Just out today, the Seattle Weekly has an in-depth article exploring the uncertainties surrounding a medical prognosis of having six-months to live and its implications for impending legislation for legalization of assisted suicide in Washington state.
From the article:
The law has deeply divided doctors, with some loath to help patients end their lives and others asserting it’s the most humane thing to do. But there’s one thing many on both sides can agree on. Dr. Stuart Farber, head of palliative care at the University of Washington Medical Center, puts it this way: “Our ability to predict what will happen to you in the next six months sucks.”
Reporter Nina Shapiro shares the somewhat “arbitrary” selection of a “six months or less” to live for assisted suicide legislation following Medicare guidelines for hospice eligibility. Here are the hoops Shapiro says doctors have to jump through to justify hospice for their patients:
To do so, doctors fill out a detailed checklist derived from Medicare guidelines that are intended to ensure that patients truly are at death’s door, and that the federal government won’t be shelling out for hospice care indefinitely. The checklist covers a patient’s ability to speak, walk, and smile, in addition to technical criteria specific to a person’s medical condition, such as distant metastases in the case of cancer or a “CD4 count” of less than 25 cells in the case of AIDS.
OTOH, the process for OKing assisted suicide is a lot less complicated:
No such detailed checklist is likely to be required for patients looking to end their lives in Washington, however. The state Department of Health, currently drafting regulations to comply with the new law, has released a preliminary version of the form that will go to doctors. Virtually identical to the one used in Oregon, it simply asks doctors to check a box indicating they have determined that “the patient has six months or less to live” without any additional questions about how that determination was made.
According to studies described in this article, roughly 20 percent of patients in hospice die at about the time their doctors say they will. Between 13 and 20 percent die after the time predicted by their doctors – some months or years after the date. The majority die sooner than the prognoses given by their doctors indicated.
But that’s just if you look at the population of hospice patients as a whole. Zeroing in on certain conditions yields some interesting data:
When a group of researchers looked specifically at patients with three chronic conditions—pulmonary disease, heart failure, and severe liver disease—they found that many more people outlived their prognosis than in the Christakis study. Fully 70 percent of the 900 patients eligible for hospice care lived longer than six months, according to a 1999 paper published in the Journal of the American Medical Association.
So, given all that uncertainty, what will doctors do? Some won’t participate. Others will only prescribe lethal medications to patients with a prognosis of a month or two to live.
Alarmingly, other doctors have a different way to deal with the dilemma:
The UW’s Farber leans toward a different approach. While he says he hasn’t yet decided whether he himself will write fatal prescriptions, he plans at least to refer patients to others who will. Given that prognostic precision is impossible, he says, “I personally just let go of the six months.” Instead, he says he would try to meet what he sees as the “spirit of the law” by assessing that someone is “near” the end of their life, so that he could say to them, “You’re really sick and you’re not going to get better.”
Knowing exactly when someone is going to die, he continues, is not as important as knowing when someone “has reached the point where their life is filled with so much suffering that they don’t want to be alive.”
In other words, according to Farber, the letter of the law and the strict guidelines that were promised aren’t important – or anything he’s obliged to follow. It’s probably not too big a leap to assume that some doctors in Oregon have already adopted that mindset (the article contains some good information the Oregon law makes it impossible to know how many people live long after getting a lethal prescription).
As I’ve noted elsewhere, “strict safeguards” are no better than posted speed limits on a highway. Farber and others of his profession know they don’t have to worry about monitoring or enforcement on this particular “highway.”
In the end, Farber is exposing what is already obvious to those of us who have watched and argued with the assisted suicide/euthanasia movement – this has nothing to do with medicine or a physician’s duties. It’s a value judgment, plain and simple. A lethal one. –Stephen Drake