New Study: Suicide Contagion and Legalized Physician-Assisted Suicide

 

Even before my 30 year old daughter Marie died by suicide in 2009 using an assisted suicide technique, I was writing and giving talks on physician-assisted suicide (PAS) for years. Even then, I worried about effect of the mainstream media portraying PAS as a civil right and even “courageous”, especially since the existence of suicide contagion aka “copycat suicides” was well known. I was not surprised when after Marie’s death, at least two people close to her became suicidal. Thankfully, they were saved by treatment.

Now we have even more information about this from a Southern Medical Journal a medical journal article that was published at the same time Governor Brown signed the California’s PAS law. In the study “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” , researchers meticulously examined suicide rates in Washington and Oregon after those states passed PAS laws.

The results are shocking. In those states, the researchers found a 6.3% increase in total suicide with a larger increase (14.5%) among individuals 65 or older. Moreover, there was no decrease in nonassisted suicides (people taking their own lives), despite the claims of PAS advocates that legalizing PAS would reduce the overall number of nonassisted suicides. Instead, the researchers found that “Rather, the introduction of PAS seemingly induces more self-inflicted deaths than it inhibits.”

On November 20, 2015, the Washington Post newspaper published an excellent op-ed article titled “The Dangerously Contagious Effect of Assisted-Suicide Laws “ by Dr. Aaron Kheriaty, an associate professor of psychiatry and head of the medical ethics program at the University of California at Irvine. Citing the medical journal study, Dr. Kheriaty concludes that:

“Debates about physician-assisted suicide raise broad questions about our societal attitudes toward suicide. Recent research findings on suicide rates press the question: What sort of society do we want to become? Suicide is already a public health crisis. Do we want to legalize a practice that will worsen this crisis?”

Is Suicide Really a Public Health Crisis?

The national Centers for Disease Control website reports the following statistics in a section titled “Suicide and Suicide Attempts Take an Enormous Toll on Society”. Here are some excerpts:

• Suicide is the 10th leading cause of death among Americans
• More than 40,000 people died by suicide in 2012
• More than 1 million people reported making a suicide attempt in the past year.
• More than 2 million adults reported thinking about suicide in the past year.
• Most people who engage in suicidal behavior never seek mental health services.

Costs to Society
The following estimates are based on 2010 CDC data and refer to people age 10 and over.
• Suicide costs society over $44.6 billion a year in combined medical and work loss costs.
• The average suicide costs $1,164,499. (Emphasis in original)

The toll on survivors, family member or friends of a person who died by suicide is also enormous, as I can personally attest:

• Surviving the loss of loved one to suicide is a risk factor for suicide.
• Surviving family members and close friends are deeply impacted by each suicide and experience a range of complex grief reactions including, guilt, anger, abandonment, denial, helplessness, and shock

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Fighting Suicide Contagion

It is tragic that suicide prevention organizations ignore the PAS issue and the mainstream media is almost uniformly sympathetic to the PAS movement despite World Health Organization and national media guidelines for suicide reporting. This has allowed PAS groups like Compassion and Choices not only to press harder for universal PAS laws but also to even change the names of such laws to euphemisms such as “End of Life Options” or “Death with Dignity” to disguise the fact that physician- assisted suicide is obviously suicide.

However, Dr. Kheriaty in his Washington Post article also talks about a related phenomenon called the Papageno effect that:

“suggests that coverage of people with suicidal ideation who do not attempt suicide but instead find strategies that help them to cope with adversity is associated with decreased suicide rates.”

I have always maintained that our stories as suicide survivors, people with disabilities or terminal illnesses, etc. offer hope and inspiration while those about PAS promote despair and hopelessness. We need to tell our stories publicly.

All of us and especially people in states that are currently targeted by groups like Compassion and Choices for legalization of PAS, need to know and share the real facts about PAS as well as suicide prevention and treatment, including the national suicide hotline number (1 (800) 273-8255) and website (www.suicidepreventionlifeline.org).  Suicide prevention and treatment can work whether people are considering PAS or killing themselves.

Addendum: Ironically, just as I was finishing this blog, I was interrupted by a call from a man living in another state with an incurable, disabling condition. He was referred to me last month when he saw a segment on a celebrity’s suicide involving the same condition and decided that he wanted to go to California to use the newly passed PAS law. I talked to this man for quite some time.

I was elated when this gentleman now told me that the resources I recommended, the people he talked to and even just the fact that someone cared did change his mind and he no longer wants to end his life. He said he now wants to start actually living again.

This man’s story shows why we must not discriminate between suicide and physician-assisted suicide when it comes to suicide prevention and treatment.

Happy Thanksgiving!

Today I give thanks  to God for all my family, friends and blessings.

We have had so many blessings this year, most especially the health of our grandson Liam who had a bone marrow transplant in 2013, almost a year after we lost his 6 year old brother Noah who also had the rare autoimmune disease called HLH. Liam’s regular checkups have just decreased to every 2 months and he is now predicted to have a normal lifespan!

I also give thanks for my wonderful husband Kevin and our wonderful now-grown children, one of whom is hosting Thanksgiving for the first time instead of me. Yea!

I hope you all have a wonderful Thanksgiving too!

 

LIVING WITH “LIVING WILLS”

In the early 1970s when I was a young ICU nurse, none of us medical professionals had even heard of a “living will”. There was a universal presumption for life and “quality of life” was something to be improved, not judged.

Nevertheless, sick people could and did refuse treatment and even check themselves out of the hospital against medical advice. When patients appeared to be dying, they or their families could agree to a “do not resuscitate” (DNR) order. Overly aggressive or useless treatments could be discouraged when such measures were considered medically futile or excessively burdensome for the patient. But one thing we didn’t do was offer to withhold or withdraw medical care like tube feedings to cause or hasten a patient’s death.

Unknown to us, all this began to change after Louis Kutner, a Chicago lawyer, wrote an article in the Indiana Law Journal titled Due Process of Euthanasia: The Living Will, A Proposal” in 1969. (emphasis added). By 1970, The Euthanasia Society of America (later renamed the Society for the Right to Die) distributed 60,000 living wills. In 1976, California passed the nation’s first “living will” law. Now, there are proposals to eventually include even physician-assisted suicide in “living wills”.

I use the common term “living will” to represent the wide variety of end of life documents that have evolved since the original “living will”, including the newest but problematic one called POLST (physician orders for life-sustaining treatment).

I wrote a 2001 article “Of Living Wills and Butterfly Ballots”   because I was concerned that many people were signing such documents with little knowledge of the history and problems with such documents that I witnessed as a nurse and ethics committee member. However, with the crucial help of a sympathetic media, court cases involving seriously brain-injured people like Terri Schiavo and government mandates such as the 1990 Patient Self-Determination Act have resulted in the heavy promotion of “living wills” as simple, worry-free documents. Now the federal government is set to begin paying healthcare providers for talking to all Medicare beneficiaries about such documents.

Can “living wills” be hazardous to your health?

Recently, I talked to lawyers who expressed confusion and concern over the “living wills” they were asked to draw up. In addition, Medscape, a subscription website for medical professionals, and the American Medical News have published recent articles such as “Advance Directives May Be Hazardous to Your Health”  and “Clearing Up Confusion on Advance Directives”. The last article even warns

“misinterpretations of end-of-life documents too often result in lost lives or unwanted care” such as when “physicians incorrectly assume that DNR means not to treat a patient who is critically ill”.

When even doctors and lawyers are confused, there is a big problem. In the real world of medicine, I even heard some doctors say that if in doubt, it might be legally safer not to treat than to treat someone with a “living will” in an emergency because of lawsuits where a patient with a “living will” survived or had serious impairments.

SHOULD I EVEN HAVE A “LIVING WILL”?

When “living wills” first came out, I felt I was safer not to have one to make sure I received treatment. Later, I changed my mind. I felt it was safer to designate someone I trusted with the legal authority to make decisions if I was unable to speak for myself rather than just leave it to my family members, some of whom vigorously disagreed with my stance for feeding brain-injured people like Terri Schiavo.

I never tell people that they must or must not have a “living will” but everyone should be fully informed. I do encourage people to check out information sites like the Pro-Life Healthcare Alliance’s “Informed-A Guide to Critical Medical Decisions”  which has sections explaining ventilators, CPR (cardiopulmonary resuscitation), feeding tubes, misuse of opioids and sedatives as well as end of life considerations.

There are also several informative and protective “living will” documents from organizations like the Patients Rights Council and the American Life League. The National Right to Life Committee even has such documents online and specific to state laws.

Some Points to Consider before signing a “living will” style document

Here are some of my personal recommendations as a nurse before signing a standard “living will” or even a protective one.

1. Make sure the document is as short as possible, simple to understand and that the presumption for life is expressly stated so that if doctors are in doubt about your wishes, they should treat you.

What most people do not know is that “living will” style documents often go unread by doctors and nurses until a critical situation develops and time is of the essence. Even worse, some doctors and nurses still assume or misinterpret “living wills” as meaning the patient does not want treatment, especially if the patient is older or disabled.

2. Avoid vague terms like “significant recovery” and “terminal event” that have no objective medical standard and can easily be misinterpreted.

I’ve seen patients who have just had a stroke or head injury incorrectly judged “terminal” or “incurable by doctors. Such patients often get better with time and treatment. And, of course, any treatment that is medically futile or excessively burdensome to the patient can be ethically withdrawn later. I add the emphasis because now futility and burden are too often assumed to mean an inadequate “quality of life” or economic burden to the family or society.

3. Designate one person you trust to make your medical decisions with a backup person or persons.

Sometimes when only one person is the designated decision maker, he or she may be unavailable or incapacitated so a backup is important especially in a critical situation.

4. Consider not checking off particular treatments or conditions to be automatically refused.

Personally, I wanted a positive “living will” that only designates my decision maker and his/her right to make decisions about my care rather than signing a “living will” to refuse future treatment or set possible future conditions where I would want treatment stopped or withheld. Instead, I want all current options, risks and benefits of treatment fully explained to my decision maker based on my current condition.

5. Many “living wills” contain a section on pain with such sentences such as “I want my doctor to give me enough pain medicine to relieve my pain”. You might consider adding a phrase like “without hastening my death.”

I have seen unnecessarily high doses of pain medicine deliberately given to make a patient unconscious while food and water were stopped. Often, this was called “comfort care” instead of terminal/palliative sedation  but the result was hastening or causing death by dehydration and/or suppression of breathing.

Everyone wants and deserves adequate pain control at the end of life. Carefully increasing doses of pain medication and other measures work in virtually any situation and family members should advocate this for their loved ones.

Conclusion

There may be no perfect “living will” but as a former hospice nurse and family caregiver myself, I believe that dying people have a right to a good death with as few medical interventions as possible for comfort without deliberately hastening or causing death. The time before death may be short or long but I believe that people have the right to die at their own natural pace.

Death is not something to get over with as soon as possible. As some people with terminal illness have told me, they hated being treated as if they were already dead when they were still alive. They wanted to hear jokes, be with family and friends, go to church, etc. And since hearing is thought to be the last sense to go, I interacted with my dying patients in comas just as I did with my conscious patients.

The process of coming to terms with  death can be difficult at times but it also can be a meaningful time to review a life with all its joys and sorrows as well as a time for family and friends to show love, support and even healing.

Terror in Paris

My first inkling that Paris had been hit by terrorists in Paris was an alarm on my smartphone that signaled the breaking news. All throughout this weekend, my husband and I monitored the news on TV with growing horror.

The pictures of the carnage were devastating. Years ago, I worked in an ICU with trauma victims. That made me extremely sensitive to the bloody reality of violence and its’ effect on victims, families and society. I could never accept the idea of extreme violence as mere entertainment in movies, video games, etc.

My family’s thoughts and prayers today are especially with the people of France. We also pray that our leaders and society will totally commit to stopping terrorism everywhere.

Germany Legalizes Assisted Suicide-As Long As It Is “Free”

While the UK Parliament overwhelmingly defeated a physician-assisted suicide bill in September 2015, less than two months later the German parliament has passed a law legalizing some assisted suicides. As Reuters News reported:

“The bill, which was upheld with 360 out of 602 votes, criminalizes organizations that assist patients in terminating their own lives for profit. It is meant to prevent the commercialization of the procedure as a “suicide business.”

However, single instances of suicide assistance – by a doctor or relative – do not contradict the new law. A husband who helps his terminally ill wife to die would not be prosecuted.

“Commercial” assisted suicide would be punished by up to three years imprisonment, even if doctors allegedly perform the procedure to relieve suffering.

Why Germany?

The law is a surprise to many, especially since Germany has long been sensitive to the issue of euthanasia following its’ history in World War II when the Nazis used the practice to kill over 200,000 people with mental and physical disabilities as well as millions of Holocaust victims.

Actually, the 1945 Hadamar Trial involving euthanasia by healthcare professionals at the Hadamar psychiatric clinic was the first mass atrocity trial in the US zone of Germany following World War II. As a nurse, I was particularly horrified when I first read about the famous study of the willing participation of nurses titled “Killing while caring: the nurses of Hadamar”

What can we expect?

Former Justice Minister Brigitte Zypries said the new German assisted suicide law “will open an era of great legal uncertainty” and will certainly be appealed to the Federal Constitutional Court.

But If efforts to stop the German law fail, the law will doubtless be expanded in the future as other countries in Europe have done.

Although ignored or dismissed in the US, the expansion and problems of euthanasia/assisted suicide in European countries like the Netherlands, Belgium, Luxembourg and Switzerland show the danger of first accepting a supposedly “limited” assisted suicide law.

For example, the Netherlands now uses lethal injections to dispatch infants with disabilities and adults of any age even without physical illness or consent. Belgium has done planned organ donation after euthanasia by lethal injection with the Ethics Committee of Eurotransplant even formulating recommendations for organ donation after euthanasia.  And Switzerland has a booming business with assisted suicide organizations like Exit and Dignitas even though a study showed that 16% of assisted suicide deaths in Switzerland are of people who have no underlying illness.

Conclusion

As the late Richard John Neuhaus wisely said ” I believe in the slippery slope the same way I believe in the Hudson River. It’s there.”

But until we are ready to recognize the potent logic about the disastrous and unintended consequences when we legalize “just a little bit” of legalized medical killing, we may find that the slippery slope has no bottom.

Physician-assisted Suicide: Nurses in the Line of Fire

Years ago, the newly legalized Oregon physician-assisted suicide law caused much discussion at my St. Louis hospital. Some of my fellow nurses said that they supported such a law but when I asked them if they would participate, they were shocked. “No, of course, the doctor would have to do it!”, one exclaimed. Some nurses, like perhaps most people,  thought assisted suicide would only occur at a patient’s home with his or her family sitting with the patient watching the drinking of the lethal overdose.

I explained that in hospitals or hospices, would we expect the assisting doctors to be present when the patient ingested the lethal overdose, not to mention staying with the patient and family during the time it could take for the patient to die? My colleague agreed that nurses, not doctors, would probably bear the brunt of the “dirty work” of assisted suicide.

Back in 2000 and three years after Oregon legalized physician-assisted suicide, I saw an article from Nursing Spectrum magazine titled “Assisted Suicide: What Role for Nurses?” that stated:

Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients,” says Pam Matthews, RN, BSN, administrator for Evergreen Hospice, Albany, OR, “but in reality, nurses are usually the ones in the line of fire…. Much of nurses’ roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.” (emphasis added)

How many nurses are really willing to “advocate” for physician-assisted suicide? The article states:

“Before PAS became law, it was publicly debated, and we performed surveys of our hospice teams’ feelings on the issue,” Matthews says. “We found that most nurses felt strongly that patients should have the choice of PAS, although most said they would not participate in the event.” (emphasis added)

Recently, I spoke to a nurse in Washington State who is against physician-assisted suicide law about nurses’ experience with physician-assisted suicide in her state. She referred me to a 2014 study in the Journal of Pain and Symptom Management titled “Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death”. (click on link and click PDF to read the full text)

While 21% of the Washington hospices in this study, mostly religiously-affiliated, refused any involvement in assisted suicide, this study sadly confirms the how legalization has affected both hospices’ and nurses’ role in assisted suicide.

Here are some excerpts:

First of all, the study notes that:

(T)he primary patient rights organization that facilitates arrangements for physician-assisted death, Compassion & Choices, refers terminally ill patients to hospice programs as a first resort for end-of-life caregiving. (emphasis added)
And admits that:
The authorizing legal statutes in both states (Oregon and Washington) make no reference to the experience of severe pain or intolerable suffering as an indication for a patient to make a request for physician-assisted death but rely entirely on the entitlement due a patient in respect of their personal dignity. (emphasis added)
However, the study rationalizes the upwards of 90% of physician-assisted suicide victims being enrolled in hospice:

The designation of a ‘‘physician’’ as the primary professional resource for patients allows hospice programs to maintain fidelity to the norm that ‘‘hospice neither prolongs nor hastens dying’’ (our emphasis). In short, although most patients who use the Death with Dignity rights are enrolled in hospice, hospice programs want to stress that this is a ‘‘physician-directed’’ process, not ‘‘hospice-assisted’’ death.” (emphasis added)

The study provides further dubious rationalization:

Although the phrase (“hastening death”) is descriptively accurate about what typically happens when a patient ingests the medication, describing the process in this manner appears to compromise a central hospice precept that dying or death is not to be hastened. It thus raises a broader question about an evolving hospice identity and integrity in which, in contrast to historical tradition and practice, hospice programs are willing to incorporate practices that hasten death. Insofar as several hospices in both Oregon and Washington have policies with respect to palliative sedation, in which pain relief is the primary goal even if death is hastened as a secondary consequence, it may be that some hospice programs could legitimately claim that the issue has already been resolved, and physician-assisted death is the moral equivalent for hospice of palliative sedation.” (emphasis added)

As far as allowing the hospice nurse to exercise his or her conscience rights:

In every circumstance in which personal, moral, or ethical values are cited as a basis for a caregiver to request they withdraw from being the responsible caregiver for a patient that makes a request, another staff member must be available to assure continuity of care and avoid violating the hospice value of non-abandonment.Two traditional tenets of hospice philosophy-non-abandonment and refraining from ‘‘hastening death’’-remain prevalent values but create their own complications. (emphasis added)

One obvious complication is that it may not always be possible to find another nurse willing to be involved in the assisted suicide and if not enough willing nurses can be found, this “right” to withdraw may result in workplace discrimination against such nurses or even rejection of some potential hospice nurses before employment.

The article also cites a surprising reason, denied or unmentioned in news stories, for some hospice policies restricting nurses from actually attending the assisted suicide:

This may be particularly compelling in circumstances where the patient experiences complications with the medication (e.g., when the patient aspirates the medication), and some further medical treatment is needed by the patient for death to occur. In this context, the restriction on hospice staff presence serves as a further check against physician-assisted death becoming hospice-assisted death.
(emphasis added)

In the conclusion, the study refers to a 2011 Hastings Center Report by ethicist Bruce Jennings, MA:

Jennings contends that legalized physician-assisted death presents a defining moral choice for hospice identity because ‘‘legalization(of physician-assisted death) would liberate dying people from what hospice had been teaching could be a meaningful and valuable time of life. On the other hand, a major part of that quality of living while dying that hospice champions is autonomy, respect, and dignity. How could hospice stand against that?”  (emphasis added.)

For the sake of ourselves, our patients and our profession, how can we nurses NOT make a stand against physician-assisted suicide?