Beyond the Five Now Sanctioning Aid-In-Dying, More States Consider 'Death With Dignity' Laws

Also opposed to death with dignity laws are some — though not all — of those who practice hospice and palliative care, who worry that their efforts to improve their services will be politically damaged if they are associated with the far more inflammatory aid-in-dying movement.

For many physicians, the issue is one that concerns the practice of medicine.

"I'm very worried about it because I meet people in my practice who conflate hospice and palliative care with assisted suicide or euthanasia,” said Ira Byock, director of the Providence Institute for Human Caring in California, which provides services that support patients and their families' lives and shares expertise and best medical practices with clinicians. He is also the author of the book The Best Care Possible.

The purpose of palliative care, Byock said, is to relieve suffering and, when necessary, to ease the way for the dying and their families — not to kill patients. "One of the founding principles of palliative care is that we did not hasten or delay a person's dying." Medical aid-in-dying, he said, becomes a viable option for people because of a shortage of or lack of access to quality hospice and palliative care.

Byock pointed out that contrary to common belief, the majority of those who ended their lives under Oregon’s law did not point to pain as the main reason. Instead, they cited loss of autonomy, decreasing ability to participate in activities that made life enjoyable and loss of dignity.

Even if pain was the chief complaint, Byock said, it can always be relieved, including by sedation.

But that is not always an acceptable alternative to some, such as Dr. Eric Kress, a Montana internist and palliative care doctor, who said he had prescribed lethal medications to 10 terminally ill patients and had been present for the deaths of four of them.

"I'm totally for delivering good palliative and hospice care for these patients as long as they want to have it," he said. "However, there's definitely a small group of patients that can't be palliated very well. And they'll sit there on a morphine drip with 50 milligrams an hour and still be in terrible pain. They end up in permanent sedation."

Permanent sedation, he said, means a patient would be sedated into unconsciousness to end their physical suffering, while their disease progressed and eventually killed them.

"Nobody who has ever been involved in terminal sedation has ever felt that good about it," Kress said. Yet, he said, those he attended during aid-in-dying are frequently surrounded by family, and are able to engage in meaningful conversations and farewells.

"I've never been to an aid-in-dying death where someone felt bad about it," he said. "To me, aid-in-dying is patient-centered care."

The Academy of Hospice and Palliative Care is noncommittal on the practice. "We’re taking a neutral position because it's very complicated, and we don’t have a consensus," said Joe Rotella, the academy's chief medical officer. "I would tell you that everybody has strong feelings about it."

Toward the end of 2013, Erwin Byrnes, in his 80s, returned home from a hospital stay with a feeding tube, weakness throughout his body and unsteadiness on his feet. He fell several times, once breaking a bone in his upper arm, which caused him great pain.

His condition worsened. He couldn't lift himself out of bed or bathe himself. Taking his medicine was an all-day regimen. By February of 2014, he’d had it. "He knew he wasn't going to get better and the pain was only going to worsen," his wife said.

The decision to end his life immediately lifted his spirits, she said, especially as he began to plan the details of his memorial service. In the meantime, visiting friends and family delighted him with a lifetime of memories.

Then came St. Patrick's Day, when he and his family continued the reminiscences in his den as guitar music (composed by a grandson) played gently in the background. Sitting in his favorite recliner, at 10 a.m., he was ready. He stretched his arm toward the IV tube and squeezed a clip as his physician had instructed him. As the fatal barbiturate streamed into his body, he continued to opine over the approaching NCAA basketball tournament, and then, drifted into silence. By the time a nurse pronounced him gone, 45 minutes had elapsed.

"It was the right thing to do," Ethel said almost a year later. "It's not a criminal thing. It is a beautiful way to be able to end your life. It has brought all of us even closer."

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