Assisted suicide 101.

'What does the handbook say about euthanasia?'

HOW SHOULD A FACILITY RESPOND TO A resident's request to die? While it is a crime in most states in this country to aid another to commit or attempt suicide, 9 out of 10 Dutch health care institutions surveyed cite specific conditions under which euthanasia or assisted suicide (EAS) is acceptable.

The question of whether they have an institutional guideline on EAS was posed recently to 324 Dutch nursing homes, according to a report citing the American Medical Association. Some 313 (97 percent) of directors of patient care responded to the mailed questionnaire, The results revealed written guidelines exist in 182 (58 percent) of the nursing homes that responded.

Of those guidelines, 135 (74 percent) concerned EAS; in 47(26 percent), EAS was part of a guideline on terminal care. EAS is an acceptable policy under specific conditions in 165 (91 percent) of these guidelines; EAS is banned completely in 18 (10 percent).

In all but Oregon, it is illegal to help residents take their own life, although patients themselves may have the right to refuse even lifesaving medical treatment. In 1994, the first Death with Dignity Law was passed in Oregon by a 51-49 percent margin. In 1997, the law was defended against repeal, winning by a 60-40 percent citizen initiative.

"There is action in Congress to overturn the law in Oregon," says Nancy Gorshe, senior vice president of Portland, Ore.-based Assisted Living Concepts. "I think the law will stay legal in Oregon. The real issue is care. That's why people in the state have voted for the right to choose," she explains.

According to The Oregon Death with Dignity Act:

* The request must be voluntary

* No doctor is forced to comply

* The patient must be an adult who is terminally ill and mentally competent

* The request must be an enduring one; a 15-day waiting period is required

* An examination by a mental health professional may be required

* The request must be made orally and in writing and witnessed

* All alternatives will be explained to the patient

* The patient receives a prescription for a lethal dose of medication, which must be self-administered

* The patient may change his or her mind at any time

The right-to-die issue is a polarizing one. "We oppose physician-assisted suicide because many of our members are religiously affiliated," says Robert Greenwood, associate director of public affairs for the American Association of Homes and Services for the Aging. "We put a lot of our energy into looking at end-of-life issues including palliative care." (See "The shift to palliative care," February 2000 CLTC, page 27.) "We want to give a resident every option available."

If a patient is asking about the right to die, "a facility's first responsibility is to contact hospice," says Tom Burke, a spokesman for the American Health Care Association. "Nursing homes are geared to providing daily living needs; hospice addresses pain management needs."

Gorshe concurs: "Hospice has been a very underutilized service. We want to educate physicians to better manage pain."

Recent studies have shown that pain near the end of life has been seriously undertreated, says Greenwood. "So you have to balance the quality of life with the quantity of life."

Gorshe says the Dutch study is as an important reminder to the health care community to keep its eye on the ball. "We need to keep heightening awareness," she says.