TAMPA — A patient's request for a hastened death—either an explicit request or a hint—should be considered a clinical emergency that offers an important therapeutic opportunity.
“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.
“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”
Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.
In Oregon—where physician-assisted suicide is legal in certain circumstances—65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.
“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.
Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.
And because many of the somatic symptoms of depression—including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion—are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.
When a patient with advanced illness asks for help dying, it's important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed. Acknowledging this is part of the therapeutic challenge.
The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen—an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.
“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.
Expressing empathy—with comments such as “I can't imagine how hard this must be for you”—can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.
It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment—antibiotics and dialysis, for example—they are essentially committing suicide. “We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.
Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.