Washington's Initiative 1000 is modeled on Oregon's Death with Dignity Act
In November, Washington will vote on an initiative to allow doctors to prescribe lethal medications for terminally ill people with less than six months to live. In Oregon, the only state in the nation with such a law, relatively few patients have chosen that option, but the 10-year-old measure still generates emotional controversy.
Seattle Times staff reporter
The Patient. A patient requesting a lethal dose of medication to end his life must:
• Be a terminally ill, mentally competent adult state resident expected to die within six months.
• Be free of depression and able to muster sound judgment.
• Request the prescription verbally and in writing and again verbally after a 15-day waiting period.
• Have two witnesses to his or her request. One of those witnesses must not be an heir, related or employed by the health-care facility caring for the patient. No witness is required to be present when the patient takes the drugs.
The Doctor Any doctor can opt out of providing the lethal prescription to a patient. A willing doctor must:
• Determine that the patient is competent and acting voluntarily.
• Inform the patient of the medical diagnosis, prognosis and the risks and probable result of taking the lethal dose.
• Offer alternatives, including pain control, comfort care and hospice.
• Inform the patient of the right to rescind the request at any time.
• Refer the patient to a second, consulting doctor who must verify that the patient has a terminal disease, is competent, acting voluntarily and making an "informed decision."
• Refer the patient for counseling if patient is depressed or otherwise not competent.
• Recommend that the patient notify next of kin.
• Document in the medical record all the steps required by the law.
• Must dispense medications directly to the patient, the doctor or a chosen representative of the patient.
Source: Initiative 1000
This measure would permit terminally ill, competent adult Washington residents, who are medically predicted to have six months or less to live, to request and self-administer lethal medication prescribed by a physician.
Tony Miller spends his days in a towel-draped chair, heavily medicated and sweating profusely as prostate cancer spreads through his body. Over and over again, he changes out of drenched T-shirts and shorts, puts them on a hanger to dry and then goes back to his chair to sweat some more.
After a lifetime of international travel as a journalist, the 65-year-old Miller has made this one-room apartment in Portland his final home.
Miller was drawn here by an only-in-Oregon-law that enables terminally ill patients to obtain lethal prescriptions once their life expectancy falls below six months.
"It all depends on the level of pain," Miller said. "When it gets to the point when the medication is not working and life is grim — I will make my final decision."
In November, Washington voters will decide on Initiative 1000, which would make the state the second to allow physicians to prescribe lethal medications for patients diagnosed with less than six months to live.
The Washington initiative is modeled after the Oregon law, which has been used by a relatively small number of people since its passage in 1997.
During the past decade, lethal prescriptions were involved in the deaths of 341 people, about 1 in every 1,000 people who died during that period. Each year, fewer than 100 doctors are involved in writing the prescriptions.
Proponents maintain the law still has had wide-ranging impacts, helping to improve pain management of terminally ill patients and spur more open discussions about end-of-life care. A 2004 study — based on a sampling of family interviews — found 15 percent of terminally ill patients discuss the lethal-prescription option.
"It has provided tremendous relief to a modest number of patients every year but brings security and comfort to all the patients who are dying of illness, in knowing that option exists," said Dr. Nicholas Gideonse, a Portland doctor who has written about a dozen prescriptions for terminally ill patients.
Recent statistics point toward an upward trend in lethal prescriptions: The 49 deaths tallied by state statistics in 2007 were more than triple the 16 people who ingested the lethal prescriptions back in 1998.
The law also continues to stir controversy.
Until 2006, for example, the Oregon Department of Human Services, called the lethal prescriptions "physician-assisted suicide," a commonly used term. Then, under pressure from advocates who believed the term was inaccurate, the state dropped that terminology and instead refers only to the "Death with Dignity Act."
That decision rankled opponents of the law.
"I believe in death with dignity," said Dr. Bill Toffler, a doctor fiercely opposed to the law. "I don't believe in empowering doctors to give massive overdoses so that patients can kill themselves."
In June, another issue provoked debate.
Barbara Wagner, a Lane County woman suffering from lung cancer, was turned down by the state's Oregon Health Plan for a new drug called Tarceva. In a letter sent by a company that administers one of the state's insurance plans, Wagner was informed of the "physician aid in dying" option that could include lethal prescriptions as well as visits to doctors required to obtain the drugs.
"I was absolutely hurt that somebody could think that way," said Wagner. "They won't pay for me to live but they will pay for me to die."
But her anger at the state, chronicled in the Eugene Register Guard, prompted Oregon officials to tell those administering the plans to stop sending such letters. The Oregon Health Plan, which allocates treatment dollars according to a priority system, continues to pay for lethal prescriptions.
During the last decade, 19 people on the state health plan have chosen that option. These prescriptions are funded solely by state dollars because of a ban on the use of federal dollars for this purpose.
The Washington state initiative does not specify whether state dollars could be used to fund the lethal prescriptions. That would be decided later, likely by the Legislature.
Final moments, final acts
Annual state reports note that 85 percent of the physician-assisted deaths in Oregon have involved various forms of cancers, The most frequently cited end-of-life concerns were losing autonomy, dignity, control of body functions and the ability to enjoy life. The vast majority of the patients also are enrolled in hospice care.
The Oregon act requires self-ingestion of the lethal prescription. That draws a crucial line between the Oregon law and The Netherlands, where euthanasia — the injection of a lethal drug by a doctor — is permitted.
Advocates say that line is respected and note many patients are unable to take advantage of the law because they become too weak to take the drugs themselves.
But the final moments often are cloaked in privacy.
Critics of the law point to one death in 1999 involving a Coos Bay man dying of amyotrophic lateral sclerosis, also known as Lou Gehrig's disease, which progressively erodes voluntary muscle control.
In an interview with The Oregonian, a brother said the man couldn't complete the act, so he helped, but his actions were not detailed. That case raised the question about how much bystanders can help, such as holding the glass so the patient can take the medication.
The average time to death after taking the lethal prescriptions is about 25 minutes, according to Oregon state statistics. But in one 2006 case noted in Oregon's annual report on the act, a man who swallowed his medication regained consciousness 65 hours later. He then died 14 days later of his underlying disease.
The Oregon law, as well as the Washington initiative, also includes safeguards to prevent depressed people from using doctors to end their lives.
Before obtaining the prescriptions, the patient must consult two doctors. Each must have consultations with two physicians who must both conclude that the patient has less than six months to live. Patients who might be suffering from mental illness are supposed to have a psychiatric evaluation.
In the first decade of the law, less than 11 percent of the patients received such referrals. Last year, there were none. "It is of concern that there are not more referrals to psychiatrists because you would expect that the rate of depression would not be zero," said Dr. Linda Ganzini, a Portland psychiatrist who helped develop an Oregon Health & Science University guidebook for health professionals about the act.
Ganzini also conducted a study of 58 terminally ill patients. She found that three people who took the prescriptions met the definitions of clinical depression, and concluded that the Oregon law " may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug."
Gideonse says that most doctors are used to assessing mental competency, since those types of assessments must be made for a range of issues. The patients who request lethal prescriptions have typically fought their disease for a long time and thought long and hard about their decision. Often they have a fierce streak of independence, and despise being shackled to the timetable of their disease.
"They are trying to regain control to write the final chapter," Gideonse said. "Their illness has robbed them of the body they knew. Their future. It's taken away their relationships."
Gideonse often shares the final moments of his patient's lives. He recalls his home visit with a cowboy who had cancer of the esophagus. Family members gathered in the room, then vacated as the man smiled and waved goodbye with his dog by his side. With Gideonse in attendance, he drank the barbiturate.
Miller is another independent soul who longs to be in Cuernvaca, Mexico, where he spent the last six years teaching history. There, he was diagnosed with severe prostate cancer and decided to leave friends behind to return to the United States for treatment in Maryland. He then made his move to Oregon.
Miller was deeply affected by the 1999 cancer death of his younger brother, who despite hospice care, still suffered through great pain at the end. Miller hopes that the Death with Dignity Act can help him avoid a similar fate.
Separated from friends in Mexico, Miller is lonely and wonders if he has enough time and strength to make a final visit south of the border. Miller reads books, e-mails friends and survives on a modest diet of Lean Cuisine microwave dinners and canned soups.
Once doctors certify he has less than six months to live, Miller intends to secure the lethal prescriptions.
"I am doing all I can to stay alive and prolong my life up to the point where my life becomes nothing but physical agony," Miller said. "With the Death with Dignity Act, I feel safe."
Hal Bernton: 206-464-2581 or firstname.lastname@example.org
Copyright © 2008 The Seattle Times Company
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