Poetry of Dying
INTERESTING STUFF – 26 January 2019

Physician Assisted Death

It's also called “Death with Dignity” and “physician-assisted suicide” among another name or two. What is important to know is that it is NOT the same thing as euthanasia which is, by definition, understood to mean that a physician acts to end a patient's life.

Generally, I use the phrase “physician-assisted death” rather than “physician-assisted suicide” because “suicide” is such a loaded word. Also, “Death with Dignity, which is catchy, seems pretentious. Better to just say what it is plainly and simply.

Physician-assisted death, by whatever name, refers to a physician supplying the means of death but with the patient administering the lethal medication. This is legal in seven U.S. States: Oregon, Washington, Vermont, Montana, Hawaii, California, Colorado, and Washington, D.C.

Oregon, where I live, was the first state, in 1997, to legalize physician-assisted death and I'm grateful to have that choice which I will use, depending on circumstances, when the time comes.

In Oregon, it is called the Death with Dignity Act (DWDA). You will find the full statute here.

And these are the are the most salient points of how the law works, from the oregon.gov website:

”The patient must make two oral requests to the attending physician, separated by at least 15 days.

“The patient must provide a written request to the attending physician, signed in the presence of two witnesses, at least one of whom is not related to the patient.

“The attending physician and a consulting physician must confirm the patient's diagnosis and prognosis.

“The attending physician and a consulting physician must determine whether the patient is capable of making and communicating health care decisions for him/herself.

“If either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder (such as depression), the patient must be referred for a psychological examination.

“The attending physician must inform the patient of feasible alternatives to the DWDA including comfort care, hospice care, and pain control.

“The attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request.

“A patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.”

As you can see, the requirements are fairly strict. Further:

”The law does not require the presence of a physician when a patient takes lethal medication. A physician may be present if a patient wishes it, as long as the physician does not administer the medication him/herself.”

You can find pretty much everything you want to know about Oregon's DWDA here.

TGB reader Elizabeth Kurata reminded me this week about an Oregon couple who, in 2017, chose to use the state's DWDA law to end their lives together. As Time magazine reported:

”On the last morning of their lives, Charlie and Francie Emerick held hands. The Portland, Ore., couple, married for 66 years and both terminally ill, died together in their bed April 20, 2017, after taking lethal doses of medication obtained under the state’s Death with Dignity law.

“Francie, 88, went first, within 15 minutes, a testament to the state of her badly weakened heart. Charlie, 87, a respected ear, nose and throat (ENT) physician, died an hour later, ending a long struggle that included prostate cancer and Parkinson’s disease diagnosed in 2012.”

The couple had allowed one of their children, Sher Safran, to make a documentary about the end of their lives, Living and Dying: A Love Story. Here is the trailer:

You can watch the full 45-minute documentary at Vimeo.

Is physician-assisted death a choice you would make for yourself?



Comments

I currently live in a state where physician-assisted death is not legal, and I don't envision that changing here in my lifetime. I am considering relocation options for the future, and this will be a factor in my ultimate choice of where to relocate. I will definitely consider physician-assisted death when the time comes. My mother experienced a very prolonged period of slow and steady decline, living for more than two years in skilled nursing. I resolved to make different choices for myself when the time comes.

Nina...

Oregon has no residency requirements. I don't know about the other states where assisted death is legal in this regard.

I read about a few people who went through the process, obtained the medication, and ended up not taking it. It may have been comforting just knowing it was there in their nightstand drawer...just in case.

I would most definitely make this choice if needed, but I don't live in a state where it is legal. I have MS, and it has progressed slowly, but inexorably, since 1993. I am now 69, and use a walker, rollator, wheelchair, scooter, etc., all the time. I hate being so dependent, and if there comes a time that my quality of life is nil, I don't want to live any more. I'm not there yet, but....

Ronni, are you saying that I could move to Oregon "temporarily", find a doctor, do all of the necessary steps, etc., and not have to establish residency?

Thanks so much for this timely blog entry. As always, you educate and inspire us. You are a gem.

From the Death with Dignity website:

Proving Residency

Legal state residency is a requirement for accessing death with dignity laws. In California, Colorado, Hawaii, Oregon, and Washington, you may prove residency with any or a combination of the following:

a state issued identification card or driver’s license;
documents showing you rent or own (residential) property in the state;
a state voter registration;
a recent state tax return.

I could see, as Daria says, getting the process going knowing I might choose never to take it just for the comfort of having the choice. I'd like being prepared with another door I could go through. I'm not at all sure what I would choose.

Yes. When I do eventually develop a terminal condition, especially Alzheimer’s, at the point where my qality of life is significantly degraded or I became a significant burden to my family I will opt for Physician Assisted Death.

Yes, I would consider this option.
Thank you for continuing to share your experience and provide insight.

I live in Oregon, and I thank god for the option. What a gift it is, as I foresee using it in about 3 to 4 years, My terminal illness will typically have me enter a coma when the end is near and I'd like to make my exit when I am cognizant, and can say goodbye to my family. That is what I truly dread, that last goodbye.

Probably not, for religious reasons. I'd be afraid the next stop would be hell! I recognize that this is probably more about my superstitions than my faith, and I wouldn't stand in the way of anyone choosing it.

My state does not allow it. For me, it would be a truly last resort, as I believe that only God can give and take life. I would fear retribution in the afterlife. It is a comforting thought, however, that if I had a terminal illness (especially one that left me powerless and senile) I could go where this is possible.

Ken Murray MD wrote a wonderful article titles "How Doctors Die" - it can be found via google. During my work as a hospice RN I have watched uncomfortable deaths, with patients in pain and struggling to breath. I've witnessed what happens in many skilled nursing and assisted living facilities. There is no doubt in my mind that physician assisted death is a blessing.
If this is an option a patient wishes to explore, timing is important. Become knowledgeable about the law, and discuss with your physician. Many physicians choose to not participate in this choice for personal or professional reasons, and that is their choice. You may have to search for help to exercise your right to choose this option.

I have certainly considered it, and thought a lot about having to move to Oregon when I'm old and infirm or, just as bad, moving away from all family while I'm still not quite so old. Moving is an absolutely horrible, draining experience. Fortunately, on it's third try, Colorado approved a death-with-dignity law a few years ago. Now I can stay here near family, in a place I love, without worrying about a wrenching move. And yes, I've thought about the comfort of having the drugs in a drawer somewhere, just as reassurance.

Yes, I will consider it, and find comfort in knowing that it is an available option.

Medical Assistence in Dying, here in Canada, with medical personnel administering the drugs. Not available to those suffering advanced dementia but the law is open to review and modifications. A choice that can end suffering, provide a dignified end to a life and bring family and friends together at the end.

Yes!

Definitely would consider this if quality of life were gone with no hope of improvement. I have thought of this before. We treat our pets with more dignity than we treat ourselves. We "put them to sleep" when the situation warrants it. It's a huge and painful decision-- but it's so often an act of love and kindness.

Shakespeare said "to die is to sleep; perchance to dream."

I like to sleep; I enjoy my dreams.

I would absolutely use this exit method if it comes to that. Luckily, I live in Washington, where it is legal. When I asked my doctor about it, she laughed and said, “Does this count as your first verbal request?” As I was laughing with her, she interrupted me and repeated, “Well you started it! Now you have to answer yes or no.” Gulp!

Yes. And, if possible (there are developments going on right now in Holland), without the assistance of a physician.

A timely question for me - a close friend has terminal cancer. We live in a state that does not have assisted suicide. She has probably voted for the people who prevent it from passing. This week she asked me how people can end their lives if assisted suicide is not available.
If I were in her position, I would certainly choose assisted suicide, and if I had to, I would go to Switzerland for it.
I did not feel very comfortable about responding to her question. One of her adult children has not accepted that she is going to die. I just told her about the end of my parents lives. Dad refused to eat or drink, and Mom finally asked for enough morphine to stop her cancer pain. No one exactly assisted them, but they did not interfere either. We accepted their choices and it pains me greatly that my friend's daughter is still insisting on drastic treatments that make things worse.

I'm glad this is becoming available for those who need it, only sorry that availability in my state will probably come later rather than sooner. Every time the vet has come over the years to euthanize an old animal, I think, we humans could benefit from this too.

I live in California where assisted death is legal.
I have already given it much thought and I will definitely use this option when/if I am no longer able to care for myself.
I helped take care of my brother when he was dying of a glioblastoma and it was so very painful and draining on everyone, mostly him.
I do NOT want to put my children into a situation where they need to take care of me at the end of my life. Nor do I want to extend my life once there is no longer any quality to it.
This is such a personal decision, and I agree with my shipmate that pointed out that having the medications available, whether they're ever taken or not, is a comfort.

Yes, I too would make the choice to shut off the music and stop dancing when it seems right for me and those around me. However, I would leave the physicians out of it for a variety of reasons.

And I want to thank you, Ronni, for sharing Mary Oliver's poem earlier. This one line truly spoke to me...
..."I think of each life as a flower, as common
as a field daisy, and as singular".

As I approach the end of life I realize what matters most to me now is the company, and the precious, poignant sense of just how brief and unique all of us are. I am grateful for the talented poets that easily and succinctly bring rare insight and understanding to the reader.

​I have paraphrased this from a friend's book of essays: "Bedside Manners", by David Watts, MD
The writer's story and the reality of your own history and wisdom benefit from each other. The two stories--one in life and one about life have now touched, leaving inside, for both poet and reader, little ideas, like enzymes of transformation that change ideas and shift outcomes. Now, without any ceremony the reader and the writer move on, better off than before.

TimeGoesBy and all of those taking time to respond and comment are a blessing in this life of mine....so far "still do-able".
Thank you all, Charlene.

Personally, I would think that dementia would be one of the primary conditions in which this option would be the most humane, yet this statute would not seem very helpful for those with dementia, especially beyond a certain point, as it might be very difficult to satisfy some of these requirements.

I watched the video the first time you shared it a while back, and was impressed by how cogent this couple was in putting this plan together and how well it seemed to go for them. I suspect that this may not always be the case and I hope that research continues to make this option as accessible to others who may not have the resources, support and knowledge that this couple did.

Each time this topic comes up, I'm reminded of Kurt Vonnegut, Jr.'s story, "Welcome to the Monkey House," featuring the Ethical Suicide Parlors run by the world government in order to maintain global population stability at 17 billion. Reading his words decades ago was my first introduction to a conceptualized image of what one's intentional death could be like, but not necessarily the same as a suicide. Vonnegut being Vonnegut, there was a lot more to the story, and it has stuck with me ever since.

I'm in Washington, where it is legal, but I'm quite ambivalent about it. I have a terminal condition but probably 4-7 years to live unless something else gets me first (quite possible because I have heart arrhythmias, too). My concern is spiritual. Shortly after my mother died, I read both the original and a Westernized version of The Tibetan Book of the Dead. I have since read two other books about the Tibetan Buddhists' views and practices related to death (mistake!), all of which stress that it's critical to be fully cognizant, aware at the moment of death. However, if I die the way it currently looks I will (and I've had an ER visit preview), I'll be so out of it on morphine unless I choose prolonged panic and suffering that either way is the same result.

So I'm working on finding something that helps me decide what I believe about how we die and what happens then so I can find more comfort, less fear, either way. Among several I've read, there are two books I've found that are helpful (not religious books) if anyone wants to know the titles. I am glad we don't live longer than we do, but I don't see a reason to make the process of dying so grueling.

If you choose this way, as a nurse stressed in a previous reply, it is critical that you not wait too late to start the request process. You can keep the medication on hand however long you choose and use it or not as you choose. But you must be able to take it yourself, without help from anyone else.

Is physician-assisted suicide something that I would use?
Emphatically, YES.

And I am glad that it is an option for many.

But I would take it a step further.
See, I have long had an "advanced directive" in place with a "DNR" option.
I signed that document when I was young and healthy.
(To my knowledge, though, a physician is not required to obey a patient's advanced directive. Is that correct?)

I see a "Catch-22" in the current law, and I would like to have the option of making an "advanced directive" that could work around it.

Personally, I would prefer to be deceased than be severely senile. Many people agree with me...and many others do not. I would never advocate for "killing Granny" just because she needs specialized dementia care...unless she had stated, as I have, prior to becoming demented, that she'd prefer death with dignity over living out her days in a confused state of mind.

Obviously, when one is in that state, one cannot possibly give legal consent to physician-assisted suicide, because one has to be able to fully-understand what one is doing. That's why I'd like to see the law expanded in such a way that one can write a (legally-witnessed/notarized) document as an "advanced directive" in which one enumerates all of the medical conditions--and their level of severity--under which one would no longer wish to go on living.

I would definitely like the option to avail myself of legal, assisted and intentional death. I might never use it, but knowing the choice exists would mean HUGE peace of mind. I'm thinking about moving to neighboring Vermont in the coming years (where it's legal).

I am 55, yet have been thinking deeply about this for over a decade. My 84 year old mother, who considers herself open-minded about most things, is aghast at the mention of the topic, let alone my strong feelings about it. I still don't understand how it touches such a nerve - in her, or in any thinking, compassionate human. We, as an enlightened society, should find this decision is a basic right of every individual.

This is a conversation about which I am going to get much more vocal in the next few years.

I had been wondering if you would bring this up, Ronni, considering you live in Oregon. I think this possibility is a gift to all suffering people.

I would certainly use it if the circumstances called for it, no question. I have left elaborate instructions in my living will and advance directive about not wanting life-saving measures should my heart stop or should I stop breathing, and asking for all needed pain relief even if it should shorten my life.

But you never know . . . Could some medical person ignore those instructions? Sure. It has happened, and not that rarely. I think self-deliverance is a mercy.

For those who are interested, there is also an organization called Final Exit that will instruct you on how to kill yourself using inert gas, and will supply people to support you (but not to do it for you). Their website will give you more information.

I've certainly considered it having seen several friends and family die awful deaths.

How I wish that I lived in a State that had the Death With Dignity statute. Unfortunately, I am living in a State controlled by the religious legislators who think they have a right to control a strangers body because of their misguided interpretation of a book several thousand years old. One that was written by men who had no knowledge of the human body.

My remaining lifetime is short; therefore I will never have that option and I might have to find a way to take matters in my own hands. It isn't easy and I hope that nature is kind and I die without having to suffer needlessly.

I am almost 72 and currently in good health. I have always considered assisted death an option for myself. Thank you for posting the video. It was moving and strengthened my decision. I would like to leave this life on my terms without being a burden to family or friends and with dignity.

I find the DWD laws to be comforting to me, especially after witnessing my own mothers protracted death from inoperable brain cancer.
My sister and I both spoke before the Oregon legislature when this controversial law was proposed.
17 years after her terrible death, the law that would have eased her suffering was passed.

I consider the option a benefit for both myself and my children. I can still clearly see my mother in pain, like a wounded animal, 39 years later. I don't want my children carrying a memory like that.

All but a couple have voiced my views. I’d take this even further than if one is terminally ill. I would definitely include Alzheimers.
I would want the choice to be able to end my life if I was just old, tired, not feeling well and simply ready to go having had a good long life. My biggest fear is ending up in a nursing home alone in an understaffed facility and often in pain and total loss of dignity. This would be hell on earth for me.
I’m in the South, so it’ll never pass here..too much religion. Not enough good education.
I wonder if Canada requires citizenship? I know Switzerland does not, but it’s very expensive.
I wish we lived in a more enlightened country.

I would definitely choose that route should I be in protracted, unrelenting pain. And I have experienced that -- when I was 23, and almost died. However, I was young and regained my health. Knowing there was no cure, and the pain was only going to worsen, there should be legal ways to end that suffering.

I live in the South too, so not an option. I often think the old-timey religious sects here actually WANT people to suffer! Regardless, there are other ways and means, which I would certainly seek out should I find myself terminal with only agony on the horizon.

It's definitely something I'd consider! Thank God I live in a state that allows it!

It warms my heart, Ronni, to see you and others speak of the comfort derived from living in Oregon or another jurisdiction that has authorized medical aid in dying (the most common "term of art" to describe the practice.) When I and my colleagues drafted and campaigned for this law some 25 years ago we did not anticipate the positive impact it would have on quality of life and peace of mind. It has been so heartening to see this positive impact become clear through the years. Today the movement is growing to encompass all kinds of personal agency and decision-making as illness advances and frailty grows. My mantra these days is "Finish Strong" by putting your own values first.

IMDb Freedive is free app with movies that have 10 secs of ads periodically. You can watch an excellent movie called "Youth and Oregon" for free using it. It addresses this issue from the family, the person, his friends, etc. I loved the movie. I am not advertising it, just shareing that it is a movie worth the time and effort to view it.

I was proud to help vote in Colorado's law. It is a matter of having the choice. I think I will do this but if I decide not to, at least I had a choice. So many go through needless suffering.

Ronni, thanks for all you have done with this blog. I hope your final Journey is a good one filled with peace and love.

I posted a "YES, absolutely" comment yesterday, but it's not here so I must not have hit "Send" or waited too long. I think it's important for ALL votes to be counted--especially in 2020!

It's not legal in New York. But I may not be in New York by the time I need to decide.

I honestly don't know if I would choose it -- it would depend -- but it would be very, very good to know that it was available.

The video was nicely done and very moving. The music was so beautiful! Thank you so much for sharing it! Yes, I definitely would choose this pathway. However, I live in FL and do not see the laws changing during my lifetime. I can only hope.

Elizabeth, it was posted it in yesterday's(?) column. I read it wherever it lays.

To answer your question, Mary: Canada does require citizenship to qualify for an assisted death.

Clearly public opinion is evolving to more of an acceptance of the idea of physician assisted death. The unfortunate thing is that the underlying assumption is that there are two choices: intractable pain and suffering, or dying peacefully. But it's not "either/or." Palliative care can go a long way to ease our suffering, whether it's physical, emotional or spiritual. We can be kept comfortable, clean and feeling valued. I've seen this countless times as a hospice volunteer. The real issue is why so many of us end up dying without these comforts; that helps drive people to think that the best option is to literally take matters into their own hands.

I think it's also unfortunate that the word dignity has been misused for this issue too.
Merriam-Webster defines dignity as “the quality or state of being worthy, honored or esteemed.” But we often mistake “indignities” for “dignity.” If I became too frail and weak to shop or cook or do any of the myriad tasks that I ordinarily do, I might consider that an indignity. If I became incontinent and needed adult diapers, I might consider that an indignity. If I became unable to walk and then became wheelchair-bound, I might consider that an indignity too. But would any of this take away from my fundamental dignity as a human being? Would I be any less worthy of being valued, respected and cared for? Would anyone? I don’t think so.

Elizabeth...
Yes, your comment was posted under the "Poetry of Dying" column. I remember seeing it there. It's a very good comment, maybe you could re-post it here.

Thank you, Katie. I'm not sure what to think of my mental acuity when I can't find my own comment! I've reposted it below.

Would I elect physician assisted death vs. a painful, lingering, debilitating, dignity-robbing "natural" demise? YES, absolutely! I've made that crystal clear to my family; everyone who knows me understands that this is what I would choose. I have also signed a POLST and prepared a specific written statement in addition to official advance directives. I live in WA State, where the process is legal, but as Ronni notes about Oregon, it is strictly regulated in both states.

Being unencumbered by religion, I join those who believe that every competent adult who so chooses should have the right to exercise control over the end of life, including a peaceful and dignified death at a time, place and means of their determination. Currently, many elders end up losing that right at the hands of the medical-industrial complex as they practice extreme medicine to preserve "life".

I have done my best to ensure that my wishes are carried out. I fervently hope that, when my time comes, it comes quickly and mercifully. If that doesn't happen, I hope I meet the requirements for physician-assisted death and am able to self-administer the medication. I realize that, if I develop dementia, I would need to consider other arrangements, but a peaceful death in my own home would for sure beat driving over a cliff or leaping from a tall bridge (which I likely couldn't pull off at this age anyway!).

To Steve, Cynthia Stern and Mary --
Aid in dying (which I believe is a better phrase) is DEFINITELY NOT NOW AVAILABLE FOR ALZHEIMER'S OR OTHER DEMENTIAS, anywhere in the USA (don't know about Europe).

Once you lose the capacity for "rational decision making" ALZ patients are doomed to live an average of 10 and up to 20 years, increasingly demented, physically wrecked (think double incontinence), dependent on caregivers, who will be your family, whose lives will be permanently scarred, not to mention bankrupted by your prolonged disease. Once you get a dementia diagnosis, no one will say, OK, here is your lethal medication. You have to commit suicide on your own while still able to do that, whether by acquiring pills somehow or by shooting yourself (the major suicide method in the US).

Aid-in-dying should be extended to a prior legal statement outlining the conditions under which a person does not want to live longer. This will not happen soon, but people who support aid-in-dying should try to keep the dementia issue front and center.
Neil Gorsuch is a self-declared enemy of all such legislation, and of course most religions will line up together on this program.

To reiterate the info in a previous comment: Final Exit Network (FEN) is there for anyone, anywhere in the 50 states who is mentally competent and who wishes to take their own life peacefully and without suffering!

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