 Clinical Pearls
        • Spring 18 Diversity & Inclusion
        • Spring 18 Feature
        • Spring 18 HMDCB Update
        • Spring 18 Pathways to Palliative Care
        • Spring 18 Presidents Message
        • Spring 18 Quarterly Progress Report
        • Spring 18 AAHPM News
        • Spring 18 Art of Caring
        • Summer 18 AAHPM News
        • Summer 18 Advocacy Update
        • Summer 18 Annual Assembly
        • Summer 18 Art of Caring
        • Summer 18 Clinical Pearls
        • Summer 18 Ethics
        • Summer 18 Feature
        • Summer 18 HMDCB Update
        • Summer 18 Pathways to Palliative Care
        • Summer 18 President's Message
        • Summer 18 Quarterly Progress Report
        • Fall 18 AAHPM News
        • Fall 18 Annual Assembly
        • Fall 18 Art of Caring
        • Fall 18 Clinical Pearls
        • Fall 18 Diversity & Inclusion
        • Fall 18 Feature
        • Fall 18 HMDCB Update
        • Fall 18 Pathways to Palliative Care
        • Fall 18 President's Message
        • Fall 18 Quarterly Progress Report
        • Winter 18 AAHPM News
        • Winter 18 Advocacy Update
        • Winter 18 Annual Assembly
        • Winter 18 Art of Caring
        • Winter 18 Clinical Pearls
        • Winter 18 Ethics
        • Winter 18 Feature
        • Winter 18 Pathways to Palliative Care
        • Winter 18 President's Message
        • Winter 18 Quarterly Progress Report
        • Winter 18 HMDCB Update
        • Spring 19 Editors Message
        • Spring 19 Meet the President
        • Spring 19 Clinical Pearls
        • Spring 19 Art of Caring
        • Spring 19 Advocacy Update
        • Spring 19 Feature
        • Spring 19 Pathways to Palliative Care
        • Spring 19 Diversity and Inclusion
        • Spring 19 Quarterly Progress Report
        • Spring 19 HMDCB Update
        • Spring 19 AAHPM News
        • Summer 19 Presidents Message
        • Summer 19 Clinical Pearls
        • Summer 19 Art of Caring
        • Summer 19 Annual Assembly
        • Summer 19 Advocacy Update
        • Summer 19 Feature
        • Summer 19 Pathways to Palliative Care
        • Summer 19 Ethics and the Hidden Curriculum
        • Summer 19 Research or Quality Improvement
        • Summer 19 Quarterly Progress Report
        • Summer 19 HMDCB Update
        • Summer 19 AAHPM News
        • Fall 19 Presidents Message
        • Fall 19 Clinical Pearls
        • Fall 19 Art of Caring
        • Fall 19 Annual Assembly
        • Fall 19 Advocacy Update
        • Fall 19 Feature
        • Fall 19 Pathways to Palliative Care
        • Fall 19 Diversity, Equity, & Inclusion
        • Fall 19 Quality Improvement
        • Fall 19 Quarterly Progress Report
        • Fall 19 HMDCB Update
        • Fall 19 AAHPM News
        • Fall 19 State of the Science
        • Winter 19 Presidents Message
        • Winter 19 Editor's Message
        • Winter 19 Clinical Pearls
        • Winter 19 Art of Caring
        • Winter 19 Annual Assembly
        • Winter 19 Advocacy Update
        • Winter 19 Feature
        • Winter 19 Pathways to Palliative Care
        • Winter 19 Quarterly Progress Report
        • Winter 19 State of the Science
        • Winter 19 HMDCB Update
        • Winter 19 AAHPM News
        • Spring 20 Presidents Message
        • Spring 20 Meet the President
        • Spring 20 Clinical Pearls
        • Spring 20 Diversity, Equity, & Inclusion
        • Spring 20 Art of Caring
        • Spring 20 Advocacy Update
        • Spring 20 Feature
        • Spring 20 Pathways to Palliative Care
        • Spring 20 Quarterly Progress Report
        • Spring 20 HMDCB Update
        • Spring 20 AAHPM News
        • Summer 20 Presidents Message
        • Summer 20 Meet New AAHPM CEO
        • Summer 20 Annual Assembly
        • Summer 20 State of the Science
        • Summer 20 Clinical Pearls
        • Summer 20 Art of Caring
        • Summer 20 Advocacy Update
        • Summer 20 Feature
        • Summer 20 Pathways to Palliative Care
        • Summer 20 Quarterly Progress Report
        • Summer 20 AAHPM News
        • Summer 20 HMDCB Update
        • Summer 20 PCQC Update
        • Fall 20 Presidents Message
        • Fall 20 Art of Caring
        • Fall 20 Annual Assembly
        • Fall 20 Clinical Pearls
        • Fall 20 Lets Think About it Again
        • Fall 20 Advocacy Update
        • Fall 20 Feature
        • Fall 20 Pathways to Palliative Care
        • Fall 20 Diversity, Equity, & Inclusion
        • Fall 20 Quarterly Progress Report
        • Fall 20 HMDCB Update
        • Fall 20 PCQC Update
        • Winter 20 Presidents Message
        • Winter 20 Annual Assembly
        • Winter 20 Clinical Pearls
        • Winter 20 Lets Think About it Again
        • Winter 20 Art of Caring
        • Winter 20 Advocacy Update
        • Winter 20 Feature
        • Winter 20 Pathways to Palliative Care
        • Winter 20 Diversity, Equity, & Inclusion
        • Winter 20 Quarterly Progress Report
        • Winter 20 HMDCB Update
        • Winter 20 PCQC Update
        • Winter 20 AAHPM News
        • Spring 21 A Message from the CEO
        • Spring 21 Meet the President
        • Spring 21 Clinical Pearls
        • Spring 21 Art of Caring
        • Spring 21 Interview with AAFP President
        • Spring 21 Advocacy Update
        • Spring 21 Feature
        • Spring 21 Pathways to Palliative Care
        • Spring 21 Lets Think About it Again
        • Spring 21 Diversity, Equity, & Inclusion
        • Spring 21 Quarterly Progress Report
        • Spring 21 HMDCB Update
        • Spring 21 PCQC Update
        • Spring 21 AAHPM News
        • Summer 21 A Message from the President
        • Summer 21 Annual Assembly
        • Summer 21 Clinical Pearls
        • Summer 21 Art of Caring
        • Summer 21 Advocacy Update
        • Summer 21 Feature
        • Summer 21 Pathways to Palliative Care
        • Summer 21 Lets Think About it Again
        • Summer 21 Quarterly Progress Report
        • Summer 21 HMDCB Update
        • Summer 21 PCQC Update
        • Summer 21 AAHPM News
        • Fall 21 A Message from the President
        • Fall 21 State of Science
        • Fall 21 Annual Assembly
        • Fall 21 Clinical Pearls
        • Fall 21 Advocacy Update
        • Fall 21 Feature
        • Fall 21 Pathways to Palliative Care
        • Fall 21 Lets Think About it Again
        • Fall 21 Diversity, Equity, & Inclusion
        • Fall 21 Quarterly Progress Report
        • Fall 21 Art of Caring
        • Fall 21 HMDCB Update
        • Fall 21 PCQC Update
        • Winter 21 A Message from the President
        • Winter 21 The Bridge Builder
        • Winter 21 Clinical Pearls
        • Winter 21 Art of Caring
        • Winter 21 Advocacy Update
        • Winter 21 Feature
        • Winter 21 Pathways to Palliative Care
        • Winter 21 Lets Think About it Again
        • Winter 21 Quarterly Progress Report
        • Winter 21 Partner Updates
        • Winter 21 AAHPM News
        • Spring 22 Meet the President
        • Spring 22 Clinical Pearls
        • Spring 22 Art of Caring
        • Spring 22 Advocacy Update
        • Spring 22 Feature
        • Spring 22 Pathways to Palliative Care
        • Spring 22 Lets Think About It Again
        • Spring 22 DEI LAB
        • Spring 22 Quarterly Progress Report
        • Spring 22 AAHPM Partner Update
        • Spring 22 AAHPM News
        • AAHPM Quarterly: Spring 2022 (Full Issue)
        • Summer 22 A Message from the President
        • Summer 22 Clinical Pearls
        • Summer 22 Art of Caring
        • Summer 22 Advocacy Update
        • Summer 22 Feature
        • Summer 22 DEI LAB
        • Summer 22 Quarterly Progress Report
        • AAHPM Quarterly: Summer 2022 (Full Issue)
      • SmartBriefs
    • AAHPM Learn
      • Interactive Activities
    • Self-Study
      • Board Prep Materials
      • Essentials
      • Primer
      • HPM PASS
      • HPM FAST
        • HPM FAST CME
      • Hospice Products
        • HMD Manual
        • HMD PREP
      • Opioid REMS
      • hpmpasscme
      • Opioid Resources
    • Fellowships
      • Competencies
        • Pediatric Competencies
      • Accreditation
      • NRMP Match
      • Grants
        • Ho/Chiang Foundation
      • Hospice Program Toolkit
      • CBME Recordings
    • CME
    • Quality
      • Measuring What Matters
      • Quality Reporting
      • Quality Resources
      • Quality Registries
      • Quality Improvement Education
    • Research
      • Research Funding
      • Successful Research Grants
    • COVID-19 Resources
    • COVID hotel
  • Advocacy
    • Stay Informed
    • Take Action
    • Key Issues
      • Opioids
      • Workforce
  • Career Development
    • Jobs
      • Virtual Career Fair
    • Clinical Training
      • Additional Training
    • Leadership Development
      • AAHPM Ascend
        • Leadership Forum Faculty and Facilitators
        • Ascend Schedule
        • Ascend Facilitators
    • Certification
      • Allopathic
      • Hospice
        • HMDCB Research
      • Osteopathic
    • Continuing HPM Certification
    • Workforce Statistics
    • Scholarships
      • Access Fund
      • Leadership Scholars
      • International Physicians
      • Pediatric Scholarship
      • Research Scholars
      • Next Gen Scholars
    • Resilience and Well-being
  • About
    • History
    • Position Statements
      • Access to Palliative Care and Hospice Position Statement
      • Artificial Nutrition Position Statement
      • Research Ethics Position Statement
      • Palliative Sedation Position Statement
      • Physician-Assisted Dying Position Statement
      • Withholding Position Statement
      • Physician Assisted Dying Position Statement Review
      • Physician-Assisted Dying
    • Talking About HPM
      • Advance Directives-Talking HPM
      • Choosing a Hospice Program-Talking HPM
      • Defining HPM-Talking HPM
      • Explaining PAD-Talking HPM
      • Costs-Talking HPM
      • Withdrawing LST-Talking HPM
      • Choosing Wisely
      • Members Talking About HPM
    • Governance
      • Board of Directors
        • Board Only
        • Past Presidents
      • Committees
      • Staff
        • Staff
      • Call for Nominations
      • Revised Bylaws
    • Giving Center
      • Reasons to Give
      • AAHPM Giving Circle
      • Year End Donations
      • Giving Tuesday Donations
      • Bogetz Educational Fund
      • Donation Form
      • Donation FAQ
    • Awards
      • Visionaries in HPM
      • Emerging Leaders
    • Social Media
  • AAHPM Learn
    • Browse All
    • Books
    • Core Content
    • Self-Study
    • Essentials
  • Legislative Action Center
  • My Account
  • Username & Password
  • Manage Credit Cards
  • Demographics
  • My Classroom
  • Quarterly Newsletter
  • Pay Open Balances
  • Purchase History
  • Membership Details
  • My Communities
  • My Volunteer History
  • Uploaded Documents
  • History
  • Position Statements
    • Access to Palliative Care and Hospice Position Statement
    • Artificial Nutrition Position Statement
    • Research Ethics Position Statement
    • Palliative Sedation Position Statement
    • Physician-Assisted Dying Position Statement
    • Withholding Position Statement
    • Physician Assisted Dying Position Statement Review
    • Physician-Assisted Dying
  • Talking About HPM
    • Advance Directives-Talking HPM
    • Choosing a Hospice Program-Talking HPM
    • Defining HPM-Talking HPM
    • Explaining PAD-Talking HPM
    • Costs-Talking HPM
    • Withdrawing LST-Talking HPM
    • Choosing Wisely
    • Members Talking About HPM
  • Governance
    • Board of Directors
    • Committees
    • Staff
    • Call for Nominations
    • Revised Bylaws
  • Giving Center
    • Reasons to Give
    • AAHPM Giving Circle
    • Year End Donations
    • Giving Tuesday Donations
    • Bogetz Educational Fund
    • Donation Form
    • Donation FAQ
  • Awards
    • Visionaries in HPM
    • Emerging Leaders
  • Social Media

Advisory Brief: Guidance on Responding to Requests for Physician-Assisted Dying

 

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. Rarely, 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.

Purpose

The emphasis of this guidance statement is to entreat those medical providers who care for patients with terminal disease to understand the complexity of the request for assisted death, to provide an educated systematic response, and to use the best practices of palliative care to alleviate the suffering of patients that triggers a desire to pursue PAD. A primary goal of the American Academy of Hospice and Palliative Medicine (AAHPM) is to promote the development, use, and availability of palliative care 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.

AAHPM has a separate position statement on PAD that addresses ethical and social policy concerns.

Systematic Approach to Evaluate PAD Requests

Determine the nature of the request.
Is the patient seeking immediate assistance or considering the possibility of hastened death in the future? Is the patient airing thoughts about ending life without a specific intent or plan? Is the patient frustrated with living with illness, but not seriously contemplating ending life?

Clarify the cause(s) of intractable suffering.
Is there a loss of functional autonomy? Does the patient feel he or she is a burden or exhausted from prolonged dying? Is there severe pain or other unrelieved physical symptoms? Is the distress mainly emotional or spiritual?

Evaluate the patient's decision-making capacity.
Is there impairment affecting comprehension and judgment? Does the patient's request seem rational and proportionate to the clinical situation? Is the patient's request consistent with long standing values?

Explore emotional factors.
Do feelings of depression, worthlessness, excessive guilt, or fear substantially interfere with the patient's judgment? Does the patient have untreated or undertreated depression or other mental illness?

Explore situational factors.
Does the patient have a poor social network? Are there coercive influences such as looming bankruptcy? Is the patient subject to emotional, financial or other forms of exploitation or abuse?


Initial Responses to PAD Requests

  • Utilize open-ended questions to understand the concerns that led the patient to request PAD
  • Respond empathically and strengthen the therapeutic relationship through respectful and non-judgmental dialogue
  • Re-evaluate and modify treatment of pain and all physical symptoms
  • Identify and address depression, anxiety, and/or spiritual suffering
  • Consult with experts in spiritual or psychological suffering when appropriate
  • Consult with colleagues experienced in palliative care/hospice as needed
  • Commit to the patient the intention of working toward a mutually acceptable solution for the patient's suffering

 

When unacceptable suffering persists over a timeline often determined by the patient and the clinical course, despite systematic evaluation and standard palliative care intervention as outlined above, search for a mutually acceptable plan is essential. In these situations, consider the benefits and burdens of other alternatives including:

  • Discontinuation of potentially life-prolonging treatments such as steroids, insulin, oxygen supplementation, dialysis, or medically assisted hydration and nutrition
  • Voluntary cessation of oral intake if ethically acceptable to the patient and treating practitioners
  • Palliative sedation, potentially to unconsciousness, if suffering is intractable and severe 

 

Cautions
Despite consideration of this stepwise response, some patients will persist in a specific request for PAD. AAHPM advises great caution before pursuing PAD where legal, ensuring that:

  • The patient continues to receive the best possible palliative care coordinated with an interdisciplinary team and other non-palliative care providers, irrespective of a decision to use PAD
  • The patient has decisional capacity commensurate to the request for PAD
  • The request is voluntary and not influenced by subtle or explicit coercion from any source
  • All reasonable alternatives to PAD acceptable to the patient have been considered
  • If the physician responds affirmatively to the request, s/he engages best available practices that limit avoidable suffering through end of life
  • If the request conflicts with the physician's values, his/her response should take into account professional obligations of non-abandonment as well as the patient's ongoing clinical needs


Read other Position Statements from AAHPM.

AAHPM Membership

Access all benefits of membership including discounts on events and product, access to timely journals, and the opportunity to connect with colleagues in HPM.

Learn More

Quick Links

  • Job Mart
  • JPSM
  • CME/CE Certificates
  • Purchased Activities
  • Terms and Conditions
  • Privacy Policy

For Exhibitors and Advertisers

  • Commercial Support
  • Exhibiting
  • Advertising
  • Mailing Labels

For Students and Residents

  • Membership
  • Careers
  • Fellowships
  • Publications
Facebook Twitter Linked In Visit our patient website: PalliativeDoctors.org

AAHPM Logo

8735 West Higgins Road, Suite 300 Chicago, IL 60631

Phone 847-375-4712 Fax 847-375-6475 E-mail info@aahpm.org

Copyright © American Academy of Hospice and Palliative Medicine