My Oral Submission to the New Zealand Health Committee Regarding Physician-assisted Suicide on March 5, 2017

As a nurse and legal consultant in the USA with 47 years of experience in the most challenging areas of medicine such as critical care, oncology, burn unit and hospice, I have seen many of the most challenging cases in medicine. I also have professional and personal experience with suicidal people, including my own 30 year old daughter Marie who died using an assisted suicide technique that she found searching the internet and after a 16 year struggle with drug addiction. I have worked with many suicidal people, including some with terminal illness. To my knowledge, my daughter was the only one lost to suicide.

I have previously submitted written testimony about physician-assisted suicide and I would like to follow up with two crucial issues that I feel must be addressed.

First I will discuss how physician-assisted suicide empowers doctors, not patients. Second, I’ll share a nurse’s perspective.

1. Physician-assisted suicide empowers doctors, not patients.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of protection for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards.

However in physician-assisted suicide, unlike any other medical intervention, any licensed doctor of any experience or specialty is granted immunity from “civil or criminal liability or professional disciplinary action for participating in good faith compliance “with an assisted suicide law[1].  The doctor or doctors involved are the ones to decide whether or not the patient is eligible, not the patient.

All the doctor is required to do is fill out a prescription and state forms. The usual standards for caring for a suicidal person including  intensive management[2]  are changed in physician-assisted suicide to “If, in the opinion of the attending physician or the consulting physician, a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling.”[3] (Emphasis added). Not surprisingly, only 3.8% of people using physician-assisted suicide in Oregon were referred for psychiatric evaluation in 2016[4].

This is dangerous medical discrimination in treatment standards for suicidal people.

In addition, since the doctor is not required to be present or examine the patient after death, any complications or other problems must be self-reported by the doctor to the state. Even the death certificate must be falsified to report the death as from natural causes rather than the lethal overdose.[5]  This violates the standards set by the Centers for Disease Control which require accuracy because, among other issues, “The death certificate is the source for State and national mortality and is used to determine which medical conditions receive research and development funding, to set public health goals, and to measure health status at local, State, national, and international levels.”[6]

The  immunity protections and the secrecy of even the minimal self-reporting standards in US assisted suicide laws eliminates the possibility of future potential lawsuits or prosecutions and keeps the myth of “no problems, no abuses” alive.

2. A Nurse’s Perspective

The dangers of the legalization of physician-assisted suicide are especially acute for us nurses. Unlike doctors, we nurses cannot refuse to care for a patient in a situation like assisted suicide unless another willing nurse can be found which can be impossible. If we do refuse, that is considered abandonment and cause for discipline and even termination. And we are necessarily involved when the assisted suicide act occurs in home health, hospice or health care facility even though the prescribing doctor is not required to be there.

And these deaths are not guaranteed quick, painless or even possible in some circumstances. As a new December 21, 2016 Kaiser Health News article revealed, doctors are trying new drugs because the old drugs are becoming too expensive and taking too long to work. Unfortunately, some new alternative drugs have “turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain”.[7]

Like most nurses, I have worked over the years with a variety of doctors who are at various points on the spectrum on competency and integrity.

Years ago, I was threatened with termination after I refused to increase a morphine drip “until he stops breathing” on a man who would not stop breathing after his ventilator was removed and no other nurse was available to take over the patient. The patient was presumed to have had a stroke when he did not wake up from sedation after 24 hours. I reported the situation up the chain of command at my hospital but no one supported me. I loved my profession and at that time, I was the sole support of three young children but I knew that nothing was worth betraying the trust of my patients.

I escaped termination that time but I refused to back down. Soon after, every nurse on a medical division of nurses refused to give an overdose to a patient and told the doctor that he would have to give it himself. The doctor cancelled the order.

Legalizing physician-assisted suicide can force nurses like us to leave healthcare, leaving no reliable safe haven for people who don’t want to end their lives.

Does anyone really want to entrust our healthcare system just to people who are comfortable with ending lives? I don’t.

FOOTNOTES

[1] “Oregon Revised Statute. 127.885s.01. Online at: https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

2 “Evaluation and Treatment of the Suicidal Patient” . American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

3 “Evaluation and Treatment of the Suicidal Patient” .American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

4 “Oregon Death with Dignity Act Date Summary” .Online at https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf

5 : “Washington state “Death with Dignity Act”. Online at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct/DeathCertificateInstructions

6 CDC Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting”. CDC. Online at https://www.cdc.gov/nchs/data/misc/hb_me.pdf

7 “Docs  In Northwest Tweak Aid-In-Dying Drugs To Prevent Prolonged Deaths” by JoNel Aleccia. Kaiser Health News. February 21, 2017. Online at http://khn.org/news/docs-in-northwest-tweak-aid-in-dying-drugs-to-prevent-prolonged-deaths/

Reports of My Death are Greatly Exaggerated-Again

In 2009, I began to get emails and calls from people who had read reports about the death of Nancy Valko from physician-assisted suicide in Oregon. Even our ages were almost the same.

After assuring people that I was not only very much alive but just as committed to opposing assisted suicide, I did a google search and found the obituary and information about another Nancy Valko who had planned and publicized a kind of party around her suicide.

Now almost 8 years later, I received an email from a friend who just read an article about the assisted suicide of Nancy Valko. I thought she had just run across an old article but she sent me the article “I will be dancing once again-Nancy Valko’s controversial final act brought her life, but not her legacy, to an end” from the current April 2017 issue of Woman’s Day, a well-known and long-running women’s magazine often displayed at grocery store checkout lines.

The article painted quite a  picture that was”carefully planned” by this Nancy : sunlight streaming through fir trees, bouquets of spring flowers, a manicured backyard and a friend playing classical music on a harp.

She was surrounded by her children and her former husband when she swallowed the lethal mixture. According to the article, her family continued to talk to her for the last two hours of her life telling her they loved her and praising her as an amazing mom.

The article notes that this Nancy was following a healthy lifestyle before she started have mobility problems and was eventually diagnosed with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. In November 2008, she decided to move to Oregon to use its physician-assisted suicide law. The article states that she wanted to be around for her kids but she “knew that dying from ALS could be brutal-in late stages, sufferers typically remain mentally alert but lose the ability to move, swallow or breathe on their own.” She would eventually have to rely on family, friends or others.

By March when this Nancy started having more trouble talking and thus might not be able to swallow the drugs, she saw a doctor who determined that she was within 6 months of dying and able to swallow the lethal dose by herself. The article notes that “nearly everyone” in Nancy’s circle stood behind her decision to die and friends and family in other states “sent bubbles toward the sky” on April 19, 2009.

After Nancy’s assisted suicide, her older sister Marnie “was inspired” to fight for an assisted suicide law in Vermont that was signed into law in 2013.

The article ends with:

“Nancy wanted her life to matter,” says Marnie. “Because this legislation passed, it still does.”

A short section “The Case Against ‘Death with Dignity'” cites the American Medical Association’s opposition against assisted suicide but says that “it will revisit the issue”. The section also mentions that “some religions” like Catholicism and disability groups like Not Dead Yet also oppose assisted suicide but cite a recent Gallup poll showing that only around 40% of Americans now feel assisted suicide is “morally wrong”.

CONCLUSION

Why did Woman’s Day tell this story again after 8 years? It seems like a desperate attempt to show an assisted suicide as a happy party with friends and family celebrating while a loved one takes her life before, as the article states, there is a “loss of autonomy and dignity”.

I see this Nancy’s death as a sad tragedy of despair.

As a former hospice nurse myself, I felt privileged to be able to help people with life-threatening illnesses and their families achieve a peaceful and comfortable natural death. The traditional hospice philosophy of neither hastening nor prolonging dying allows a natural and truly dignified death that benefits both the patient and his or her family. Personally, these patients and their families inspired me with their devotion and love for each other. People should never feel that they are a burden to themselves, their families or to society.

Physician-assisted suicide is never the answer and I would never inflict it on my family and friends.

What You Need to Know Now That the District of Columbia Has Become the Seventh Jurisdiction in US to Legalize Assisted Suicide

Despite emails and other efforts to encourage the US Congress to exercise its legal authority to stop the Washington D.C. assisted suicide law, the expected congressional action was not completed within the 30 legislative days required.

However, there may be hope on the horizon according to a  February 18, 2017 Washington Times article that said “Congress can still neutralize the Death with Dignity Act by cutting off its funding through the appropriations process.”

What went wrong with the process of nullifying the assisted suicide law in time?  No one seems to know.

But one thing we do know is that Compassion and Choices, the well-funded assisted suicide activist organization, will continue its relentless fight over and over again in every state without an assisted suicide law and in the courts to make assisted suicide legal throughout the US. But even that is not the final goal.

Ominously, we are now seeing assisted suicide leaders like influential lawyer Kathryn Tucker even criticizing the so-called “safeguards” in assisted suicide laws  as “burdens and restrictions”. She now argues that  assisted suicide should be “normalized within the practice of medicine”.

WHAT WE NEED TO KNOW AND DO NOW

We cannot just depend on lobbying our politicians and legislatures to fight assisted suicide only when such bills are introduced in states legislatures or as public initiative votes. We must constantly reinforce our message that every life is worthy of respect and care, not medical termination.

But we must also understand that the assisted suicide/euthanasia movement has had decades of experience in shaping and publicizing its lethal message through carefully crafted steps to convince the public that physician-assisted suicide must be legalized to prevent or end suffering.

As I wrote in my 2013 article “Then and Now: The Descent of Ethics”, the assisted suicide/euthanasia movement has been very busy in the last several decades. I included a short history of the movement that people should know:

The 1970s brought the invention of “living wills” and the Euthanasia Society of America changed its name to the Society for the Right to Die. The so-called “right to die” movement received a real boost when the parents of Karen Quinlan, a 21-year-old woman considered “vegetative” after a probable drug overdose, “won” the right to remove her ventilator with the support of many prominent Catholic theologians. Karen continued to live 10 more years with a feeding tube, much to the surprise and dismay of some ethicists. Shortly after the Quinlan case, California passed the first “living will” law.

Originally, “living wills” only covered refusal of life-sustaining treatment for imminently dying people. There was some suspicion about this allegedly innocuous document and, here in Missouri, “living will” legislation only passed when “right to die” advocates agreed to a provision exempting food and water from the kinds of treatment to be refused.

But, it wasn’t long before the parents of Missouri’s Nancy Cruzan, who was also said to be in a “vegetative” state, “won” the right to withdraw her feeding tube despite her not being terminally ill or even having a “living will.” The case was appealed to the US Supreme Court, which upheld Missouri law requiring “clear and convincing evidence” that Nancy Cruzan would want her feeding tube removed, but, in the end, a local judge allowed the feeding tube to be removed. Shortly after Nancy’s slow death from dehydration, Senators John Danforth and Patrick Moynihan proposed the Patient Self-Determination Act (never voted upon but became law under budget reconciliation), which required all institutions to offer all patients information on “living wills” and other advance directives. Since then, such directives evolved to include not only the so-called “vegetative” state and feeding tubes but virtually any other condition a person specifies as worse than death and any medical care considered life-sustaining when that person is deemed unable to communicate.

But this “choice” is becoming an illusion. In 1999, Texas became the first state to pass a medical futility law to allow doctors and/or medical committees to  override advance directives and patient or family decisions to continue life-sustaining treatment on the basis that doctors and/or medical committees know best when to stop treatment.

In the 1990s, Jack Kevorkian went public with his self-built “suicide machines”  and the “right to die” debate took yet another direction. By the end of the decade, Oregon became the first state to allow physician-assisted suicide. At first, the law was portrayed as necessary for terminally ill people to die with allegedly unrelievable pain. Within a short time, though, it was reported that “according to their physicians, the patients requested assistance with suicide because of concern about loss of autonomy and control of bodily functions, not because of concern about inadequate control of pain or financial loss.”

Other states eventually followed Oregon but efforts to pass assisted suicide laws often failed in other states so Compassion and Choices (the former Hemlock Society) promoted palliative/terminal sedation and VSED (voluntary stopping of eating and drinking) as a legal alternative to assisted suicide in states without such laws.

Compassion and Choices has found much success in working with sympathetic news outlets and pollsters to encourage the public and even medical professionals to support assisted suicide.

Even TV’s popular Dr. Phil McGraw hosted a 2012 segment featuring a Canadian woman who wanted her adult disabled children to die by lethal injection. Ironically, the mother, along with former Kevorkian lawyer Geoffrey Feiger, argued that removing their feeding tubes was an “inhumane” way to end the lives of the adult children. Tragically, when the studio audience was polled, 90% were in favor of lethal injections for the disabled adults. Disability organizations protested after the show, writing that “By conveying social acceptance and approval of active euthanasia of individuals with disabilities by their family members, the segment threatens their very lives”.

Exploiting the natural fear of suffering most people have has also led to a growing acceptance of the premise that it can even be noble to choose death instead of becoming a burden on family members or a drain on society. It is up to us to combat this attitude of despair by  not only educating ourselves and others about the facts and dangers of assisted suicide but also by offering hope and support to those of us most at risk.