Approved
by the Board of Directors
February 14, 2007
Suffering
near the end of life arises from many sources
including
relentless pain, depression, loss of sense of self, loss of control and
dignity, AAHPM
fear of the future, and/or fear of being a burden upon others.
A primary goal of the American Academy of Hospice and Palliative
Medicine (AAHPM)
is to promote the development, use, and availability
of palliative care
to relieve patient suffering and to enhance quality
of life
while upholding respect for patients' and families' values and
goals.
Excellent
medical care, including state-of-the-art palliative care,
can control most symptoms and augment patients' psychosocial and
spiritual resources
to relieve most suffering near the end of life.
On
occasion, however, severe suffering persists;
in such a circumstance a
patient may ask his physician for assistance
in ending his life by
providing Physician-assisted Death (PAD).
PAD is defined as a physician
providing, at the patient's request,
a lethal medication that the
patient can take by his own hand
to end otherwise intolerable
suffering.
The term PAD is utilized in this document with the belief
that it captures the essence of the process in a more accurately
descriptive fashion
than the more emotionally charged designation
Physician-assisted Suicide.
Subject to safeguards, PAD has been legal
and carefully studied in Oregon since 1997.
In all other states, PAD
remains prohibited by law,
although there is an underground practice
that remains largely unstudied.
Situations
in which PAD is requested are particularly challenging
for physicians and other healthcare practitioners
because they raise
significant clinical, ethical and legal issues.
When
a request for assistance in hastening death is made by a
patient,
AAHPM strongly recommends that medical practitioners carefully
scrutinize
the sources of fear and suffering leading to the request
with the goal of addressing these sources without hastening death.
A
systematic approach is essential.
Evaluation
of requests:
Initial
responses to requests for hastened death:
When
unacceptable suffering persists,
despite thorough evaluation,
exploration, and provision
of standard palliative care interventions as
outlined above,
a search for common ground is essential.
In these
situations, the benefits and burdens of the following alternatives
should be considered:
Despite
all potential alternatives, some patients may persist in
their request specifically for PAD.
The AAHPM recognizes that deep
disagreement persists regarding the morality of PAD.
Sincere,
compassionate, morally conscientious individuals stand on either side
of this debate.
AAHPM takes a position of "studied neutrality"
on the
subject of whether PAD should be legally regulated or prohibited,
believing its members should instead continue to strive to find the
proper response
to those patients whose suffering becomes intolerable
despite the best possible palliative care.
Whether or not legalization
occurs, AAHPM supports intense efforts
to alleviate suffering and to
reduce any perceived need for PAD.
For
physicians practicing in regions where PAD is legal,
AAHPM
advises great caution before instituting PAD including assurance that:
Whenever
PAD is being considered by a patient with his or her
physician,
patients should continue to receive the best possible
palliative care.
Although many hospice and palliative care
practitioners
find it morally unacceptable to participate in PAD even
where legal,
neither a person requesting PAD nor his family should be
deprived of
any other measure of ongoing palliative care during the
dying process and period of bereavement.
The most essential response to
the request for PAD in the practice of palliative care
is to attempt to
clearly understand the request,
to intensify palliative care treatments
with the intent to relieve suffering,
and to search with the patient
for mutually acceptable approaches
without violating any party's
fundamental values.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fourth ed. New York: Oxford University Press, 1994
Block SD, Billings JA. Patient requests to hasten death: Evaluation and management in terminal care. Arch Intern Med 1994; 154:2039-2047.
Foley K, Hendin H, eds., The Case Against Assisted Suicide: For the Right to End-of-Life Care. Baltimore: Johns Hopkins University Press, 2002.
www.egov.oregon.gov/DHS/ph/pas/index.shtml
Meier DE, Emmons C, Wallenstein S, Quill TE, Morrison RS CC. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338:1193-1201.
Okie S, "Physician-Assisted Suicide-Oregon and Beyond." NEJM 2005; 352 (16):1627-1630.
Quill TE, Battin MP.eds. Physician-Assisted Dying, The Case for Palliative Care and Patient Choice. Baltimore: Johns Hopkins University Press, 2004.
Quill TE, Byock I. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. Ann Intern Med 2000; 132:408-414.
Quill TE, Cassel CK. Professional organizations' position statements on physician-assisted suicide: a case for studied neutrality. Annals of Internal Medicine 2003; 138(3):208-11.