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Friday, January 11, 2008

Former Governor's Death With Dignity Initiative

Booth Gardner, former Washington State Governor is campaigning to have physician-assisted suicide legalized in Washington State. Since the New York Times published an article on his initiative the same week the healthpolicymaven posted an article about palliative care and medical directives, a closer look at the ramifications of the proposed legislation follows.

Gardner is traveling throughout the state soliciting support for an Oregon style assisted suicide law, which would allow physicians to provide patients with suicide medication dosing under very specific circumstances. A similar measure was put before Washington voters in 1991 and defeated by 54% of the voters. Though suicide is legal in Washington, physician aided death is not.

Here are the provisions for the proposed Death with Dignity referendum if it copies Oregon State Law:
-Permits legally competent patients who are at least eighteen years of age, state residents, and who suffer from a terminal disease, to obtain lethal prescriptions
-The patient must make two requests to end to their suffering, with at least a fifteen day separation between the pleas
-Patient must obtain two separate opinions from physicians indicating the patient has less than six months to live
-Would allow Physicians to prescribe a lethal dose of medications to patients, but not administer the drugs
-The state would track the number of assisted suicides, just as it tracks other causes of death

Oregon’s Death with Dignity Law was passed with a 51% majority in 1994, and enacted in 1997 after overcoming legal challenges. Oregon has reported just 292 assisted suicides over the last ten years. Though 455 people in that time frame obtained prescriptions for lethal medications, only 64% acted on the desire to end their life. When you compare the number of Oregonians who died a natural death from similar causes, less than one tenth of one percent of the residents opted for assisted suicide.

Difference between terminal sedation and euthanasia
It is important to differentiate terminal sedation from euthanasia and both practices were analyzed in a Netherlands study in 2006. In the Netherlands study, clinical practices were reviewed for 410 physicians and their patients who were primarily diagnosed with cancer. The report showed that patients who requested euthanasia were typically more concerned about loss of dignity and were less anxious (15%) than patients requesting sedation (37%). Physicians reported that terminal sedation had shortened participant’s lives by one week in 27% of the cases, whereas 73% of the euthanasia cases were shortened by a week.

Opponents of suicide frequently express concerns that the uninsured and vulnerable will be taken advantage of with a formalized right to assisted suicide. First, lets hope the United States decides to provide health care for all of its residents in the near future. Secondly, since such a small portion of the population who are eligible for assisted suicide in Oregon and elsewhere, actually make this election, there is minimal financial incentive for a health care system to hasten the death process. Using the Netherlands example of a life reduced by one week, we could apply the Medicare reimbursement to the number of patients who would make that choice. This scenario would depend on whether or not the patient was in an acute care or long-term care facility and the location of the facility. Lets assume all of the patients were Medicare eligible and use the Oregon average of 38 assisted suicides per year to calculate the potential reduction in Medicare charges. According to the Washington State Hospital Association, the average Washington State hospital payment under Medicare was $4,603 in 2005, with an average length of stay of 4.37 days. Based on the Netherlands study we could assume Washington might save $1,053 per day or $7,373 per patient, by avoiding a week of inpatient care for end-of-life treatment. In this example, the maximum savings to Medicare would be $280,183 for this population over an entire year.

Who else does it
Other countries have legalized assisted suicide protocols, foremost of which is Netherlands, who report 2,000 assisted suicides per year. Netherlands is the only country that also permits legal euthanasia. In 2002, the Council of Europe conducted a comprehensive survey on assisted suicide provisions, which found eight countries that responded they did not outlaw the practice of assisted suicides. However, only four countries had legal and transparent provisions for assistance with suicide: Netherlands, Switzerland, Belgium, and Oregon State in the U.S.A.

Certainly some practitioners in the medical profession may raise concerns about violation of the Hippocratic oath for assisting patients with suicide. However, in a 1998 survey of oncologists, the Journal of the American Medical Association reported 16% indicated they had anonymously assisted in patient suicides. So, it would seem the practice of helping patients end their suffering is not new, just lacking in formality for Washington and other states. Gardner needs to have 225,000 signatures by July to get this initiative on the ballot in November.

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