Physician assisted suicide (PAS):

Does PAS increase pain of dying patients?

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Overview of the Oregon law:

A Death With Dignity law went into effect in Oregon in 1997. It allows some terminally-ill patients to request assistance in committing suicide. They must have fewer than six months to live. They must make at least two oral requests for help, make at least one written request, and convince two physicians that they are not depressed or suffering from another mental illness.

By the end of 2003, 171 individuals have ended their life with the help of lethal prescriptions. The number appears to be leveling-off at fewer than 50 assisted suicides per year. Physician assisted suicide under the act accounts for only one-seventh of one percent of all deaths in the state.

Oregon study:

According to the Associated Press, there is a widespread belief that pain control has improved markedly in Oregon following the passage of the law. Pain control for those who took advantage of the law certainly has improved; they were able to hasten their death and be free of protracted physical and emotional pain. But about 99.9% of people in Oregon still die a natural death, or die in accidents, unassisted suicide, or as a result of homicide. Of these, most are believed to die due to natural causes; many spend their last weeks in moderate or severe pain.

Researchers at the Oregon Health & Science University (OHSU) conducted a survey of the level of pain among 1,724 patients in Oregon who died outside of hospitals -- that is, at home, in nursing homes or assisted living centers. Their findings were published in the Journal of Palliative Medicine. ₄ They studied 1,384 patients who died from 2000-JUN to 2002-MAR, and compared them with 340 who had died between 1996-NOV and 1997-DEC, mostly before the PAS became available in 1997-NOV. Actually, the study actually examined pain levels as subjectively perceived by family members of the patient, not the patients themselves.

The study found that 48% of the post-1997 patients were judged to be in moderate or severe pain in their last week of life, compared to 31% of the pre-1997 patients. Associated Press reported that:

"After accounting for medical and demographic differences, the researchers concluded that dying patients in the later group were twice as likely to be described as having endured moderate or severe pain."

Interpretation of the results by the researchers and secular media:

Researchers suggested three reasons why an increased number of patients are judged to be in moderate or severe pain may be:

	The two ballots and the intense public, legislative, court and religious debate over the Death with Dignity law raised expectations about pain control in the state. Family members have become sensitized to pain being experienced by their terminally ill loved ones. The Oregonian newspaper indicated that recent studies "...have suggested that both doctors and patients are more aware of the importance of pain relief." 2
	Stretched budgets for the care of Medicaid and Medicare patients prevent adequate patient care. 1
	"The negative impact of overstretching nursing resources on pain management ...." 2

The Oregonian newspaper added two more possible reasons:

In recent years, there has been "...controversy over the misuse and addictiveness of the prescription narcotic OxyContin [which has] scared doctors and patients." The end result is that some patients are not prescribed a sufficiently high dose to control pain.

Some physicians have been "...skittish about prescribing strong pain drugs..." because the U.S. Attorney General has threatened to prosecute doctors for violating federal drug laws if they prescribed a lethal dose of medication in response to a request for assisted suicide under Oregon law. Again, the result is that some physicians feel that the government is looking over their sholder whenever they issue a prescription for narcotics. Some of their patients are under-medicated and others are not medicated at all. 2

The study was led by Dr. Erik Fromme, assistant professor of general medicine and geriatrics at OHSU and senior scholar in its Center for Ethics in Health Care. He said:

"What this study did for me was contrast our view of things versus what's actually happening....People all around the state have heard the publicity, but they haven't necessarily gotten better care. If people's expectations are higher, I'm glad.  But in addition to expecting more, I hope they'll push health care providers to get them the care and pain relief they need."

Ann Jackson, executive director of the Oregon Hospice Association said that the results show how important it is for family members "to be constantly vigilant when it comes to pain and end-of-life care. The system default is to do as little as possible."

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Interpretation of the results by the conservative religious media:

The conservative religious media are have given the report from Oregon a high profile. It supplies them with ammunition with which they can fight current initiatives to bring PAS choice to Hawaii, Maine, Michigan, and Vermont. However, they seem to have distorted their coverage of the Oregon study.

The conservative religious media generally imply that:

	The Oregon study is an objective evaluation, implying that actual pain levels of dying patients were measured and have increased. Secular media generally report that the study is subjective and the result of the opinion of families of patients.
	The direct cause of the problem is a degeneration in the quality of palliative care in the state.
	The availability of PAS is the direct cause of the deterioration in care.

They generally ignore what are probably the main reasons for the degeneration in care:

	As a result of publicity and debate surrounding PAS, families of terminally ill patients have now become much more sensitized to levels of pain that are endured by their loved ones.
	Medicare and Medicaid is chronically under-funded and that funding is is not keeping up with the increased drain on the system due to increased poverty and an aging population in the U.S.
	There are inadequate nursing resources in the state.
	There are problems in prescribing medication arising from controversy over its addictive properties and threats of prosecution by the Federal government.

Family News in Focus, a service of the fundamentalist group, Focus on the Family:

Concluded that "The study shows terminal patients in Oregon are about twice as likely now to suffer pain than before assisted suicide became legal."  This is not accurate; the research showed that a subjective evaluation by families of a dying person indicated that more patients experience moderate or severe pain. The actual pain being experienced by the terminally ill was not measured.

Quoted Carrie Gordon Earll, their bioethics analyst, who said that the deterioration of the state of palliative care in Oregon should have been anticipated. She said that: "Earlier studies were interpreted to indicate that there was somehow a silver lining in helping bring better palliative care to Oregon after they had legalized assisted suicide. And that doesn't even make sense because the message is: if you can't deal with your pain and your symptoms, go a head and kill yourself." 3

LifeNews interviewed Dr. Robert Orr, president of the Vermont Alliance for Ethical Healthcare about the OHSU report. He said:

"Proponents of the legalization of physician-assisted suicide in Vermont often cite the Oregon experience, saying that the 1997 passage of such a law in that state has resulted in better end-of-life care. The facts contradict this assertion....Indeed, Oregon was a pioneer in hospice care, leading the nation in percentage of patients dying at home with hospice care...But this happened in the 1980s and early '90's -- several years before legalization of physician-assisted suicide. And this study from the Journal of Palliative Medicine now shows that pain management at the end of life is no better in Oregon than in other states. In fact, this most important quality indicator of hospice care has deteriorated since 1997." ₅

References:

1. "Study: Ore. patients twice as likely to experience pain at end of life," KGW.COM, 2004-JUL-23, at: http://www.kgw.com/
2. Don Colburn, "Study says pain control isn't better. An OHSU study finds that pain management has not kept up with expectations of the 1997 law," The Oregonian, 2004-JUL-23, at: http://www.oregonlive.com/
3. Terry Phillips, "Oregon Patients Die in Pain, Despite Assisted Suicide," Family News in Focus, 2004-AUG-2, at: http://www.family.org/
4. Erik K. Fromme, et al., "Increased Family Reports of Pain or Distress in Dying Oregonians: 1996 to 2002, Journal of Palliative Medicine, 2004-JUN-01, Vol 7, #3, Pages 431 to 442. Abstract available at Ingenta, at: http://www.ingenta.com The article itself can be ordered from http://www.ingenta.com/ for $42.00 US plus tax.
5. Paul Nowak, "Palliative Care for Elderly, Disabled, Worse Since Assisted Suicide Legalized," LifeNews. Online at Christian Life Resources at: http://www.christianliferesources.com/

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Copyright © 2004 to 2010 by Ontario Consultants on Religious Tolerance
Last updated 2010-SEP-03
Author: Bruce A Robinson

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