A Surprise in Maryland, Compassion and Choices is Not Happy

Last month, I joined many other people fighting the fourth attempt in Maryland  to legalize physician-assisted suicide. At that time, the Maryland “End of Life Options” bill  was in a Maryland house committee. We all were disappointed when the bill was later passed and went to the senate committee.

But then things got interesting.

According to a 3/22/19 Baltimore Sun article “Medically assisted suicide bill advances in Maryland, but with changes that frustrate advocates” , committee chairman Senator Bobby Zirkin  said the bill as introduced to the committee was “flawed to its core”, even though he admitted he didn’t want to stand in the way of terminally ill people who wanted assisted suicide.

According to the article, the senate committee members “spent more than 7 hours hashing out dozens of proposed amendments to the bill” before agreeing to vote it out to the full senate with these changes requiring patients:

“Be at least 21 years old, a change from 18 in the original bill.

Have their diagnosis confirmed by their attending physician and a consulting physician. Those two physicians cannot be in the same practice or have a financial relationship

Ask for the prescription three times, including once in private with a doctor and with witnesses.

Undergo a mental health evaluation.”

The senators also set a stricter definition of who could qualify for assisted suicide and removed the prescribing doctors’ immunity “from civil lawsuits related to prescribing the fatal drugs.”

The revised version now heads to the full Maryland Senate for a final vote, probably this week.

Compassion and Choices CEO Kim Callinan says  “The bill in its current form would create many needless hoops and roadblocks for dying patients and put doctors at risk for baseless lawsuits” and make assisted suicide “nearly impossible for patients to access.”

Compassion and Choices is urging the Maryland senate to pass a “more patient-friendly bill” that won’t erect “barrier after barrier for dying patients” including “a mandatory psychological evaluation, numerous additional witness requirements” and “preventing them (family members) from enjoying the precious time they have left with their loved one.”

However, the Maryland Against Physician Assisted Suicide coalition correctly notes that even with the revisions, the bill  “does not offer sufficient protection of those in our system of health care who are most vulnerable to abuse” and should not be passed.

CONCLUSION

Ironically and just last year, I wrote about the impatient calls to expand medically assisted suicide from advocates like influential lawyer Thaddeus Pope argued that the some so-called “legal safeguards” like age limits, the definition of terminal illness and the ability to ingest the lethal overdose were actually “burdensome obstacles”.

Trying to educate the public and especially legislators about the dangers of legalized assisted suicide is a daunting task, especially against extremely well-funded groups like Compassion and Choices and a mostly supportive mainstream media.

But the unexpected surprise in the progression of the Maryland assisted suicide bill and the new opposition by the Connecticut Division of Criminal Justice to the death certificate falsification in that state’s proposed assisted suicide bill shows how cracks are beginning to grow in the false narrative that legalizing assisted suicide is perfectly safe and harmless to society.

 

 

 

 

Is the American Nurses Association Ready to Drop Opposition to Assisted Suicide?

In 2013, the American Nurses Association (ANA) stated this : “The American Nurses Association (ANA) prohibits nurses’ participation in assisted suicide and euthanasia because these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements (ANA, 2001).” (Emphasis added)

But now in 2019, the ANA is proposing a new position paper to change this. Not only is the ANA attempting to change its previously used term assisted suicide to “aid in dying” (the approved term of Compassion and Choices), but also the Code of Ethics itself.

The draft position paper is titled “The Nurse’s Role When a Patient Requests Aid in Dying” There is an online form for public comments which must be submitted before April 8, 2019. There is no requirement that you have to be a member of ANA or even a nurse to make a public comment. The ANA can also be contacted by email at customerservice@ana.org or by phone at 1-800-284-2378.

There is much in the draft position that I find shocking both as a nurse and a patient. For example, the draft position begins:

“It is the shared responsibility of professional nursing organizations to speak for nurses collectively in shaping health care and to promulgate change for the improvement of health and health care” and “(t)he nurse should remain non-judgmental when discussing end of life options with patients, who are exploring AID” (a.k.a. physician-assisted suicide). (Emphasis added)

This statement flies in the face of the way nurses have traditionally cared for patients considering suicide, whether they are terminally ill or not. Unfortunately, this follows the lead of several medical, nursing and hospice/palliative care organizations that have changed their positions on assisted suicide to “neutrality” or even support.

The ANA draft also states, “The nurse has the right to conscientiously object to being involved in the AID process” but “Nurses are obliged to provide for patient safety, to avoid patient abandonment, and to withdraw only when assured that nursing care is available to the patient.”  (Emphasis added)

The draft suggests that such nurses can “ensure the ongoing care of the patient considering AID by identifying nurse colleagues willing to provide care.”

This is forced cooperation and does nothing to protect nurses’ conscience rights. Such a position would impact not only current nurses but also potential future nurses who have strong ethical principles against helping patients kill themselves.  Many nurses already are worried about the impact of other ANA positions, such as the 2017 “Nutrition and Hydration at the End of Life”  which states, “People with decision-making capacity have the right to stop eating and drinking as a means of hastening death. (Emphasis added)

In a section titled Social Justice, the draft position states:

“Nurses must continually emphasize the values of respect, fairness, and caring,”(ANA, 2015a, p.35). Statutes that allow AID are not present in every state, which presents geographic inequity in terms of access. Additionally, AID medication is expensive, which presents an additional barrier to access for those who cannot afford it, even if they live in a jurisdiction or state where this option is legal. Nurses act to reduce or eliminate disparities. While this is most commonly associated with health promotion and disease prevention, the current AID landscape raises questions of fairness which require ethical reflection.” (Emphasis added)

I find it outrageous to encourage nurses to become social justice warriors  fighting for more access to assisted suicide and cheaper lethal overdoses. And one recommendation in the ANA draft position eliminates all doubt about a radical departure from the 2013 Code of Ethics prohibition of  “participation in assisted suicide”: “Nursing research is needed to provide an evidence base for AID.”

NON-JUDGMENTALISM: IS IT REALLY IN OUR PATIENTS’ BEST INTERESTS?

When I first met “Frank” (not his real name) many years ago, I was puzzled. Frank was a terminally ill man who had just been admitted to my oncology unit for control of his “unbearable pain”. However, Frank didn’t seem to be in any physical pain.

I talked privately to Frank’s wife, Joan, who tearfully confided that Frank was cleaning his gun collection when he asked her if she would still be able to live in their home if, in his words, “anything happened”.

Joan said she knew he was talking about shooting himself and even though she was horrified, she said she thought the right thing to say was: “I will support any decision you make”. However, she later panicked and called the doctor to say that Frank was having unbearable pain. The doctor agreed to admit him and ordered morphine to be given as soon as he arrived.

When I suggested to Joan that Frank’s real question might not be about their home but rather about whether his lingering dying might be too hard on them both, she was stunned. This had never occurred to her. She said she loved Frank and she wanted to care for him until the end. I told her that she and her husband needed to talk.

Frank and Joan then finally had a long overdue open discussion about their sorrow and fears. I told the doctor what I discovered and when I last saw Frank and Joan later that day, they were holding hands and smiling as they left the hospital.

I learned that Frank died peacefully — and naturally — a few weeks later with his wife at his side.

I believe that this situation shows how being “non-judgmental” can itself be lethal. Unfortunately, the public as well as we healthcare professionals are being given the message that a patient’s “right to self-determination” is the most important ethical principle.

What I did with Frank and his wife was a lot like a recent UCLA project started when California legalized physician-assisted suicide. The project showed that “most of what patients needed was to discuss their feelings about their approaching death and process their grief and sense of loss.” The project also found that “only” 25% of these patients seeking assisted suicide went on to use assisted suicide.

When someone is suicidal, it should not matter whether they are terminally ill. Instead, we should treat them with the same care and concern we would give a physically healthy suicidal person.

Anything less would be discrimination and I am telling this to the ANA.

 

 

 

 

Dying Well?

I discovered that former San Francisco Chronicle reporter Katy Butler is now publishing yet another book on dying well (her first book “Knocking on Heaven’s Door” was a best seller) when I read her lead essay in the February 8, 2019 Wall Street Journal article titled “Preparing for a Good End of Life”.

However, I recognized her name from reading her 2014 interview with Compassion and Choices , the well-funded former Hemlock Society that promotes physician-assisted suicide .

In that interview, she urged people to back the 2014 “Better Care. Lower Cost Act” sponsored by Senator Ron Wyden of Oregon “to improve appropriate medical support for people with chronic illness” and to “advocate to reduce payments to doctors who perform futile ‘Hail Mary’ surgeries, tests and treatments near the end of life”. Ms Butler also added that “we have an epidemic of unnecessary suffering at the end of life, and what’s more, it’s expensive!” (All emphasis added)

In that interview, Ms. Butler also talked about how her mother was “exhausted from nonstop caregiving” and how they fought doctors to have her father’s pacemaker turned off after he developed dementia, couldn’t walk to the neighborhood pool, became deaf and “too blind to read the New York Times-his last remaining pleasure”. Ms. Butler said she was glad to learn “from Judith Schwartz at Compassion and Choices that we each have a constitutional right to refuse any medical treatment or ask for its withdrawal.” (Compassion and Choices also promotes VSED, the voluntary stopping of eating and drinking, as well as terminal sedation as two legal options to hasten death in states without physician-assisted suicide laws.)

SCARE TACTICS?

In the Wall Street Journal article, Ms. Butler flatly states-without a source-that “Pain is a major barrier to a peaceful death, and nearly half of dying Americans suffer from uncontrolled pain.” (Emphasis added)

However, in an article “Pain Control at the End of Life” , June Dahl, PhD, a professor of pharmacology at the University of Wisconsin at Madison, and a founder of the American Alliance of Cancer Pain Initiatives states that:

“Thanks to recent advances in pain treatments, roughly 90 to 95 percent of all dying patients should be able to experience substantial relief from pain.”

Although Ms. Butler doesn’t mention physician-assisted suicide specifically, she does strongly advocate taking control of how we die, especially as we get older, because “Advanced medicine is replete with treatments (ventilator, dialysis, defibrillators, feeding tubes, to name a few) that postpone death and prolong misery without restoring health“. (Emphasis added)

She writes that “The best way to achieve a peaceful death is by planning ahead and enlisting the help of loved ones.”

In the Wall Street Journal article, she approvingly writes:

“When Liz Salmi’s mentor lay unconscious on a ventilator in a dark, windowless ICU room, attended by a cacophony of hisses and electronic bloops, she and other close friends lobbied for a better setup. All monitors but one were silenced, a doctor removed the breathing tube, and nurses and aides gurneyed her dying friend quickly into the ICU’s “best room”—a sunny spot, with windows opening to the outdoors.” (Emphasis added)

In this instance, note that the friends-apparently not the family or a “living will”- lobbied  the doctor to remove (not try to wean off) the ventilator. I am not surprised since I have personally heard some doctors say that, if in doubt, it might be legally safer not to treat rather than treat a patient because of the risk of a future lawsuit.

These kinds of articles and books are being used as “end-of-life education” for both the public and professionals. Can this be dangerous?

CAN WHAT YOU SAY POTENTIALLY BE USED AGAINST YOU?

My own mother often told me “I never want to be a burden on you children”. Then she developed Alzheimer’s and a terminal thyroid cancer. I was asked if the family wanted her fed if she got worse. “Of course, if she needs it”, I responded. My mother should die from her condition, not from starvation and dehydration. I  never told the doctors her comment about not wanting to be a burden because she wasn’t a burden. Mom died shortly after she went to a nursing home for safety reasons and we spoon-fed her at the end. She had no pain, thanks to a short course of radiation and chemo that she tolerated. My last memory of my mother was her smiling and enjoying the attention of her family before she died in her sleep.

In 1990, 2 years after my mother’s death, Nancy Cruzan died after 12 long days without a feeding tube, even after the US Supreme Court ruled that Missouri could require “clear and convincing evidence” that she would not want a feeding tube if she was in a “vegetative state.” At the time of the decision, there was no evidence of this.

However, Nancy’s parents later returned to a Missouri court with some of Nancy’s former co-workers who testified that they recalled her saying she would never want to live ‘like a vegetable’.

Three years later in a letter published in the Journal of the American Medical Association by Dr. Ezekiel Emanuel, one of the future architects of Obamacare, acknowledged that this “proof” of Nancy Cruzan’s alleged statement rested only on “fairly vague and insubstantial comments to other people”.

However and most disturbing, he also wrote that:

“…increasingly it will be our collective determination as to what lives are worth living that will decide how incompetent patients are treated. We need to begin to articulate and justify these collective determinations.” (Emphasis added.) Source: The American Journal of Medicine January 1993 Volume 94 p. 115

CONCLUSION

As a hospice and critical care nurse, I strove to make sure dying patients and their families had a good death, either in a hospital or other institution or at home.

Personally, my husband and I also made a careful durable power of attorney document that only designates each other as our decision maker with the right to make decisions about our care rather than signing a “living will” to refuse potential future treatments or set possible future conditions like dementia where we would want treatment stopped or withheld. Instead, we want all current options, risks and benefits of treatment fully explained to the decision maker based on the current condition.

I also encourage people to check out information sites like the Healthcare Advocacy and Leadership organization (I am an advisor) and magazines like “Informed-A Guide for Critical Medical Decisions”  which has sections explaining ventilators, CPR (cardiopulmonary resuscitation), feeding tubes, use and misuse of opioids and sedatives as well as other end of life considerations.

Death is a journey we all will take someday. Especially in today’s world, we should protect ourselves and our loved ones by trying to ensure a truly good death.

The Most Important Thing I Told a Maryland Legislator

I just recently returned from a trip to Maryland where Jack Ames of Defend Life asked me to speak to various groups, hopefully including legislators, about opposing a current physician-assisted suicide bill in the Maryland legislature. The Maryland “End of Life Options” bill was, as usual, based on the first physician-assisted suicide law passed in Oregon with a few additional loopholes.

I was able to speak to many groups during my trip but unfortunately, I could not be scheduled to speak at the legislature’s committee meeting where people from both sides of the issue were able to speak.

However, one of the Defend Life people and I went to the statehouse to see if we could get in to talk to some legislators personally. We were only able to get to speak to one legislator and he was considered to be on the side of passing such a bill. We were told we only had 5 minutes to talk to him.

We were there for much longer.

We talked about our personal experiences, especially about my 30 year old, physically healthy daughter Marie who killed herself after a 16-year struggle with substance abuse using an assisted suicide technique she learned after reading pro-assisted suicide advocate Derek Humphry’s book Final Exit.

I told him about Marie’s death which was horrific instead of peaceful and that was like an atom bomb dropped on our family. I talked about the reality of suicide contagion which led two people close to Marie became suicidal but who were able to be saved. We talked about the increasing epidemic of suicides we have now  and how seductive is the message that killing ourselves can solve problems like not wanting to be a burden on our families. That is what my daughter told me and one of the biggest reasons given by people who have resorted to physician-assisted suicide.

I also told him about at least six problems with physician-assisted suicide laws that most legislators-and the public-don’t know but that are inherent in physician-assisted laws. These include such problems as the total immunity for doctors and the secrecy involved, mandatory falsification of physician-assisted suicide death certificates and the obvious medical discrimination between treating suicidal people who are physically healthy and suicidal people who are considered terminally ill and seeking physician-assisted suicide.

I also told him about my experiences as a nurse with suicidal people-some of whom were terminally ill-and how (except for my daughter) they all changed their minds with listening, support and referral to a mental health specialist. I also told him about a UCLA project started when California legalized physician-assisted suicide. The project offered an intensive intake process for patient requesting physician-assisted suicide conducted by trained psychotherapists and social workers instead of physicians and offering help and support for any needs the patient might have. Not only did the project show that “most of what patients needed was to discuss their feelings about their approaching death and process their grief and sense of loss”, but also that “only” 25% of patients went on to commit physician-assisted suicide.

When you combine this with the fact that an admitted 1/3 of terminally ill Oregon patients who obtain the lethal overdose for assisted suicide never take it and with no follow-up as to whether the diagnosis was wrong, people changed their minds or even what happened to the dangerous lethal medication in the home etc., it is obvious that lethal mistakes are being made.

THE MOST IMPORTANT THING I TOLD THE LEGISLATOR

However, what seemed to be the most important point that stunned the legislator was telling him that if he voted for the physician-assisted suicide bill, he would have to personally shoulder the responsibility for the lives subsequently lost that obviously could have been saved.

I told him that like other ethical medical professionals, my most profound fear was harming or worst of all killing a patient, however inadvertently. I told him that despite my decades of nursing, I always knew I would have to leave my profession if such a tragedy happened because I would be devastated and lose my confidence in my abilities.

I told him that now with the facts we gave him, it was up to him to vote responsibly and hopefully share our information with others.

CONCLUSION

Most people assume that legislators are always lawyers who carefully read and understand legislation before voting. Wrong!

And most people don’t understand that most legislators rely on lobbyists for their information. Well-funded groups like Compassion and Choices are able to afford lobbyists, activists, access to sympathetic media outlets, etc. that promote their physician-assisted suicide agenda while other groups like pro-life groups and disability advocates have to rely on passionate volunteers.

Years ago, a legislator here in my home state of Missouri said he felt his constituents were against a certain piece of legislation. Why? Because he said he had received 4 letters!

This was before the internet has made it easier to contact our representatives but this shows how powerful our individual efforts can be.

We need everyone to speak out and speak up, especially when it comes to dangerous legislative bills like physician-assisted suicide.

 

 

 

Roe v. Wade’s Disastrous Impact on Medical Ethics

This was published in the National Right to Life News January 2019 issue “The Consequences of Roe v Wade” on page 8.

Most people volunteer for the pro-life movement. I consider myself a draftee. For me, there was no “choice.” I became a conscript because of personal and professional experiences that followed in the wake of the Roe v Wade decision.

I was a young intensive care unit nurse when the Roe v. Wade decision came down in 1973. Like most people I knew, I was shocked when abortion was legalized. As a medical professional, I couldn’t imagine good doctors and nurses condoning — much less participating in — such a brutal act.

However, I quickly found that my medical colleagues were split on the issue. In a foreshadowing of what was to come, those supporting what was then said to be “only” early abortions were the most vocal and insistent.. Our formerly cohesive unit began to fray.

However, I was professionally offended by the pro-life argument that legalizing abortion would lead to the legalization of infanticide and euthanasia. It was one thing to deny the truth with an early and unobserved unborn baby but it was quite another to imagine any doctor or nurse looking a born human being in the eye and killing him or her.

How wrong I was!

INFANTICIDE AND MEDICAL DISCRIMINATION AGAINST PEOPLE WITH DISABILITIES

My eyes were opened with the 1982 Baby Doe case in Indiana. Baby Doe was a newborn baby boy with an easily correctable hole between his esophagus (food pipe) and trachea (windpipe). He was denied this lifesaving surgery by his parents and a judge because he also had Down Syndrome. He also was not fed. Six days later, Baby Doe starved and dehydrated to death while his case was being appealed to the Supreme Court.

When we read the story, my husband and I wanted to adopt Baby Doe. But all offers of adoption were refused.

When our daughter Karen was born a few months after Baby Doe, we were stunned that she had both Down Syndrome and a severe heart defect but I was determined that she would not become another Baby Doe.

The cardiologist told us that Karen had an 80-90% chance of survival with one open-heart surgery by age 6 months. He also gave us a “choice”- to let Karen die. I was outraged that he could even consider not treating my daughter like any other baby with the same heart defect.

Even worse, when my daughter was hospitalized with pneumonia at 4 months, I was tipped off that my trusted pediatrician had made her a “do not resuscitate” without my knowledge or consent because “Nancy is too emotionally involved with that retarded baby”. I then realized that “choice” was just an empty slogan that had infected medical ethics.

Although Karen survived that incident, she unfortunately died at age 5 1/2 months just before her scheduled surgery.

At last I finally joined the disability rights and the pro-life movements.

THE “RIGHT TO DIE” MOVEMENT

A few years after Karen, I was shocked by the so-called “right to die” movement that pushed “living wills” to refuse even food and water by tube if or when a person became incapacitated. I became involved in both the Nancy Cruzan and Terri Schiavo cases.

Both involved seriously brain-injured, non-dying young women declared “vegetative”, a dehumanizing term invented in 1972. I wrote an op-ed for my local paper predicting that the potential pool of victims would expand if death by starvation and dehydration was allowed.

I was thinking about my own mother who had Alzheimer’s and cancer and indeed I was asked at one point if our family was going to feed her. I replied that my mother would die naturally from her condition, not starvation and dehydration.

How far we have descended! Now,  prominent doctors and the American Nurses Association are promoting what Compassion and Choices calls voluntary stopping of eating and drinking by mouth (VSED) as a legal option to  “speed up dying” for competent people with serious illnesses. “Living wills” to prevent even spoon feeding for people with dementia are also being developed.

PHYSICIAN-ASSISTED SUICIDE

The “right to die” movement ultimately did expand into the Compassion and Choices organization, the well-funded former Hemlock Society that promotes physician-assisted suicide by lethal overdose. In the late 1990s, Oregon became the first state to legalize assisted suicide. Now a handful of states and the District of Columbia have followed Oregon but the relentless effort to legalize physician-assisted suicide continues in the other US states.

Over the years, I had cared for many suicidal people and I saw the seductive effect of people like Jack Kevorkian, the infamous “Dr. Death” on them. As a nurse, I knew how dangerous it was to portray suicide as a “solution” to many at-risk people.

But it became personal when my 30 year old daughter Marie killed herself using an assisted suicide technique that she learned reading the pro-assisted suicide book “Final Exit”. My Marie had struggled with drug addiction for 16 years and despite our best efforts and those of her therapists, she finally succumbed to despair. She was the only suicidal person I ever lost.

I was not surprised when two people close to Marie became suicidal after her death. Fortunately, they were saved.

Suicide contagion is not a figment of someone’s imagination but a real phenomenon. It is no coincidence that the US suicide rate has skyrocketed since Oregon first legalized physician-assisted suicide.

EUTHANASIA

I also discovered that it’s only a short step from “I wouldn’t want to live like that” for assisted suicide to “No one should have to live like that” for euthanasia.

In 2003, Dr. Lloyd Thompson, then head of the Vermont Medical Society, escaped prosecution for intentionally giving a paralyzing, “life ending drug” to an elderly woman with terminal cancer whose breathing machine had been removed. The family had opposed prosecuting the doctor.

 Ironically and around the same time, I was threatened with the loss of my job after I refused to increase a morphine drip “until he stops breathing” on an older man who did not stop breathing as expected after his ventilator was removed. 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 escaped termination that time but I refused to back down.

An autopsy later showed that the man had no lethal condition or brain injury.

CONCLUSION

As the late Fr. 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 and unless we are ready to recognize what we unlock when we legalize “just a little bit” of medical killing, we may find that the slippery slope has no bottom and that no one is safe.

And I saw it all start with the Roe v Wade decision legalizing abortion.

Physician-Assisted Suicide and the Fight for the Soul of Healthcare

Despite the US Supreme Court’s unanimous rejection of a constitutional right to physician-assisted suicide in the 1997 Vacco v. Quill decision , the well-funded   pro-assisted suicide organizations like the Hemlock Society (now called Compassion and Choices) remained undeterred in their efforts to legalize assisted suicide throughout the US.

Along with its efforts to pass physician-assisted suicide laws, Compassion and Choices also focused on changing the health care system itself by influencing health care professionals and especially their organizations.

Thus, Oregon became the first state to pass a physician-assisted suicide law (by voter referendum), but only after the Oregon Medical Association changed its position from opposition to neutrality and despite the American Medical Association’s long-standing opposition to physician-assisted suicide.

However, only a few other states eventually did legalize assisted suicide over the next 20 years either by legislation or voter referendum while most states rejected physician-assisted suicide, even after almost yearly efforts in legislatures and overwhelmingly supportive mainstream media coverage.

But now Compassion and Choices is touting  that “(a) growing number of national and state medical organizations have endorsed or adopted a neutral position regarding medical aid in dying (physician-assisted suicide) as an end-of-life option for mentally capable, terminally ill adults.” (Emphasis added)

For now at least, the American Medical Association (AMA) itself continues to oppose physician-assisted suicide  despite strong pressure from groups like American Association of Family Physicians to take a neutral stance. If the AMA does change its stance to neutrality, it won’t take long until groups like Compassion and Choices finally realize their goal of “integrating and normalizing medical aid in dying (aka physician-assisted suicide) suicide as an additional end-of-life option“.

Nurses are also not immune to the efforts to convince health care professionals to accept or be neutral on physician-assisted suicide. For example, a “policy dialogue” at the American Academy of Nursing’s annual conference in Washington, DC. was covered in a May 2018  article in the American Journal of Nursing titled “Assisted Suicide/Aid in Dying: What is the Nurse’s Role?” (reprinted in full by Death with Dignity). The article included this disturbing news

“In 2018, the American Nurses Association (ANA) will be updating its current position statement “Euthanasia, Assisted Suicide, and Aid in Dying”. (Emphasis added)

Ominously and just last year the ANA approved VSED (voluntary stopping of eating and drinking) stating that “people with decision making capacity have the right to stop eating and drinking as a means of hastening death.” (Emphasis added)

Not surprisingly, our government is also not immune to the aspirations of Compassion and Choices. In its “Federal Policy Agenda / 2016 & Beyond” , Compassion and Choices set the following priority:

Establish federal payment for palliative care consultations provided by trained palliative care professionals who will advocate for and support the values and choices of the patient….”

Compassion and Choices lists as one of its accomplishments that it:

Pioneered the medical model of aid in dying that helps ensure that doctors can ethically practice aid in dying in an open, legitimate and accessible way, and integrates the option into patients’ end-of-life care. The culmination of that work was the publication of clinical criteria in the Journal of Palliative Medicine in December 2015. (Emphasis added)

Now, a Compassion & Choices’ website even has a video presentation based on this article  titled  “Understand the Clinical Practice of Aid in Dying”  for doctors and other clinicians. The presentation even offers continuing medical education credits.

We may now be seeing the potential results of this agenda in the current  “The Palliative Care and Hospice Education and Training Act” that is endorsed by Compassion and Choices . The bill was passed in the US House of Representative and is currently in the Senate health committee as SB693. If passed, the bill would authorize grants and contracts to promote education, research and the development of faculty careers in hospice and palliative care. (I have already contacted my home state senator about the potential problems with this legislation.)

CONCLUSION

Several years after Oregon voted to legalize physician-assisted suicide, I began to notice a stark difference between my fellow health care colleagues who supported legalizing physician-assisted suicide and those who didn’t. Doctors and nurses who supported such laws often spoke about patients who “needed to die” even though those patients never even mentioned wanting to die. They often tried to get out of caring for or even talking to difficult patients. In contrast, those doctors and nurses who were appalled by physician-assisted suicide were the ones who patiently listened to patients and addressed their fears and hopes, treated relatives as part of the care team and actively advocated for the best care for their patients.

But with Compassion and Choices’ leaders like Barbara Coombs Lee, one of the architects of Oregon’s assisted suicide law, even arguing against strong conscience rights protections for those of us who refuse to participate, it may become impossible in the future to even find a health care professional committed to protecting the life of every patient.

All of us, both medical and lay people, must speak out against physician-assisted suicide before our health care system becomes irreparably corrupted.

Now Even Family Assisted Suicide?

Her obituary  stated that Tessa was 55 years old and the divorced mother of two adult children when she died on May 14, 2002 in San Francisco, California after a nearly four year fight with breast cancer . She had been a real estate agent and later worked as controller in her son’s company.

Her son was Gavin Newsom, who just won the race for California governor November 6, 2018.

However and just the day before, a November 5, 2018 article in The New Yorker titled “Gavin Newsom, the Next Head of the California Resistance gave a different version of Tessa’s death:

“Newsom’s sister, Hilary, said that when their mother had breast cancer, in her fifties, he was difficult to reach. ‘Gavin had trouble explaining to me how hard for him it was to be with her when she was dying, and I had trouble explaining to him how much I needed him,’ she said. ‘Back then, he seemed like the kind of guy who would never change a diaper.’

In May, 2002, his mother decided to end her life through assisted suicide. Newsom recalled, “’She left me a message, because I was too busy: ‘Hope you’re well. Next Wednesday will be the last day for me. Hope you can make it.’ I saved the cassette with the message on it, that’s how sick I am.’ He crossed his arms and jammed his hands into his armpits. ‘I have P.T.S.D., and this is bringing it all back,’ he said. ‘The night before we gave her the drugs, I cooked her dinner, hard-boiled eggs, and she told me, ‘Get out of politics.’ She was worried about the stress on me.’” (Emphasis added)

Sadly, a previous 2016 San Francisco Chronicle article entitled How Gavin Newsom’s family tragedy led to ammo-control initiative” quoted Gavin Newsom on an earlier suicide tragedy in his mother’s life:

“My grandfather committed suicide, but not before putting his daughter — my mother — and her twin against the fireplace and saying he was going to blow their brains out,” Newsom said.”(Emphasis added)

THE CRAZY HISTORY OF CALIFORNIA’S PHYSICIAN ASSISTED SUICIDE LAW

I admit I was puzzled when California governor Jerry Brown signed a new law in September, 2018   titled  “AB-282 Aiding, advising, or encouraging suicide: exemption from prosecution”. This amended the 2016 physician-assisted suicide law that “Every person who deliberately aids or advises, or encourages another to commit suicide is guilty of a felony” to “A person whose actions are compliant with the provision of the End of Life Option Act (physician-assisted suicide) shall not be prosecuted under this section.” (Emphasis added)

For many years, California was especially targeted by assisted suicide groups like Compassion and Choices, the former Hemlock Society, for the legalization of physician-assisted suicide because of its size and influence. By 2015, there had been 8 failed attempts for legalization of physician-assisted suicide.

However, the Brittany Maynard tragedy started a media frenzy around the 30-year-old newlywed with an aggressive brain tumor when she announced that  she and her family left California for Oregon to commit assisted suicide where it was legal and picked November 1, 2014 for her assisted suicide. Brittany Maynard also became a spokesperson to raise funds for Compassion and Choice’s campaign to legalize assisted suicide throughout the US. Her family continued to vigorously fight for a physician-assisted suicide law in California after her assisted suicide in Oregon.

Significantly and because of the Brittany Maynard tragedy, most mainstream media outlets have now dropped the term “physician-assisted suicide” in favor of more palatable terms like “death with dignity” and “physician aid in dying.”

Surprisingly though, another attempt to pass  the “End of Life Options Act” in California failed in the 2015 legislature-until a sudden extra and controversial legislative session was called to pass it. This new law was signed into law by Gov. Brown and took effect in June 2016.

However in May 2018 and after at least 111 assisted suicide deaths, a Superior Court judge overturned the law, ruling it unconstitutional because of  how it was improperly passed in the special legislative session.

Physician-assisted suicide was again illegal until a month later when California’s 4th District Court of Appeals granted the state’s request to reinstate physician assisted suicide while it considers the case.

Then, as I mentioned before, Gov. Brown signed the law to prevent prosecution of anyone involved in an assisted suicide, including family members.

CONCLUSION

According to Findlaw:

“If you’re not a licensed physician, then assisting someone with suicide is most definitely a crime. But in states that have enacted “right to die” or “death with dignity” laws, eligible patients may request lethal drugs and administer them on their own.” (Emphasis added)

But the reality is that very few cases of a friend or family member assisting a suicide are prosecuted and even then, the penalty is light or nonexistent.  So-called “safeguards” are useless.

There is no chance that Governor Newsom will be prosecuted or even investigated for allegedly assisting his mother’s death in 2002 (long before California legalized physician-assisted suicide). But the new California law that forbids prosecuting anyone involved in a physician-assisted suicide who “aids or advises, or encourages suicide” further reinforces the dangerous myth that assisting  suicide is a victimless and even loving act.

American Academy of Family Physicians Urges the American Medical Association to Drop Opposition to Physician-assisted Suicide

Compassion and Choices, the former Hemlock Society and now well-funded promoter of assisted suicide and other death “choices”, is celebrating the new resolution by the American Academy of Family Physicians (AAFP) to oppose the American Medical Association’s (AMA) long-standing opposition to assisted suicide.

The AFFP, the second largest component society of the AMA with over 131,000 members, just approved a new resolution adopting a position of  “engaged neutrality toward medical-aid-in-dying (aka physician-assisted suicide) as a personal end-of-life decision in the context of the physician-patient relationship.” (Emphasis added)

But as Dr. Rebecca Thoman, campaign manager for Doctors for Dignity for Compassion and Choices explained when the Massachusetts Medical Society adopted the same policy in 2017:

A “‘neutral engagement’ position is even better than a simply neutral position. It means if Massachusetts enacts a medical aid-in-dying law, the medical society will offer education and guidance to physicians who want to incorporate medical aid in dying into their practices.” (Emphasis added)

Now, yet another physician-assisted suicide bill is expected to be introduced next year in the Massachusetts legislature.

The AAFP resolution also stated that:

“By supporting the AMA’s opposition to medical aid in dying, some members feel the AAFP is telling them that they are unethical

and that

“the American Academy of Family Physicians reject(s) the use of the phrase ‘assisted suicide’ or ‘physician-assisted suicide’ in formal statements or documents and direct(s) the AAFP’s American Medical Association (AMA) delegation to promote the same in the AMA House of Delegates.” (Emphasis added)

CONCLUSION

In 1994, Oregon became the first state to pass a physician-assisted suicide law. This came after the Oregon Medical Association changed its position from opposition to neutrality. 21 years later and after multiple failed attempts, the California state legislature approved a physician-assisted suicide law after the California Medical Association changed its opposition to neutrality.

The unfortunate message sent-and received- was that if doctors themselves don’t strongly oppose physician-assisted suicide laws, why should the public?

Still, it was a surprise that in June 2018, the American Medical Association House of Delegates rejected the AMA’s Council on Ethical and Judicial Affairs (CEJA) strong report recommending that the AMA continue its long standing policy opposing physician assisted suicide. Instead the delegates “voted 314-243 to refer the matter back to the trustees for further deliberation”.

With the crucial help of a supportive media, Compassion and Choices started this momentum towards acceptance of physician-assisted suicide and other death choices like VSED (voluntary stopping of eating and drinking), terminal sedation and withdrawal of even spoon-feeding, affecting not just doctors but also nurses and other health care professionals and institutions.

In addition, Compassion and Choices also opposes conscience rights, even stating that  the new Federal Conscience and Religious Freedom Division:

“is not about freedom; it’s about denying patient autonomy. Under their proposed rules, providers are encouraged to impose their own religious beliefs on their patients and withhold vital information about treatment options from their patients — up to, and including, the option of medical aid in dying. And your federal tax dollars will be used to protect physicians who make the unconscionable decision to willfully withhold crucial information regarding their care from a patient and abandon them when they are most vulnerable.” (Emphasis added)

However, here are a few ways any of us can help turn around this dire situation:

When the most basic medical ethic of not killing patients or helping them to kill themselves can be discarded in favor of “choice” or “quality of life”,  none of us of us can afford to be neutral- or silent-on this life or death issue.

How the New “Palliative Care and Hospice Education and Training Act” Could Threaten Conscience Rights.

Two weeks ago, I wrote about the new Senate Bill 693 titled the “Palliative Care and Hospice Education and Training Act” (now referred to the Committee on Health, Education, Labor, and Pensions) and warned about the current and future involvement of Compassion and Choices (the former Hemlock Society now pushing for legalizing physician-assisted suicide throughout the US) in “end of life” education for healthcare professionals. But Compassion and Choices is not the only organization supporting practices that, until the last few decades, were universally condemned.  For example, last year the American Nurses Association took a position approving VSED (voluntary stopping of eating and drinking) to hasten death  and that those decisions “will be honored” by nurses.

In addition, this year the American Medical Association House of Delegates rejected the AMA’s Council on Ethical and Judicial Affairs (CEJA) report recommending that the AMA continue its long standing policy opposing physician assisted suicide. Instead the delegates “voted 314-243 to refer the matter back to the trustees for further deliberation”.

Unfortunately, Senate Bill 693 does not contain any requirement of conscience rights protection in allocating grants to groups proposing to expand hospice and palliative care education programs for healthcare professionals.

BIOETHICS AND CONSCIENCE RIGHTS

According to Dr. Edmund Pellegrino, writing on the origin and evolution of ethics in 1999 for the Kennedy Institute of Ethics :

“In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.”

Instead of the old Hippocratic Oath principles requiring high ethical and moral standards for doctors including prohibitions against actions such as assisting a suicide, bioethics has evolved into essentially four principles: Respect for autonomy (the patient’s right to choose or refuse treatment), Beneficence (the intent of doing good for the patient), Non-maleficence (not causing harm) and Justice (“fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation” ) which often compete in actual medical situations.

Unfortunately, the principles of the new bioethics do not address the issue of conscience, which has now become a contentious issue in bioethics.

For example at the 2018 AMA meeting where the House of Delegates voted not to accept the Committee on Ethical and Judicial Affairs report’s recommendation to continue the AMA’s opposition to physician-assisted suicide, one doctor responded:

“We feel the AMA abandoned all physicians who, through conscience beliefs, want to support patients with this in states where it’s legal,” said Lynn Parry, MD, a Colorado delegate, on behalf of the PacWest group, which includes AMA delegates from six Western states that have legalized physician aid-in-dying. “I personally think we need to protect physicians in those states and would ask for referral back.” (Emphasis added)

Dr. Ezekiel J Emanuel, MD, PhD, an influential physician who was one of the architects of Obama care and a formerly strong opponent of assisted suicide, wrote in a 2017 New England Journal of Medicine article “Physicians, Not Conscripts — Conscientious Objection in Health Care” that:

“ Conscientious  objection  still  requires  conveying  accurate  information  and  providing  timely  referrals to ensure patients receive care.

……

“Health care professionals who are unwilling to accept these limits (on conscience rights) have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession.

……

“Laws may allow physicians, nurses, pharmacists, and other health care workers to deny patients treatment or to refuse to care for particular populations, but professional medical associations should insist that doing so is unethical.” (All emphasis added)

CONCLUSION

When it comes to issues like withdrawing feeding tubes from so-called “vegetative”  patients, terminal sedation to hasten death and physician-assisted suicide, this last point from Dr. Emanuel leaves those of us physicians and nurses who refuse to kill our patients or help them kill themselves with few options to continue in our professions.

Years ago when I was threatened with firing for refusing to increase a morphine drip on a comatose man who was removed from a ventilator but still continued breathing, I was told that this was acceptable “end of life” care to “prevent pain”.  I know one nurse who was fired for refusing to give morphine every hour to a dying patient in no distress and barely breathing because the family demanded it. I’ve heard from families who were automatically offered hospice instead of rehab when their loved one was elderly and injured.

When such outrages occur even outside of formal hospice or palliative care programs and considered “normal” end of life care, ethical healthcare professionals find no recourse through their professional organizations or the law to protect their patients from premature death.

Thus when healthcare legislation like SB 693 promotes giving grants to organizations who support or might support VSED, assisted suicide, etc. to train healthcare professionals in hospice and palliative care without clear conscience rights protection, both healthcare professionals and the public are at risk of a normalized culture of premature death.

 

Beware the New “Palliative Care and Hospice Education and Training Act”

Right now, there is a Senate Bill 693 titled “The Palliative Care and Hospice Education and Training Act” to authorize more and better training in palliative and hospice care. Although a provision (SEC. 6. Clarification) was recently added to explicitly forbid federal funding for any health care furnished for the purpose of causing or assisting the death of any individual by assisted suicide, euthanasia or mercy killing, many of us have serious concerns. (The similar House Bill 1676 has already passed and sent to the Senate.)

As an RN with decades of nursing experience in hospice, oncology (cancer) and critical care, I have been involved with many end-of-life situations. I am an enthusiastic supporter of ethical palliative and hospice care which is indeed wonderful for patients of any age and their families.

Unfortunately, there is a growing trend towards calling unethical practices “palliative” or “hospice” care.

For example and just a few years ago in a Catholic hospital, I saw a nurse/friend’s life deliberately ended due to so-called palliative and hospice care labeled “comfort care.” She had recently suffered a serious brain injury and was declared hopeless after a couple of weeks. The family was strongly pushed to switch to “comfort care”.  She was taken off a ventilator, had her feeding tube removed (against her adult son’s wishes), and continued to receive the sedation medications used when she was on the ventilator, even receiving an increase in those medications when she continued to breathe on her own. Despite my friend’s son insisting that he wanted the feeding tube replaced and that he wanted to eventually care for his mother at home whatever her level of functioning was, he was told to wait until a doctor could order the feeding tube replaced. The hospital waited until he went home to sleep, transferred her to the hospice unit without his permission and she was dead by morning.

Unfortunately, similar stories have become increasingly more common since the 1970s when the Euthanasia Society of America changed its name to the Society for the Right to Die and promoted the new “living wills”. Now we have well-funded groups like Compassion and Choices (the former Hemlock Society) not only promoting physician-assisted suicide but also trying to change medical ethics from never deliberately causing or hastening death to merely a “choice” about when and how to die.

Two years ago in my blog “Is Compassion and Choices aiming to become the “Planned Parenthood” of Euthanasia?, I warned about the current and future involvement of Compassion and Choices in “end of life” education.

Here are some excerpts:

With over $22 million in 2015 net assets,  a 4 star rating from Charity Navigator, enthusiastic media coverage and a new  Federal Policy Agenda for 2016 and Beyond” , Compassion and Choices increasingly appears to be following in the 4 star, politically and media supported, $1.3 billion dollar revenue ($528 million in government taxpayer funding) steps of the Planned Parenthood Federation of America.

While Compassion and Choices claims that it just “works to improve care and expand choice at the end of life”, it also admits that “We employ  educational training programs, media outreach and online and print publications to change healthcare practice, inform policy-makers, influence public opinion and empower individuals.” (Emphasis added)

……….

THE PALLIATIVE AND HOSPICE CONNECTION

Compassion and Choices has worked for decades not only to legalize physician-assisted suicide in every state but also to normalize and integrate physician-assisted suicide into medical practice and reaches out to established medical groups like the American Academy of Palliative and Hospice Medicine (AAPHM.

………..

Now, Compassion & Choices’ website has a video presentation based on this article  titled  “Understand the Clinical Practice of Aid in Dying” for doctors and other clinicians. The presentation even offers continuing medical education credits.

This would not be possible if the AAPHM had not changed its position on assisted suicide from opposition to “studied neutrality”, a position that the American Medical Association itself is now considering.

………….

Compassion and Choices also supports two other “legal” options for assisted suicide in states that haven’t passed physician-assisted suicide laws. One is “voluntary stopping of eating and drinking (VSED)” and the other is “palliative sedation-Sometimes called terminal sedation”. Significantly, the recommendations include the admission that “VSED includes pain and symptom management” and “Palliative sedation must be medically managed by a healthcare provider”. Thus the need to influence and train hospice and palliative care providers.

………..

WHERE THE MONEY AND POWER IS

Compassion and Choices now has its “Federal Policy Agenda / 2016 & Beyond”.

The priorities on its agenda include:

Establish federal payment for palliative care consultations provided by trained palliative care professionals who will advocate for and support the values and choices of the patient….”  (Emphasis added)

Also included are

Professional Education and Development” training programs for doctors and other providers “in discussing terminal prognoses and death” and  “Policies and Payment Systems” to change medical policies and payments to a “a value-based healthcare payment system” that will “(e)ncourage Congress to direct CMS (the Centers for Medicare and Medicaid Services) and other federal agencies” to withhold   “appropriations or other funds”  for treatment that was “provided but (deemed) unwanted”.

This last provision reinforces the fear many healthcare providers already have that, if in doubt, it is safer not to treat a person rather than treat him or her in hope of a good result because of potential lawsuits or reimbursement problems.

………

In the meantime, if the Compassion and Choices federal policy agenda is successful, they stand to benefit from a potential windfall of government taxpayer funding to provide their currently  “free consultation, planning resources, referrals and guidance”.

CONCLUSION

I have already contacted my state senator to express my concerns and urged him to vote “no” on SB 693.

As Nancy Elliot, chair of the Euthanasia Prevention Council USA, ended in a great letter to Senators opposing the Palliative Care and Hospice Education and Training  Act :

“instead of creating a rival form of palliative care…Wouldn’t it be better to educate/update all physicians and nurses about pain and symptom management?”