Physician-assisted Suicide and the ICU

The authors of a paper on the divisive issue of PAS disagree on many points, but are unified on one—doctors should not be required to participate.

As of the November election, five states and Washington D.C. have laws on the books allowing physician-assisted suicide. While it usually takes place outside the hospital setting, the practice is bound to find its way into intensive care units.

Intensivists will need to understand the new laws and be prepared to act in compliance with the law, the wishes of patients and families, their own views, and the policies of the organizations in which they are working.

In Colorado, some hospitals are refusing to allow the procedures in their facilities. According to a statement from SCL Health, the Denver-based Catholic health system: "Any of our patients wishing to request medical aid-in-dying medication will be offered an opportunity to transfer to another facility of the patient's choice."

While state legislatures continue to do their work, the debate among healthcare providers goes on.

The Society of Critical Care Medicine (SCCM) last week published a document spelling out two opposing positions on physician-assisted suicide (PAS) and euthanasia.

The authors disagreed on many points, but were unified on one—doctors should not be required to participate in PAS: "Conscientious objections should be accommodated without unduly obstructing patient's access to medical interventions permitted by law."

The document was published in the group's journal, Critical Care Medicine and was discussed at the annual meeting of the Critical Care Congress.

Two Sides Debate
Wes Ely, MD, of the Vanderbilt University School of Medicine in Nashville, Tennessee helped write the SCCM position paper. Ely opposes the practice, in part because he believes it will lead to the use of euthanasia, where the doctor delivers the fatal dose of medication. With PAS, the doctor prescribes, but does not administer, the fatal dose.

He thinks the two practices are linked.

"Eventually what happens is that somebody comes along and says, 'wait a minute, you've already said that I can get a doctor's help in dying,'" he said. "'But what if have a disease like ALS where I'm totally paralyzed and I can't move? You are discriminating against me now.'"

That patient could insist that if doctor is willing to write a prescription for a patient, he or she should be prepared for patients to ask for an injection, Ely said.

At last's week annual meeting of the SCCM, Ely and co- author Jan Bakker, MD, presented opposing arguments, described in the paper as Position 1 and Position 2. Bakker, is affiliated with University Medical Center, Rotterdam, the Netherlands and Columbia University Medical Center in New York.

In a video of the session, Bakker told the group that PAS has created a new role for doctors: facilitators of dying. He said PAS should be considered an element of end of life care and that he has witnessed both "magnificent dying processes "and "horrible "dying processes.

"You have to have the conviction that there is no other reasonable solution to the suffering of the patient," he said.

Bakker recalled telling a family member that a patient might not die immediately after being removed from life support. The family member asked why he wouldn't give her something to stop her heart after he took the tube out?

"The simple answer in this case is it's illegal. We cannot do that, even in the Netherlands," Bakker said.

The paper brings to light three main questions:

1. Are there patients for whom death is beneficial?

2. Is it morally acceptable for physicians to cause death intentionally?

3. Are PAS and euthanasia morally equivalent to withholding or withdrawing life support (WWLST)?

On the third question, the two sides of the argument go like this:

• "WWLST does not always result in death, but death is so likely after withdrawing life support that a physician must accept some degree of moral agency when it occurs."

• "We argue that WWLST is categorically different from PAS/E, and we may embrace the former as an integral part of benevolent care while firmly acknowledging the latter as a breach of the patient-physician covenant."

The group's position paper comes as data is emerging about the benefits of providing palliative care services to patients in the ICU. Until recently, the ICU was not seen as an appropriate setting for palliative care, but demand is rising. A single hospital study found that requests from the ICU for palliative care services rose 17.6% between 2004 and 2013.

The paper concludes with this: "As the debate about legalizing PAS/E continues unabated around the world, intensivists will be caught up with these important medical, legal, and ethical issues."