“Death with Dignity,” also known as Physician Assisted Death, Physician Assisted Suicide and Medical Aid in Dying, refers to the legal ability of a physician to provide a potentially …
“Death with Dignity,” also known as Physician Assisted Death, Physician Assisted Suicide and Medical Aid in Dying, refers to the legal ability of a physician to provide a potentially lethal medication to be self-administered by a terminally ill patient at their request. The first state to legalize Death with Dignity was Oregon in 1997, and currently there are 10 states, plus the District of Columbia, and 12 countries that have passed similar laws.
The Lila Manfield Sapinsley Compassionate Care Act (H-6600 and S-2112) will be reintroduced in Rhode Island in 2023 by Rep. Edith Ajello and is co-sponsored by state Rep. Susan Donovan of Bristol and Portsmouth. Lila Sapinsley was a Rhode Island state senator, and this bill was initially introduced in 2015 shortly after her death, according to her wishes.
In general, the guidelines established for Death with Dignity (DwD) are similar across the states. The Rhode Island bill would require the requesting patient to have a terminal condition defined as an “incurable and irreversible disease which would, within reasonable medical judgment, result in death within six months or less” and that the patient is competent, informed and a resident of Rhode Island. It also requires two oral requests from the patient in the physician’s presence that are at least 15 days apart, as well as a written request signed by two witnesses not in line to gain from any estate inheritance.
The patient must be informed by the physician of alternative treatment options, end of life services including hospice and palliative care, and the likely results of ingesting the medication. The opinion of a second physician is necessary to confirm the medical diagnosis and prognosis and that the patient has decision-making capacity, is informed and acting voluntarily.
The prescription for the medication(s) would then be written and dispensed if and when the patient so choses.
Why people consider Death with Dignity
Oregon has allowed DwD for over 20 years and as of January 2022, a total of 3,280 people had received prescriptions and 2,159 people (66%) died from ingesting the medications. About one third of the people who received the prescriptions did not use them.
Data for the year 2021 revealed that 218 people died after ingesting the medications, with a median age at death of 75. Most died at home (95%) while receiving hospice care (98%). Consistent with previous years, the three most common end of life concerns were loss of autonomy (93%), decreasing ability to participate in activities that made life enjoyable (92%), and loss of dignity (68%).
Inadequate pain control was not cited as a primary reason, but rather issues that imply profound emotional and existential suffering. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year24.pdf
Compassion and Choices is a nonprofit advocacy group active in all 50 states with a mission to expand access to Death with Dignity and to empower patients to choose end-of-life care that reflects their values, priorities and beliefs. https://www.compassionandchoices.org
The practice of DwD, however, is emotional territory and can be debated from religious, legal, ethical, and medical points of view. Supporting and respecting personal autonomy or the patient’s right to make informed decisions, including when, where, and how they will die, is at the core of these laws.
Some in favor of DWD feel it is no different than a patient refusing or stopping life sustaining treatments, but it can also be argued that accepting death is not the same as facilitating it.
In defense, some patients emphasize that it is the terminal disease that is killing them, and their wish is to be allowed to control the circumstances.
The physician’s duty to relieve suffering that a patient deems intolerable has also been offered in support of this practice. However, the American Medical Association is opposed to Physician Assisted Suicide (call it what it is, they maintain) but acknowledges the right of a physician to act in accordance with their conscience.
The American Nursing Association (ANA) neither supports nor opposes DwD. In their position statement, they reaffirm that the role of the nurse is to offer nonjudgmental support, respect patients’ end of life choices and values, and to prevent and alleviate suffering. The ANA also included that nurses have the right to conscientiously object to being involved in the process. https://www.nursingworld.org/news/news-releases/2019-news-releases/ana-advises-objectivity-in-new-medical-aid-in-dying-position/
The Hospice and Palliative Nursing Association is in clear opposition to DwD and asserts it is not part of palliative care, which neither seeks to hasten nor postpone death.
Having structure and guidelines for what some patients will attempt to do on their own with less than optimal “home-made” plans should also be considered when debating DwD. The fear of the dying process can outweigh the fear of death itself and lead to desperate acts.
Since Oregon passed laws allowing DwD, opponents point to the fact that each year the number of requests for prescriptions has increased. The concern is that DwD normalizes “suicide” and that it could become an increasingly routine response to a serious fatal illness. Much effort is put into suicide prevention, so DwD is seen by some as a public health threat.
Others do not feel it is accurate to even use the word “suicide” if the individual is already terminally ill. Most organized religions are opposed to DwD, except for the Universalist Unitarians and the United Church of Christ, who support the right to die with dignity. https://www.pewresearch.org/religion/2013/11/21/religious-groups-views-on-end-of-life-issues/
The slippery slope
Some of the loudest voices arguing against the legalization of DwD has come from national disability organizations who see it as a slippery slope that could eventually allow wider coverage to other vulnerable populations. DwD is interpreted as stigmatizing those with disabilities and could have a negative impact on individuals living with chronic illnesses or who are dependent on others. In fact, last year Canada changed its assisted death law to permit people with chronic, “grievous and irremediable” conditions and physical disabilities to commit suicide, even if they are not terminally ill. https://www.nytimes.com/2022/09/18/world/canada/medically-assisted-death.html
This emphasizes the importance of strict medical and legal guidelines, along with oversight and regulation.
Are we as a healthcare system and a community doing enough to help people approaching the end of life? Maybe with more support and earlier conversations around these issues there would be fewer requests for aid in dying.
It is important to elicit any misconceptions and provide accurate information and reliable resources. Being better prepared can contribute to a sense of control, reduce anxiety, and help to prevent unnecessary suffering. To quote Lisa Shulz, the author of the book “A Chance to Say Goodbye,” “If the push towards life-sustaining technology was balanced with options for comfort care in … the healthcare culture, more people would have the chance to transition to death with dignity and grace.”
There are those, however, who can see death coming and are asking for help to exit in their own way at a time of their choosing.
Bonnie Evans, RN, MS, GNP-BC, lives in Bristol and is a geriatric nurse practitioner and End of Life Doula. She can be reached at firstname.lastname@example.org.