Responding to Requests for Physician-Assisted Suicide

Abstract

Studies of dying patients have shown that about half would like the option of physician-assisted suicide (PAS) to be available for possible future use. Those percentages decrease significantly with each step patients take toward action. Studies show that although about 10% of patients seriously consider PAS, only 1% of dying patients specifically request it, and 1 in 10 of those patients actually receive and take a lethal prescription. However, most patients' desires for PAS diminish as their underlying concerns are identified and addressed directly. To help identify concerns motivating a patient's request for PAS, physicians should talk with patients about their expectations and fears, options for end-of-life care, goals, family concerns and burdens, suffering or physical symptoms, sense of meaning and quality of life, and symptoms of depression. A patient with advanced amyotrophic lateral sclerosis (ALS) who requested PAS illustrates how a hasty response may adversely affect patient care and the health care team. Although physicians should remain mindful of their personal, moral, and legal concerns, these concerns should not override their willingness to explore what motivates a patient to make this request. When this approach is taken, suffering can be optimally alleviated and, in almost all cases, the patient's wishes can be met without PAS.

Wishes to die at the end of life and subjective experience of four different typical dying trajectories. A qualitative interview study

“…A study in Switzerland and Germany [22] showed that 44% of ALS patients interviewed had already thought once about suicide, every second patient could imagine asking for assisted dying, and 14% currently had a WTD. This corresponds to other international findings in the quantitative literature [23][24][25][26][27][28]. Only one study found that wishes to hasten death was low in this group and even decreased within one year despite physical decline [29].…”

Desire to Die Statements in the Era of Voluntary Assisted Dying: An Audit of Patients Known to a Victorian Consultation-Liaison Palliative Care Service

“…Our findings reflect previous studies which demonstrate that only a small proportion of patients expressing a wish to die through VAD complete the process. 9,10 This highlights that even in an era of legal VAD, not all DTDSs are necessarily synonymous with a desire for a medically hastened death. These findings demonstrate the importance of clinicians identifying underlying contributors and reasons behind DTDSs, and supporting the patient in exploring them.…”

“…16 Health professionals may feel ill-equipped and uncertain, in part due to lack of appropriate training, to enquire and respond to the experiences of patients at the end of life, particularly those related to existential or spiritual suffering. 5 As a result, clinicians may avoid or dismiss such conversations, 9 with the concerns therefore remaining unaddressed. 1,9 Missing the opportunity to explore patients' fears, expectations and understanding about end-of-life options reduces that physician's capacity to provide meaningful support to the patient.…”

“…5 As a result, clinicians may avoid or dismiss such conversations, 9 with the concerns therefore remaining unaddressed. 1,9 Missing the opportunity to explore patients' fears, expectations and understanding about end-of-life options reduces that physician's capacity to provide meaningful support to the patient. This can, in turn, lead to patients feeling isolated and further distressed.…”

“…17 Clinicians may feel challenged if DTDSs conflict with their ethical or moral beliefs, however, this should not override their willingness to try to understand what a patient is asking of them. 9 In other cases, feelings of inadequacy may arise in the physician 15 who may interpret the request as a judgement on their capacity to care for the patient. 9 As a result of physician discomfort and avoidance, patients may feel they are not receiving an adequate response and are not being heard, as suggested by the repeated nature of their request.…”