suicide

NAPN Position Paper on AMA Considering New Resolutions on Assisted Suicide

nancyvalko AMA, assisted suicide, Compassion & Choices, law, medical ethics, nursing, suicide, VSED

A May 1, 2023, article by Dallas R. Lawry, DNP, FNP-C, AOCNP® from the University of California, San Diego in the Journal of the Advanced Practitioner in Oncology titled “Rethinking Medical Aid in Dying: What Does It Mean to ‘Do No Harm?’” at Rethinking Medical Aid in Dying: What Does It Mean to ‘Do No Harm?’ – PMC (nih.gov) reveals that:

“Until 2019, the American Medical Association (AMA) maintained that MAID (medical aid in dying aka assisted suicide) was incompatible with their code of ethics and a physician’s responsibility to heal (AMA, 2022)“.

 But now, the AMA Medical Code of Ethics is considering two provisions that support both positions on MAID, including: “Physicians who participate in MAID are adhering to their professional, ethical obligations as are physicians who decline to participate” (AMA, 2019, 2022; Compassion & Choices, 2022) (Emphasis added)

Now, such ethical dissonance has now led the AMA to considering two new resolutions  at the Interim meeting of the AMA House of Delegates on November 10-14, 2023:

“Resolution 4 is to change the position of the AMA on Medical Aid in Dying (Resolution Link).

Resolution 5 is for the AMA to adopt a neutral stance on Medical Aid in Dying (Resolution Link).”

and, as Alex Schadenberg writes:

“It is important to note that Resolution 4 would remove the AMA statement on not performing euthanasia or participating in assisted suicide:

Physicians must not perform euthanasia or participate in assisted suicide. A more careful examination of the issue is necessary. Support, comfort, respect for patient autonomy, good communication, and adequate pain control may decrease dramatically the public demand for euthanasia and assisted suicide. In certain carefully defined circumstances, it would be humane to recognize that death is certain and suffering is great. However, the societal risks of involving physicians in medical interventions to cause patients’ deaths is too great in this culture to condone euthanasia or physician- assisted suicide at this time.

Both resolutions use the term Medical Aid in Dying (MAiD) rather than Physician Assisted Suicide. The term Medical Aid in Dying is not limited to assisted suicide, it also includes euthanasia. The assisted suicide lobby wants to legalize euthanasia (medical homicide) in America.”

NURSES AND ASSISTED SUICIDE

In 1995, the American Nurses Association stated:

“The American Nurses Association (ANA) believes that the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession. “ (Emphasis added)

But in 2017, the ANA revised its’ position on VSED (voluntary stopping of eating and drinking) “with the intention of hastening death” to “People with decision-making capacity have the right to stop eating and drinking as a means of
hastening death.” (Emphasis added)

In 2019, the American Nurses Association revised their position on assisted suicide titled “The Nurse’s Role When a Patient Requests Medical Aid in Dying”, stating that nurses:

“• Remain objective when discussing end-of-life options with patients who are exploring medical aid in dying.

• Have an ethical duty to be knowledgeable about this evolving issue.

• Be aware of their personal values regarding medical aid in dying and how these values might affect the patient-nurse relationship.

• Have the right to conscientiously object to being involved in the aid in dying process. (But “Conscience-based refusals to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness”)

• Never “abandon or refuse to provide comfort and safety measures to the patient” who has chosen medical aid in dying (Ersek, 2004, p. 55). Nurses who work in jurisdictions where medical aid in dying is legal have an obligation to inform their employers that they would predictively exercise a conscience-based objection so that appropriate assignments could be made” (All emphasis added)

But while the ANA is states that “It is a strict legal and ethical prohibition that a nurse may not administer the medication that causes the patient’s death“, it is silent when some states with assisted suicide laws like Washington state’s where Governor Jay Inslee signed a new expansion to the law in April 2023 to “allow physician assistants and advanced nurse practitioners to be one of the medical providers who sign off on the procedure”, “eliminates a two-day waiting period for prescribing the drugs” and “allow the necessary drugs to be mailed to patients instead of picked up in person”. (Emphasis added) https://www.axios.com/2023/04/24/washington-death-with-dignity-law

CONCLUSION

NAPN opposes both AMA resolutions and the ANA policy on assisted suicide, not only for the safety and welfare of our most vulnerable people but also because there are now many state and national medical professional organizations that support assisted suicide, and other problematic ethical issues and this will have a discouraging effect on idealistic, ethical people considering or remaining in health care which would be devastating to our trust in the healthcare system itself.

Is Donation after Circulatory Death a “Game Changer” for Heart Transplant?

nancyvalko assisted suicide, brain death, brain injury, culture, disability, end-of-life, euthanasia, futility, law, medical ethics, organ donation, suicide, ventilators/life support

In 2002, I wrote a paper titled “Ethical Implications of Non-Heart-Beating Organ Donation” (NHBD) and presented it at Trinity College at a medical ethics conference. At that time, brain death organ donation was well-known, but NHBD was virtually unknown to the public although it comprised about 2% of organ donations at that time.

As I wrote then:

“It is now apparent that the number of organs from people declared brain dead will never be enough to treat all patients who need new organs. ” and “doctors and ethicists have turned to a new source of organs — patients who are not brain dead but who are on ventilators and considered “hopeless”. In these patients, the ventilator is withdrawn and organs are quickly taken when cardiac death (DCD) rather than brain death is pronounced.”

Now, the term “Donation after Circulatory Death” (DCD) is used instead and means:

“Circulatory death occurs when the heart has irreversibly stopped beating and when circulation and oxygenation to the tissues irreversibly stops.” (Emphasis added)

However, with heart transplantation, the heart will be restarted as explained in a March 24, 2023 Medscape article “A ‘Game Changer’ for Heart Transplant: Donation After Circulatory Death Explained”.

In the article, Adam D. DeVore, MD, MHS is interviewed by Ileana L. Piña, MD, MPH and explains how this works and why he is excited:

“Adam D. DeVore, MD, MHS: In the field of heart transplant, DCD or donation after circulatory death is really a game changer. For decades now, we’ve been doing heart transplants from donors who die or have been declared brain dead.

There’s a whole population of potential donors who have very similar neurologic injuries — they’re just not technically declared brain dead — whose organs the family would like to donate. We didn’t have a way before.”

“There are two mechanisms. The family would withdraw care. Somebody affiliated with the hospital would declare that the donor has died. There’s usually a standoff period. That is a little variable, but it’s around 5 minutes.” (All emphasis added)

and added that then:

“…There are then two ways where that heart could be resuscitated or revived, outside the body on the organ care system. Or it could remain in the body through normothermic regional perfusion (NRP), or they’ll go on cardiopulmonary bypass and re-perfuse the heart in the room, and then look at the heart and try to evaluate it before donation. The rest of that donation looks just like every other brain-dead donation.”

…I remember when we were first starting this, I was thinking of how we would explain this to potential recipients and what would this look like. It turns out that something terrible has happened, and families that want to donate organs are relatively enthusiastic and less focused on the details.” (All emphasis added)

ETHICAL CONCERNS

In another March 23, 2023 Medscape article titled “Does New Heart Transplant Method Challenge Definition of Death?, Sue Hughes, a journalist on Medscape Neurology, writes:

“The difficulty with this approach, however, is that because the heart has been stopped, it has been deprived of oxygen, potentially causing injury. While DCD has been practiced for several years to retrieve organs such as the kidney, liver, lungs, and pancreas, the heart is more difficult as it is more susceptible to oxygen deprivation. And for the heart to be assessed for transplant suitability, it should ideally be beating, so it has to be reperfused and restarted quickly after death has been declared.” (Emphasis added)

When the NRP technique was first used in the US, these ethical questions were raised by several groups, including the American College of Physicians (ACP).

“The difficulty with this approach, however, is that because the heart has been stopped, it has been deprived of oxygen, potentially causing injury. While DCD has been practiced for several years to retrieve organs such as the kidney, liver, lungs, and pancreas, the heart is more difficult as it is more susceptible to oxygen deprivation. And for the heart to be assessed for transplant suitability, it should ideally be beating, so it has to be reperfused and restarted quickly after death has been declared.” (Emphasis added)

Harry Peled, MD, Providence St Jude Medical Center, Fullerton, California, co-author of a recent Viewpoint on the issue said that:

“There are two ethical problems with NRP, he said. The first is whether by restarting the circulation, the NRP process violates the US definition of death, and retrieval of organs would therefore violate the dead donor rule.

“American law states that death is the irreversible cessation of brain function or of circulatory function. But with NRP, the circulation is artificially restored, so the cessation of circulatory function is not irreversible,” Peled points out.

The second ethical problem with NRP is concern about whether, during the process, there would be any circulation to the brain, and if so, would this be enough to restore some brain function? Before NRP is started, the main arch vessel arteries to the head are clamped to prevent flow to the brain, but there are worries that some blood flow may still be possible through small collateral vessels.” (Emphasis added)

Nader Moazami, MD, professor of cardiovascular surgery, NYU Langone Health, New York City, is one of the more vocal proponents of NRP, stating that:

“”Our position is that death has already been declared based on the lack of circulatory function for over 5 minutes and this has been with the full agreement of the family, knowing that the patient has no chance of a meaningful life. No one is thinking of trying to resuscitate the patient. It has already been established that any future efforts to resuscitate are futile. In this case, we are not resuscitating the patient by restarting the circulation. It is just regional perfusion of the organs.” and “We are arguing that the patient has already been declared dead as they have a circulatory death. You cannot die twice.” (Emphasis added)

CONCLUSION

Ms. Hughes also wrote in her article that:

“Heart transplantation after circulatory death has now become a routine part of the transplant program in many countries, including the United States, Spain, Belgium, the Netherlands, and Austria.”

And in the US, “348 DCD heart transplants were performed in 2022, with numbers expected to reach 700 to 800 this year as more centers come online.” And “It is expected that most countries with heart transplant programs will follow suit and the number of donor hearts will increase by up to 30% worldwide because of DCD. ”

So how important is it to have strict medical ethics standards in organ donations?

In a February 9, 2023 Transplant International article titled “Organ Donation After Euthanasia in Patients Suffering From Psychiatric Disorders: 10-Years of Preliminary Experiences in the Netherlands“, it was reported that:

“Over the ten-year study period 2012–2021 59,546 patients underwent euthanasia of whom 58,912 suffered from a somatic (physical) disorder. The number of patients that underwent euthanasia for an underlying psychiatric disorder was 634 (1.1%). An estimated 10% (5955) of patients who undergo euthanasia in general are medically eligible to donate one or more organs (11).” (Emphasis added)

Organ transplants can be wonderful and lifesaving, but we must know all the facts, be able to trust our healthcare providers, and especially not allow the “slippery slope” of legalized assisted suicide/euthanasia to get any steeper.

Over 600 Doctors Send Powerful Letter to President Trump Calling the Covid 19 Lockdown a “Mass Casualty Incident”

nancyvalko Covid 19, culture, drug addiction, economics, end-of-life, media, medical ethics, suicide

Although it received little media notice, a May 19, 2020 letter to President Trump signed by over 600 doctors detailed the physical and mental impact of the lockdown in the US due to Covid 19, calling it a “mass casualty incident” with “exponentially growing negative health consequences” to millions of non-COVID patients. 

As the highly contagious Covid 19 virus was spreading around the world, President Trump issued a proclamation on March 12, 2020 declaring a national emergency with “preventive and proactive measures to slow the spread of the virus and treat those affected”.

On March 18, the Centers for Medicare and Medicaid Services recommended that hospitals cancel all elective surgeries and nonessential medical, surgical and dental procedures to prepare for the expected deluge of patients with Covid 19 and the health system complied.

Regular healthcare became virtually suspended as states went to lockdown with rules to shelter in place except for essential errands or work. Schools and many businesses were closed. 

Ironically,  except for New York and other hotspots that received massive federal help including ventilators and emergency field hospitals, US hospitals wound up with many empty beds and even emergency room visits dramatically declined. 

Many hospitals are now facing a financial crisis and health care professionals are being furloughed.

THE IMPACT OF THE LOCKDOWN ON AMERICANS’ PHYSICIAL AND MENTAL HEALTH

The doctors’ letter to President Trump focused on the devastating impact on Americans’ physical and mental health of the lockdown and why the months-long lockdowns should be ending. 

Here are some excerpts:

“Suicide hotline phone calls have increased 600%,” the letter said. Other silent casualties: “150,000 Americans per month who would have had new cancer detected through routine screening.”

“Patients fearful of visiting hospitals and doctors’ offices are dying because COVID-phobia is keeping them from seeking care. One patient died at home of a heart attack rather than go to an emergency room. The number of severe heart attacks being treated in nine U.S hospitals surveyed dropped by nearly 40% since March. Cardiologists are worried “a second wave of deaths” indirectly caused by the virus is likely.“

“The millions of casualties of a continued shutdown will be hiding in plain sight, but they will be called alcoholism, homelessness, suicide, heart attack, stroke, or kidney failure. In youths it will be called financial instability, unemployment, despair, drug addiction, unplanned pregnancies, poverty, and abuse.“

“It is impossible to overstate the short, medium, and long-term harm to people’s health with a continued shutdown,” the letter says. “Losing a job is one of life’s most stressful events, and the effect on a person’s health is not lessened because it also has happened to 30 million [now 38 million] other people. Keeping schools and universities closed is incalculably detrimental for children, teenagers, and young adults for decades to come.” (All emphasis added)

But while nearly all 50 states are starting to relax lockdown rules to some extent, some officials are threatening to keep many businesses closed and other draconian measures in place until August or even later. Many schools and universities now say they may remain closed for the remainder of 2020.

But as Dr. Marilyn Singleton, a California anesthesiologist and one of the signer of the letter said, “Ending the lockdowns are not about Wall Street or disregard for people’s lives; it’s about saving lives.” (Emphasis added)

CONCLUSION

We know a lot more about Covid 19 now. The US Center for Disease Control’s new ‘best estimate’ implies a COVID-19 Infection fatality rate below 0.3% with an estimated 35% of people with Covid 19 never having symptoms. 

States have rescinded orders that forced long term care facilities with our most vulnerable people to admit Covid 19 patients after hospital discharge resulting in lethal outbreaks.

But as more states are slowly opening, Grace-Marie Turner of the Galen Institute writes:

“Will patients come back? COVID-phobia is deathly real.

Patients still are fearful about going to hospitals for heart attacks and even for broken bones and deep lacerations. Despite heroic efforts by physicians to deeply sanitize their offices, millions have cancelled appointments and are missing infusion therapies and even chemotherapy treatments. This deferred care is expected to lead to patients who are sicker when they do come in for care and more deaths from patients not receiving care for stroke, heart attacks, etc.”

While still observing social distancing, sanitizing and other common sense measures to protect ourselves and others, it is my opinion that the more than 600 doctors writing to President Trump are right when they urge ending the Covid 19 shutdown as soon as possible for all Americans’ physical and mental health.

 

 

 

 

 

 

 

No Suicide Discrimination!

nancyvalko assisted suicide, medical ethics, suicide

When I was asked by my late daughter Marie’s best friend to join her on a family and friends fundraising walk for suicide prevention last Sunday, I hesitated.

I was in the process of reading yet another disturbing article about assisted suicide, this time a Journal of Clinical Psychiatry article titled “Working with Decisionally Capable Patients Who Are Determined to End Their Own Lives”  and I found it outrageous that the suicide prevention groups I know exclude potential physician-assisted suicide victims.

As a nurse, I have personally and professionally cared for many suicidal people over decades including some who were terminally ill. To my knowledge, none of these people went on to die by suicide except one-my own daughter.

Almost nine years ago, my 30 year old daughter Marie died by suicide using an assisted suicide technique she found after searching suicide and assisted suicide websites and reading assisted suicide supporter Derek Humphry’s book “Final Exit”.

Marie was a wonderful woman who achieved a degree in engineering despite struggling off and on with substance abuse and thoughts of suicide for 16 years. She was in an outpatient behavioral health program at the time of her suicide. Her suicide was my worst fear and it devastated all of us in the family as well as her friends. Two people close to Marie also became suicidal after her death but were fortunately saved.

For years before and after Marie’s death, I have written and spoken to groups around the country about the legal and ethical problems with assisted suicide as well as suicide contagion  and media reporting guidelines for suicide.

So it was with mixed feelings that I participated in the suicide prevention walk but now I am glad I did.

“WORKING WITH DECISIONALLY CAPABLE PATIENTS WHO ARE DETERMINED TO END THEIR OWN LIVES”

I finally finished reading this article after the walk and found that while the authors of this Journal of Clinical Psychiatry article insist that they are only discussing “decisionally capable” people with “advanced medical illness”, they write:

“The 24% increase in US suicide rates from 1999 to 2014 has led to greater efforts to identify, prevent, and intervene in situations associated with suicidality. While the desire to kill oneself is not synonymous with a mental illness, 80%–90% of completed suicides are associated with a mental disorder, most commonly depression. Understandably, psychiatrists and other clinicians face strong moral, cultural, and professional pressures to do everything possible to avert suicide. Hidden within these statistics are unknown numbers of individuals determined to end their lives, often in the context of a life-limiting physical illness, who have no mental disorder or who, despite having a mental disorder, were nevertheless seemingly rational and decisionally capable and in whom the mental disorder did not seem to influence the desire to hasten death.”

Tragically, the authors also state:

“In reviewing the either sparse or dated literature in this field, surveys from the United States and Canada support that most psychiatrists believe that PAD (physician aid in dying, a euphemism for assisted suicide) should be legal and is ethical in some cases and that they might want the option for themselves.”

And

“Although we see ‘assisted death’ as an option of last resort, we instead ask whether on certain occasions psychiatrists might appropriately not seek to prevent selected decisionally capable individuals from ending their own lives.” (All emphasis added)

This flies in the face of long-standing professional suicide prevention and treatment principles.

Notably, the article ends with an addendum, the 2017 Statement of the American Association of Suicidology (AAS): “Suicide is not the same as ‘Physician Aid in Dying’”

That concludes:

“In general, suicide and physician aid in dying are conceptually, medically, and legally different phenomena, with an undetermined amount of overlap between these two categories” but “Such deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.” (Emphasis added)

WHY I AM GLAD I WENT ON THE SUICIDE PREVENTION WALK

The Sunday walk was sponsored by the American Foundation for Suicide Prevention (AFSP), a group that I discovered states it is trying to “Develop an updated AFSP policy position on assisted death (other common terms include physician assisted suicide or Death with Dignity Laws)”

The next day, I was able to contact a policy person at their Washington, DC office and, unlike other suicide prevention group representatives I have contacted in the past, I found this woman surprisingly interested and receptive to the idea that we should not discriminate against certain people when it comes to suicide prevention and treatment. She even asked for my contact information.

Of course, the AFSP may decide to exclude potential assisted suicide victims like other organizations have done but at least I tried and that’s the best tribute I can give to my daughter now.

 

Six Things You Need to Know about Physician-Assisted Suicide

nancyvalko assisted suicide, disability, medical ethics, suicide

This article was originally published in The Public Discourse on December 19, 2017

Six Things You Need to Know about Physician-Assisted Suicide

by Nancy Valko, RN ALNC

Pull quote: Is the real healthcare crisis not enough physician assisted suicide laws? Or
is it the staggering and increasing number of people losing their battles
with mental illness and committing suicide?

It has been twenty years since Oregon’s physician-assisted suicide law took
effect after a public referendum. Since then, four other states have
legalized physician-assisted suicide.

Polls seem to show strong public support for physician-assisted suicide. They ask questions like this one from a  2017 Gallup poll: “When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should
not be allowed by law to assist the patient to commit suicide if the patient
requests it?”

Unfortunately, most people have only a vague idea about what such laws
actually say and do. Here are six things you must know before you decide
whether to support or oppose physician-assisted suicide.

1. Pain or any other suffering is not a requirement for a person seeking
assisted suicide; “a disease that cannot be cured” can include manageable
conditions like diabetes as well as terminal illnesses like cancer.

None of the US laws are restricted to patients experiencing pain, which can
be addressed in ways that do not deliberately kill the patient. In 2016, for
example, almost half of patients using assisted suicide in Oregon cited their reason for seeking death as “Burden on family, friends/caregivers” while just 35 percent cited “Inadequate pain control or concern about it.”

2. Medical professionals participating in physician-assisted suicide are
immune from accountability and standards of due care.

“No person shall be subject to civil or criminal liability or professional
disciplinary action for participating in good faith compliance with”
Oregon’s law. Thus any licensed doctor (or other healthcare provider), with
or without experience and regardless of his or her medical specialty, can
write a lethal overdose prescription for a patient as long as he or she
claims to be in “good faith compliance.” As a legal standard, this test is
effectively meaningless, because it relies only on the physician’s word.

The physician is not required to be-and often is not-the patient’s primary
care doctor. Many physicians do not want to be involved in this process,
according to “Compassion & Choices,” an organization that promotes the legalization of physician-assisted suicide throughout the United States. When one doctor (or many) conclude that it would be irresponsible to give a lethal overdose to a patient, such
organizations encourage patients to find a doctor with lower standards.

No other medical intervention has such immunity protection from lawsuits or
criminal investigation. In addition, no other medical intervention is so
devoid of standards for the clinical expertise or education required of the
physician involved.

3. Physician-assisted suicide does not involve the stringent documentation
and oversight required for other medical interventions.

In all jurisdictions where physician-assisted suicide is allowed, to
prescribe a lethal overdose the doctor need only fill out the required state
forms that include a consultation with a second physician who agrees.
Neither doctor is required to have a professional relationship with the
patient before the physician-assisted suicide request.

Documentation of physician-assisted suicides relies on doctors’
self-reporting. There is no requirement that the actual taking of the lethal
overdose be witnessed by a medical professional or anyone else. This means
that there is no safeguard against medical complications, coercion by family
members, or other problems.

The Oregon law also specifies that, “Except as otherwise required by law, the information collected shall not be a public record and my not be made available for inspection by the public”, after which the original forms are destroyed.

Unfortunately, the immunity protections and secrecy surrounding even the minimal self-reporting in state-level assisted-suicide laws eliminate the possibility of future potential lawsuits or prosecutions for abuse. They keep alive the myth that there are strong safeguards in the law that eliminate problems like coercion or elder abuse.

4. The cause of death must be falsified.

States with physician-assisted suicide laws require that the cause of death is reported as death from an underlying condition rather than the lethal overdose, supposedly to ensure the patient’s privacy. But this clearly violates the standards set for coroners
and medical examiners by the Centers for Disease Control. Those standards require accuracy in determination of death because “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.”

Falsified death certificates also quietly function to smooth over any problems with life insurance policies that have suicide clauses denying death benefits if the insured commits suicide within two years of taking out a policy. And since doctors are only required to “recommend that the patient notify next of kin” about the plan for assisted suicide, the rest of the patient’s family may never know the real cause of death. This means that they are also deprived of the chance to reassure their loved ones of their
support and willingness to help take care of them until their natural death.

5. Assisted suicide laws promote discrimination against suicidal people.

The usual standards for caring for a suicidal person include intensive management to prevent suicide attempts. These are changed in physician-assisted suicide: “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.” Only the evaluation of a patient’s competence, not the diagnosable mental disorders that afflict more than 90 percent of people who die by suicide, is required . It is shocking that only 3.8 percent of those seeking physician-assisted suicide in Oregon were referred for psychiatric
evaluation in 2016. Patients with dementia and with clinical depression that had existed for years before they contracted a physical illness have died under the Oregon law.

6. Suicide is contagious.

A 2015 article in the Southern Medical Journal titled “How Does Legalization of
Physician-Assisted Suicide Affect Rates of Suicide?” studied Oregon’s and Washington’s rates of non-assisted suicide after assisted suicide laws were passed. Despite claims that assisted suicide laws would reduce other suicides or only substitute for them, the authors reached the disturbing conclusion that “Rather, the introduction of PAS (physician assisted suicide) seemingly induces more self-inflicted deaths than it inhibits.”

This does not surprise me. In 2009 my thirty-year-old, physically healthy daughter Marie died by suicide. She killed herself using a technique she learned after visiting assisted suicide/suicide websites and reading Final Exit (1991) by Derek Humphry, founder of the Hemlock Society (an organization that merged with another group to form Compassion & Choices). The medical examiner called her suicide “textbook Final Exit.”

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, they were saved, but suicide contagion, better known as “copycat suicide,” is a well-documented phenomenon. Often media coverage or publicity around one death can encourage other vulnerable people to commit suicide.

According to the Centers for Disease Control and Prevention, suicide rates have been
increasing since 2000 after decades of decline. Suicide is now the tenth leading cause of death in the United States, with more than 44,000 people dying by suicide every year. Suicide costs society over $56 billion a year in combined medical- and work-loss costs, not to mention the enormous toll suicide takes on family and friends. Oregon’s suicide rate is more than 40 percent higher than the national average.

Is the real healthcare crisis not enough physician-assisted suicide laws? Or is it the staggering and increasing number of people losing their battles with mental illness and committing suicide?

No matter what Compassion & Choices says, physician-assisted suicide is not a civil right or just one of an assortment of morally neutral end-of-life options. It’s time to stand up and fight to keep the medical profession from abandoning its most fundamental ethical principles.

Nancy Valko, RN, ALNC, is a longtime writer and speaker on medical ethics issues who recently retired from critical care nursing to devote more time to consulting and volunteer work. She is also a spokesperson for the National Association of Pro-Life Nurses.

[Non-text portions of this message have been removed]

Defending Physician-assisted Suicide

nancyvalko assisted suicide, Compassion & Choices, medical ethics, mental health, nursing, suicide

In a recent letter to the editor in the Wall Street Journal,  Dr. David Grube, national medical director of Compassion and Choices, defended physician-assisted suicide by stating:

“I knew that the people who requested it didn’t want to end their life. They loved life but realized they had an incurable, terminal disease and didn’t want to suffer needlessly as the inevitable end of life approached.

The proof is that more than one-third of terminally ill Oregonians who obtain the medication never take it, but they get great comfort in knowing they have access to it if they need it, which helps them suffer less.” (Emphasis added)

Is this really the crucial argument to upend our medical and legal ethics to legalize physician-assisted suicide?

Especially when more than 33% of people approved for assisted suicide don’t use the lethal overdose prescriptions, this should be a wake-up call for assisted suicide activists as well as suicide prevention groups and the rest of society.

As a former oncology (cancer) and hospice nurse who cared for many terminally ill patients including relatives over decades, I encouraged my patients and family members to talk about all their concerns. I found very few who wanted to end their lives out of fear of future suffering. I  reassured my patients and relatives that we would make them as comfortable as possible and support them until their natural death. Not one died by suicide and all died with true dignity.

But this was before physician-assisted suicide began to be legalized, glamorized and  promoted by activists, especially through sympathetic media outlets.

WHERE IS THE FOLLOW UP ON THE PATIENTS WHO DON’T TAKE THE LETHAL OVERDOSE?

What happened to these patients who decided not to take the lethal overdose? Did they unexpectedly improve or find their symptoms adequately treated? Was the terminal diagnosis wrong? Did they find the physical, emotional and spiritual support to continue living?

Unfortunately, those writing state assisted suicide reports are apparently not interested in this important information that could help save other lives.

WHAT HAPPENS TO THE UNUSED LETHAL OVERDOSE?

Another concern is what happens to the lethal overdose that the patient does not take?

In any home health situation, every unused dose of a controlled medication must be accounted for and disposed of carefully. We know how important it is to keep such medication out of a child’s reach or from misuse by a family member or friend. Keeping overdoses for possible future ingestion is obviously dangerous, especially when our nation is in the middle of an opioid crisis that now kills almost 100 Americans every day.

However when it comes to unused lethal overdoses in assisted suicide, Death with Dignity’s advice is that:

“Anyone who chooses not to ingest a prescribed dose or anyone in possession of any portion of the unused dose must dispose of the dose in a legal manner as determined by the federal Drug Enforcement Agency or their state laws, if any.”

CONCLUSION

When even assisted suicide supporters admit data suggests that the “distress prompting patients to request these lethal medications primarily stems from their fear over losing control at the end of life” but claim that the more than 33% who don’t take the prescribed lethal overdose should still have it to supposedly “get great comfort in knowing they have access to it if they need it”,  physician-assisted suicide is further exposed as a terrible response to human fear and despair.

As our National Association of Pro-life Nurses states, patients need us to take their hands, not their lives.

 

Can There Really Be a “Safer” Physician-assisted Suicide?

nancyvalko assisted suicide, Compassion & Choices, end-of-life, medical ethics, mental health, suicide

In August, I wrote a blog “Physician-assisted Suicide and the Palliative Care Physician”  about Dr. Jessica Nutik Zitter,  a palliative care doctor in California who approved of physician-assisted suicide, would want it for herself but had still had serious some qualms about actually writing for the lethal overdose herself.

In the end, Dr. Zitter decides that assisted suicide can be rendered “safe” by being rare and practiced by specially trained medical practitioners as “just one tool in the toolbox of caring for the dying-a tool of last resort.”

Thus, Dr. Zitter, perhaps unknowingly, gives support to the Compassion and Choices goal of “normalizing” and “integrating” physician-assisted suicide into standard medical practice. Note  their own description of their activities:

“We help clients with advance directives, local service referrals and pain and symptom management. We offer information on self-determined dying when appropriate and provide emotional support through a difficult time. 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. Compassion & Choices devotes itself to creative legal and legislative initiatives to secure comprehensive and compassionate options at the end of life.” (Emphasis added)

Now in her new article “De-Medicalizing Death”, Dr. Zitter is excited about a new University of California, Los Angeles (UCLA) Health Centers’ program where “only” 25% of patients went on to commit physician-assisted suicide after an “intake process…conducted by trained psychotherapists (psychologists and clinical social workers) instead of physicians”.

Ironically, current physician-assisted suicide laws tout the “safeguard” that “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.” (Emphasis added),  But that only means evaluating a patient’s competence, not the diagnosable mental disorders that afflict more than 90 percent of people who die by suicide, is required. Thus, it should not be surprising that only 3.8% of people using physician-assisted suicide in Oregon were even referred for psychiatric evaluation in 2016, unlike the standard of care for other suicidal people.

Also, the UCLA new intake process for physician-assisted suicide that so excites Dr. Zitter paradoxically undermines the common media depiction of a terminally ill person in unbearable pain desperate for immediate relief:

“The intake consisted of an extensive set of questionnaires designed to assess all possible sources of distress. Any patient with physical or psychiatric needs was referred on to the appropriate services. But as the UCLA committee expected, most of what patients needed was to discuss their feelings about their approaching death and process their grief and sense of loss. This mirrors data from the entire state of California as well as Oregon, which suggest that the distress prompting patients to request these lethal medications primarily stems from their fear over losing control at the end of life. It is not, as many may think, due primarily to physical suffering.” (Emphasis added)

And

“Anne Coscarelli, psychologist and founding director of the Simms/Mann–UCLA Center for Integrative Oncology, described the conversations that came from this intake process as revelatory and comforting for the patients. Several patients ultimately completed legacy projects, such as video or written messages and stories, for their children and grandchildren. This invitation to talk, which opens up a discussion that most of us are taught to avoid, turned out to be a game-changer”. (Emphasis added)

And, I would add, this “game-changer” ultimately resulted in most patients NOT dying by assisted suicide.

As a former hospice and oncology nurse, this kind of listening and support is very familiar to me. We gave our patients such care along with symptom control and our patients died with real dignity with their families supported as well.

Personally, I was never even once tempted to help end any of my patients’ lives.

CONCLUSION

Dr. Zitter is like many people. The idea of controlling one’s own death or avoiding watching a loved one slowly die is very seductive. But, as Dr. Zitter has unwittingly discovered, suicide is the loneliest kind of death and very amenable to intervention.

On the other hand, the legalization and approval of physician-assisted suicide reinforces the underlying despair that leads even many healthy people to think death is the solution to their problems.

When “Losing autonomy” and “Less able to engage in activities making life enjoyable” are the top two end of life concerns of Oregon’s assisted suicide victims in 2016, we have a bigger societal problem than an alleged lack of enough lethal overdose prescriptions.

We need true caring and support, not abandonment to suicide of any kind.

“13 Reasons Why”and Why Not

nancyvalko education, faith, family, mental health, suicide

Today, it is hard to keep up with the constant stream of information coming not only from TV and movies but also from the social network. But to understand and hopefully to protect and help our children and others in today’s culture, it is important to keep up with current media and trends as much as possible.

This is why, after reading articles like “13 Reminders About Netflix’s ‘Thirteen Reasons Why’” about a popular Netflix series featuring a high school girl named Hannah who gruesomely kills herself and leaves 13 tapes for the people she blames for her suicide, I decided to watch this often acclaimed  and controversial TV series myself.

After watching several episodes, I recognized some of the factors that made “Pretty in Pink” and “The Breakfast Club” so popular when my children were teenagers. The characters are attractive and bright high school students who wrestle with problems of self-esteem, setbacks, hormones and popularity.  In the end, most of the characters in those older movies were happier and/or wiser.

But the story arc and characters in “13 Reasons Why” are much darker. So far in the episodes I have watched, these teenagers are apathetic about school, seem to have no sense of humor and they dislike or barely tolerate their parents. Their overwhelming self-absorption with real or perceived offenses often leads them to be thoughtlessly cruel even to their friends. The adults in the series fare little better as they struggle with their own anger, sadness and guilt in trying to understand the tragedy.

The main character Hannah sounds almost triumphant in the tapes while chronicling the deficiencies in the people she holds responsible for her suicide. The people hearing the tapes are understandably devastated but revenge seems to be Hannah’s goal.

Even worse, the series’ depiction of Hannah’s descent to suicide, making the tapes and the reactions of her classmates tends to sensationalize suicide with little to no insight about prevention and treatment. The big lesson seems to be that bullying and sexual assault can be life-threatening to vulnerable teens.

Because this deliberately shocking series is so accessible to young people and teen suicides are rising,  many schools are now concerned about this series as are mental health experts  who recognize the phenomenon of suicide contagion.

In response to complaints and concerns from as far away as Canada and New Zealand, Netflix has now issued the following statement:

 There has been a tremendous amount of discussion about our series 13 Reasons Why. While many of our members find the show to be a valuable driver for starting important conversation with their families, we have also heard concern from those who feel the series should carry additional advisories. Currently the episodes that carry graphic content are identified as such and the series overall carries a TV-MA rating. Moving forward, we will add an additional viewer warning card before the first episode as an extra precaution for those about to start the series and have also strengthened the messaging and resource language in the existing cards for episodes that contain graphic subject matter, including the URL 13ReasonsWhy.info  — a global resource center that provides information about professional organizations that support help around the serious matters addressed in the show.

As a nurse who has worked professionally and personally with suicidal people as well as the mother of a daughter who died by suicide, I am glad Netflix is acknowledging at least some of the problems with the series. However, this series and the plight of our young people growing up in an increasingly secularized, materialistic and divided world that rejects God demands more.

We need to give our young people hope and support as they navigate the often rocky road to adulthood. And we also need to show them that the real heroes are those people whose dedication, moral virtues, hard work, selflessness and idealism inspire all of us to make a better world where no one will want to watch the so-called “entertainment” of a “13 Reasons Why”.

 

“Physician-Assisted Dying: Is a Patient’s Despair Reversible?” by Arthur Caplan, PhD. And Maurie Markman, MD

nancyvalko assisted suicide, end-of-life, futility, law, medical ethics, mental health, suicide

A while back, I received a phone call asking me to talk to a man in another state who was desperately seeking physician-assisted suicide. He was in the later stages of a degenerative disease and wanted to die before his condition “got too bad”.

I talked to this man I will call “John” for quite a while about his life, his frustrations, his strengths, some resources, etc. He said he had told his caregivers at the nursing home that he would like to talk to someone about his concerns months ago but nothing happened. With his permission, I spoke to his caregivers and I asked John to keep in touch.

About a month later, John contacted me and said that he had changed his mind about assisted suicide and was enjoying being with friends and going out on trips with other residents.

He said the biggest help was talking with someone like me who listened and who cared.  Best of all, he said “I do deserve a better life!”

I thought about John when I read an April 06, 2017 commentary from Medscape, a password protected news site for medical professionals, titled “Physician-Assisted Dying: Is a Patient’s Despair Reversible?” 

The commentary was a discussion between Arthur Caplan, PhD, a prominent ethicist  who was against legalizing assisted suicide until the Brittany Maynard case, and Maurie Markman, MD, an oncologist and professor who also supports assisted suicide, that I found disturbing.

For example, Dr. Markman says that:

 “My concern is that the reason someone may ask for death, which is their right, is because of despair. Despair may be potentially temporary or it may be permanent, but death itself is permanent. My concern would be that some part of an individual patient’s despair may be reversible; I would want to be certain that it is not reversible before deciding that this (physician-assisted suicide) makes sense for that person, from my perspective.”
(Emphasis added)

But amazingly, neither Dr. Markman or Dr. Caplan even mentions or recommends  mental health evaluations for people considering assisted suicide-something which no assisted suicide law now requires because such suicides are considered “rational”.

Instead, there is this exchange:

Dr Caplan: I remember when Jack Kevorkian was bringing people to Michigan and helping them die in the back of Volkswagen vans and so on. One problem I had was that he did not know these people.

Dr Markman: That’s right.

Dr Caplan: They would show up, and 24 hours later, they would be gone to the hereafter; some of them were terminally ill, and some were not, as a matter of fact. Given the constraints that physicians face in terms of time and other activities they have to engage in—paperwork and so on—can they get to know patients well enough to have reliable discussions about the authenticity of their wishes to die?

Dr Markman: That is a concern. Physicians don’t have enough time to do a lot of things. The kind of conversation we are talking about would involve a lot of time and effort. I would suggest that physicians would want to be able to spend that time with their patients, but it does not mean they have that time. Quite frankly, it may be relatively immediate time. A patient comes in at a particular point and says, I’m thinking of doing this and I’m thinking of doing it now, and the doctor has a full schedule. The physician would want to take that time, would want to bring in the family, but it is difficult with time constraints. (Emphasis added)

There is another discussion of financial burdens impacting assisted suicide, with Dr. Caplan saying:

“Dr. Caplan: Here is a source of growing despair: These treatments (for cancer) are causing me to go broke. I cannot afford a $100,000 biologic or immunotherapy, or I simply do not want to linger on and on while my grandson’s tuition is spent, or whatever. We have come to think about this as the problem of financial toxicity: more tools, but more associated cost. How does physician-assisted dying fit into this emerging area of financial burden?

Dr. Markman: … The potential for bankruptcy is becoming a major issue among patients with cancer. We know that during the Great Depression, people went bankrupt and committed suicide. Why could it not happen now, when we are talking about therapies that cost hundreds of thousands of dollars a year and patients have copays of 20%? Financial toxicity is real.” (Emphasis added)

CONCLUSION

Where is the compassion for these suicidal people grappling with issues that lead them to consider physician-assisted suicide?

This dispassionate discussion of some qualms that these supposed experts seem to have about physician-assisted suicide still leaves assisted suicide laws intact and does nothing to promote non-discriminatory suicide prevention and treatment or even conscience rights for those of us who oppose physician-assisted suicide.

My Submission to the AMA Opposing Neutrality on Physician-Assisted Suicide

nancyvalko Compassion & Choices, medical ethics, nursing, suicide

Amid conflicting reports about whether or not the American Medical Association was going to consider a position of neutrality on physician assisted suicide, I was informed that the AMA’s Council on Ethical and Judicial Affairs was collecting data, position statements, etc. for consideration of assisted suicide and other topics before the June AMA Annual meeting. The deadline for submissions was February 15.

The following is my submission titled “Neutrality on physician assisted suicide also hurts nurses”

Dear AMA,

I have been a registered nurse since 1969. After working in critical care, hospice, home health, oncology, dialysis and other specialties for 45 years, I am currently working as a legal nurse consultant and volunteer as well as spokesperson for the National Association of Pro-Life Nurses. Over the years, I have cared for many suicidal people as well as people who attempt suicide.

I have served on medical and nursing ethics committees, served on disability and nursing boards. I have written and spoken on medical ethics-especially end of life issues-since 1984.

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 doctor is not required to be there.

marievalko

Marievalko Picture of Marie Valko 1979-2009

As a nurse and the mother of a suicide victim (see picture above), I am alarmed by reports that the AMA is considering a position of neutrality on physician-assisted suicide. I beg you to uphold the legal and ethical standard that medical professionals must not kill their patients or help them kill themselves. Suicide is a tragedy to be prevented if possible, not a civil right.

MY DAUGHTER KILLED HERSELF USING AN ASSISTED SUICIDE TECHNIQUE

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over physician-assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

SUICIDE CONTAGION

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon. Often media coverage or publicity around one death encourages other vulnerable people to commit suicide in the same way.

STUDY SHOWS LEGALIZING PHYSICIAN-ASSISTED SUICIDE IS ASSOCIATED WITH AN INCREASE RATE OF TOTAL SUICIDES

A 2015 article in the Southern Medical Journal titled “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” came to these conclusions:

“Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.”

THE HEALTH AND ECONOMIC COSTS OF SUICIDE

My Marie was one of the almost 37,000 reported US suicides in 2009. In contrast, only about 800 assisted-suicide deaths have been reported in the past 16 years in Oregon, the first state to legalize physician-assisted suicide. According to the Centers for Disease Control (CDC) suicide was the 10th leading cause of death for Americans in 2012, with “More than 1 million people reported making a suicide attempt in the past year” and “More than 2 million adults reported thinking about suicide in the past year.” The CDC estimates that suicide “costs society approximately $34.6 billion a year in combined medical and work loss costs”, not to mention the emotional toll on families.

Obviously our real health-care crisis here is a staggering and increasing rate of suicides, not the lack of enough assisted suicides.

BRITTANY MAYNARD

There was a media frenzy in October 2014 when Brittany Maynard, a young newlywed woman with a brain tumor, announced plans to commit physician-assisted suicide on November 1 and raise money to have physician-assisted suicide legalized in all US states. There was an immediate and unprecedented media frenzy surrounding Ms. Maynard’s tragic story that routinely portrayed her pending assisted suicide as “heroic” and even counting down the days to her suicide. Personally, I thought this looked like a crowd on the street shouting for a suicidal person on a window ledge to jump.

In the end, Brittany hesitated for a day before she went through with her pledge to take the lethal overdose.

Now, assisted suicide supporters even deny that physician-assisted suicide is suicide, insisting that media stories use euphemisms like “aid-in-dying” and “death with dignity” in cases like Ms. Maynard’s to make assisted suicide more palatable to the public. However, this defies common sense when the definition of suicide is the intentional taking of one’s own life.

PHYSICIAN-ASSISTED SUICIDE AND MEDICAL DISCRIMINATION

I have been a registered nurse for 47 years, working in intensive care, oncology, hospice and home health among other specialties. Personally and professionally, I have cared for many people who attempt or consider killing themselves.

Some of these people were old, chronically ill or had disabilities. Some were young and physically healthy. A few were terminally ill. I cared for all of them to the best of my ability without discrimination as to their condition, age, socioeconomic status, race or gender. I will do anything to help my patients — except kill them or help them kill themselves.

Suicide prevention and treatment works, and the standards must not be changed just because some people insist their desire for physician-assisted suicide is rational and even a civil right.