Death with dignity: A physician's perspective.

"And now, the end is near
And so I face the final curtain . . . .
I did it my way"
          "Comme d'habitude," translated into English by Paul Anka, made popular by Frank Sinatra, 1969

Sometimes people have had enough. 

Of almost 4,000 posts over 11 years, the post with the widest distribution was the one where I described helping my friend die.

It was a solemn, emotionally-charged day for me. It was a quiet relief for my friend. I wrote about it from the point of view of the helpful friend who could legally acquire and mix the prescription medicine that would end his life, then hand it to the patient. Bill Southworth read that post. He writes today sharing a physician's perspective on end-of-life care.

Bill Southworth became a licensed physician in Oregon in 1979, then worked and practiced in Ashland, Medford, Yreka and other locations. When he retired 2003, he changed his Oregon license to “active emeritus status” which allows him only pro bono volunteer work. He told me he follows the rules and answers to Oregon law, to the Oregon Health Authority (OHA), and follows best practices and reporting requirements of the Academy of Aid in Dying Medicine.

Guest Post by Bill Southworth, M.D. 

I am now 85 and see only terminally ill patients seeking access to MAID. The term Physician Assisted Suicide is discouraged (I consider it pejorative.) Assisting a suicide by a physician or anyone else is a felony in all U.S. jurisdictions. The cause of death recorded on certificates of patients who have met all eligibility requirements for obtaining and using a legal MAID prescription carry the diagnosis of the underlying disease that allowed them to qualify.

I became exclusively a MAID provider in 2016. Since then I have counseled around 100 patients, and have written prescriptions for 40 or more, around 10 per year. I attend ingestions and deaths when asked or needed. I taught a class at OLLI (Osher Lifelong Learning Institute) on DWD/MAID, which was well attended. This has been the most important and deeply satisfying work I have ever done. It is time-consuming to visit patients in homes or places of care, examining them, reviewing records, seeking a confirming consultation, communicating with family members, to establish eligibility according to the DWDA. Add to that record-keeping and reporting requirements. I’m not held to productivity goals and cannot send bills. I don’t know how I would have fit this into an office schedule. Most of the patients I see are too ill to leave home easily and be transported to an office. I have received more expressions of gratitude from patients and families than I ever did during my previous practice years. I don’t hide what I do. Even a couple of my conservative friends, probably Trump voters, have said MAID is a good thing, consistent with their ideals of freedom of choice.

I learned about caring for dying patients as an internal medicine resident in 1975 during my rotation on hematology-oncology. I learned more in the 1990s as an office-based internist when I referred several terminal patients to hospice programs. I continued to follow them at home or in nursing homes. Hospice agencies have greatly improved since then. MAID and hospice are not either/or choices. I require admission to hospice before issuing a prescription.

I encourage an effective advance directive and sometimes refer to the federally enacted 1990 Patient Self Determination Act (PSDA). In recent years more local community physicians have become comfortable with prescribing for their own dying patients and accepting referrals, no longer afraid of the “doctor death” stigma or attacks from militant moralists. Clinic-based specialty physicians have become more willing to provide the confirming consultation to enable another doc to prescribe, though some groups forbid their member physicians from prescribing.

Other pro bono MAID providers around Oregon believe the option rightfully belongs within the range of services provided by hospice for patients who ask for it. Several already have in Washington and California. Their medical directors can now prescribe MAID drugs. I’ve been told by an unnamed source that two Oregon hospice programs include MAID, but so far none in our part of the state.

I wrote in support of Oregon’s DWDA in 1997 when the initiative was on the ballot. Several respected and sincere colleagues at the time wrote in opposition, citing adherence to the Hippocratic Oath and religious values. When I graduated from UCSF School of Medicine in 1969 my class of 120 was asked to stand and recite the oath in unison. I remained silent. I thought it was a perfunctory exercise, pledging to mythical Greek gods to abide by an archaic ethical code. It was never enforced in modern times anyway. The AMA code of medical ethics still said that lethal medication to end a dying patient’s suffering was incompatible with a physician’s role as healer. That has changed. It’s now a matter of individual conscience, and in a 2017 issue of JAMA (Journal of the American Medical Association) a secular pledge of responsibility to patients was published based on the World Health Organization’s 1948 Articles of Geneva for Health Care Professionals, emphasizing patients’ rights to self-determination and privacy.

All local hospice programs provide professional and compassionate bedside care. The MAID cocktail is not included with hospice comfort medications, nor covered by insurance. Hospice personnel are not expected (in most cases prohibited) to mix or handle the MAID medications, but their continuing bedside support of dying persons and their families following ingestion is essential. Unconscious and in deep coma after 5-10 minutes, 80 percent of deaths occur within two hours after voluntary ingestion, but occasionally it may take several hours. Patients are never left alone.

Bedside support and guidance by trained volunteers is encouraged through End of Life Choices Oregon (EOLCOR), a non-profit agency with local teams based in several regions including in Southern Oregon. They are proficient in finding cooperating physicians (don’t ask for a list) and handling the compounded powder, mixing it at the bedside, relieving family or hospice personnel of that task with steady hands. I’m counting on them to be there should the need arise.

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