Doctors explore life-end options.

Byline: TIM CHRISTIE The Register-Guard

Even doctors who are morally opposed to physician-assisted suicide should listen when patients ask for help ending their lives and explore the reasons behind the request, two Oregon researchers concluded in a case study published Tuesday.

By listening to patient concerns and fears, doctors can in most cases present alternatives that ensure that the person will die comfortably without resorting to suicide, the authors say in the article published in the Journal of the American Medical Association.

"Many patients are not afraid of death, but of the process of dying," said Dr. Paul Bascom, the article's lead author and an assistant professor of medicine at Oregon Health & Science University in Portland.

In the study, he said a patient's initial request for physician-assisted suicide "should be interpreted as a call for information about the future and an appeal for a commitment to respond to anticipated suffering."

"Patients and their families are eager for the physician to provide guidance about what lies ahead," he wrote. "The physician who responds with avoidance, dissuasion or rejection has failed to hear the patient's cry."

The authors made a point not to debate the merits of assisted suicide, focusing instead on the obligation of doctors to provide comfort and put patients' needs first.

Bascom, a Eugene native, and co-author Dr. Susan Tolle, who directs the Center for Ethics in Health Care at OHSU, also report that the vast majority of people who ask a doctor about assisted suicide never follow through.

About 10 percent of patients seriously consider doctor-assisted suicide, and only 1 percent specifically request it. About 10 percent of the 1 percent who request it actually receive and take a lethal dose of prescription drugs.

In their article, Bascom and Tolle examined a case study involving a man dying of amyotrophic lateral sclerosis, known as ALS or Lou Gehrig's disease. The article was published as part of a series in the medical journal called "Perspectives on Care at the End of Life."

The man, a 47-year-old Oregon truck driver identified as Mr. G, was transferred to a skilled nursing facility after he could no longer care for himself. He came under the care of Dr. R, the house physician.

When Mr. G asked Dr. R for help in ending his life, Dr. R did not respond directly or ask Mr. G why he would make such a request. Instead, he referred Mr. G to a home hospice program and discontinued caring for the patient.

"I explained that I wasn't trying to abandon him as a patient, but I couldn't facilitate" physician-assisted suicide, Dr. R told researchers. "I made no judgment about someone else doing it; I just felt that, as a physician, there was a line I couldn't cross."

The doctor's abandonment left Mr. G distressed and "terrified," a hospice worker said in the article.

"He wept at what he called his loss of control and his options," she said. "He felt like everything was pulled out from under him."

The hospice medical director, Dr. L, began caring for Mr. G and the two began having conversations about end-of-life issues. Mr. G's father did not receive aggressive pain treatment while dying of colon cancer and died a lingering, painful death. Mr. G feared a similar fate.

Dr. L told Mr. G what he could expect to face in the final stages of his disease, how symptoms could be treated and about various life-sustaining treatment options. After these conversations, Mr. G decided against assisted suicide.

"Dr. L made him feel very sure that his end would be pain-free and peaceful; that he would not suffer the burning legs and the anguish that he was afraid he would suffer," the hospice social worker said. "Dr. L would give him whatever amount of pain medication or sedation was necessary so that he would not suffer at the end."

Mr. G died comfortably under a treatment plan designed by Dr. L.

"The case study is a perfect example of what can and does occur in health care settings," Bascom said. "At times, communication can break down, causing additional stress to dying patients and their families."

But more important, the case demonstrates the importance of in-depth and open patient-doctor conversations about end-of-life issues to identify concerns, put patients at ease and help them make informed decisions, Bascom said.

"While Oregon is the only state where physician-assisted suicide is legal, we believe this message of communication can be of value to physicians and patients throughout the U.S. and around the world," he said. "If we are afraid to talk about the tough issues, our patients suffer."

The report was praised by assisted suicide supporters. The Oregon Death with Dignity Center said the article "vividly demonstrates the positive impact" Oregon's law has had on end-of-life care.

"Physicians, who for their own reasons choose not to assist a patient under the law, are free to make that choice, too," said the group's executive director, Scott Blaine Swenson. "It's the dialogue and the choice that are vital."

Dr. Gregory Hamilton, of Physicians for Compassionate Care, which opposes assisted suicide, said the authors didn't go far enough and should have stated that "nobody needs this assisted suicide."

"This article is a soft sell for assisted suicide, attempting to legitimize it in the minds of doctors in the entire United State of America," he said. "Yes, you should explore (the patients') feeling, but you should not write them a prescription for a lethal overdose, because that's like handing someone a loaded gun. You just don't do that. You don't hand a desperate and suicidal patient a loaded gun."