Physician-Assisted Death Scanning the Landscape: Proceedings of a Workshop (2018) / Chapter Skim
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6 Physician-Assisted Death in the Context of Long-Term Services and Supports, Palliative Care, and Hospice
6 Physician-Assisted Death in the Context of Long-Term Services and Supports, Palliative Care, and Hospice
Pages 99-120
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From page 99... ...
(Phillips) • Challenges to physician aid-in-dying for the population in long-term care occur in three areas: assessing cognitive compe tence, ensuring voluntariness in potentially coercive situations, and defining terminal illness.
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From page 100... ...
• Ethnocultural disparities in accessing hospice, palliative care, and physician-assisted death are not fully understood, but factors include mistrust of the medical system based on past abuses, religious beliefs, and disparities in communication and health care planning. (Berger)
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From page 101... ...
, with long-term care occurring in many settings, including at home and in skilled nursing facilities, rehabilitation facilities, long-term care hospitals, nursing homes, and assisted living facilities. How care is paid for in these settings depends on specific Medicare and Medicaid regulations as well as on an individual's personal finances.
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From page 102... ...
Phillips suggested the direct care workforce will need to increase 50 percent by 2030 to meet anticipated demand. Few clinicians are prepared to work in a palliative care setting or are trained in geriatrics.
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From page 103... ...
Speaking about the barriers to accessing physician-assisted death for individuals in long-term care, Barbara Hansen, the chief executive officer of the Oregon Hospice and Palliative Care Association and the executive director of the Washington State Hospice and Palliative Care Organization, said that individuals who lack an attending physician or family or
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From page 104... ...
To illustrate the range of issues and concerns specific to physicianassisted death, Lynn read a statement from the American Geriatrics Society in its amicus briefs for the Vacco v. Quill1 and Washington v.
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From page 105... ...
Lynn listed a number of research questions relevant to long-term care and physician-assisted death, including • What are the current practices in long-term care settings regarding physician-assisted death in locations where it is legal? • What are the financial, emotional, and other pressures being faced by older individuals using long-term services and supports, and how do they affect considerations of physician-assisted death?
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From page 106... ...
Stephanie Harman Clinical Associate Professor of Medicine and Clinical Chief of Palliative Care Stanford University School of Medicine When Stanford Medicine deliberated as an institution about how it would participate in California's new medical aid-in-dying law, the process was led by the institution's ethics department, said Stephanie Harman, a clinical associate professor of medicine at the Stanford University School of Medicine and the clinical chief of palliative care. This process included 20 town hall meetings which provided a broad perspective on what the medical staff thought about physician-assisted death as well as on the role that palliative care should be playing from an institutional perspective.
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From page 107... ...
As a final note, she said that by codifying palliative care into Stanford's physician-assisted death process, palliative care has become more widely recognized across the institution as a resource and source of support for clinicians, patients, and families going through a very difficult experience. Gary Pasternak Medical Director Mission Hospice and Home Care Saying that his views have been shaped by his 20 years of experience as a practicing palliative care and hospice physician, most of it at a small, nonprofit, community-based hospice in San Mateo, California,
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From page 108... ...
The policy states that only one of the physicians (either the consulting or attending physician) involved in a patient's request for physician-assisted death can come from the hospice and that multidisciplinary involvement would always be offered and encouraged.
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From page 109... ...
She had lived in a large assisted-living facility for many years, and when she was diagnosed with a terminal illness, her goals of care were clear, and her primary care doctor honored her request for EOLOA and agreed to be the prescribing physician. One week before her final day, her assisted living facility had developed a policy that allowed this to occur at the facility.
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From page 110... ...
After extensive discussions, Pantilat continued, his team decided that it did not want everyone requesting assisted death to get a mandatory referral to palliative care. Most, but not all, of the palliative care physicians on the team did decide to be willing to serve as the consulting physician for most patients and as the prescribing physician for longstanding patients.
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From page 111... ...
He also said that pharmacies and pharmacists are crucial partners in the process and that it is vital to ask questions of patients and listen carefully to their answers about why they are bringing this up now and what they worry about most in the days ahead. Pantilat recommended that institutions developing policies in response to physician-assisted death laws should prioritize establishing a clear process and support for patients, families, and clinicians.
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From page 112... ...
It is also important to ensure that a patient has full informed consent and active participation of close family members. Quill listed the range of last-resort options, roughly ordered by how much societal agreement exists about their acceptability: • accelerating opioids to sedation for pain or dyspnea • stopping life-sustaining therapies • voluntarily stopping eating and drinking • palliative sedation, potentially to the point of unconsciousness • physician-assisted death • voluntary active euthanasia
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From page 113... ...
. Some hospice programs -- more than 35 percent in Oregon and 20 percent in Washington -- identified as non-participating, he said, largely because of religious considerations, though some non-religious programs have decided that physician-assisted death was outside of the scope of hospice care as they defined it.
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From page 114... ...
as non-participating indicated that it would discharge a patient from hospice care because that patient made a request or inquiry or had a conversation about physician-assisted death. A second group of hospice programs -- approximately 30 percent in both states -- were generally neutral on physician-assisted death and treated it as an issue between the physician and patient.
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From page 115... ...
. The reasons that various researchers have posited based on assorted studies include mistrust of the health care system, religious beliefs, health literacy differences, disparities in effective communication and care planning, and disparities between palliative and hospice care teams and minority populations.
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From page 116... ...
DISCUSSION Vulnerable Populations A workshop participant with experience as a palliative care nurse in Baltimore said she had felt uncomfortable when hearing in some presentations and workshop discussions that patients must be very persuasive in convincing their physician of the seriousness and legitimacy of their request for aid-in-dying. She said that she has seen that an already unequal power dynamic exists between patients from a vulnerable or minority population and their physician and that she is not surprised that few patients take this option, given the challenges of navigating the system as well as the need to persuade providers in multiple situations that this is the right approach for that individual patient.
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From page 117... ...
Christopher Kearney, the medical director for MedStar Health Palliative Medicine, said that he had been surprised that physician-assisted death was legalized in Washington, DC, and questioned whether the legalization would have been successful if the measure were voted on by ballot referendum as opposed to a city council vote. His experience as a physician in nearby Baltimore would indicate that there would not be support for such a law, he said.
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From page 118... ...
Lynn responded that on the broader issue of supporting long-term services and supports, few of the professional societies have spoken up in support of these issues. Regarding physicianassisted death policies, Lynn said, there could be efforts by professional associations into developing a relevant policy by receiving a wide range of input and having extensive discussions (as discussed by several representatives of hospital and hospice systems in Chapter 5)
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From page 119... ...
2010. Hospice and physician-assisted death: Collaboration, compliance, and complicity.
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From page 120... ...
Journal of Palliative Medicine 11(5)
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