170.994 Euthanasia and Physician-Assisted Death

“Euthanasia” contains the Greek words “eu” + “thanatos” (death) which means an easy death. Only the competent patient or the authentic proxy of the incompetent patient may decide what for each patient constitutes a good death.

Medical interventions may be withheld or withdrawn, allowing a disease process to continue its natural course leading to death. Competent patients have a moral right to seek a good death by refusing treatment if that is their wish. Furthermore, physicians have a moral obligation to honor the wishes of their competent patients or the authentic proxy of their incompetent patients, with respect to withholding and withdrawing undesired medical interventions.

“Euthanasia” has been used to describe a process in which an intervention by someone other than the patient is intended directly and immediately to bring about the death of a suffering patient at the patient’s request. Euthanasia is not permitted in the United States. Because it often involves a patient who cannot provide active participation or may not be capable of making an informed decision at the time, it remains an ethical barrier to physician participation.

Physician assisted death is defined as providing a terminal patient, who is capable of making an informed and independent medical decision, with the means of a medication that the patient can self-administer with the intent of causing death.

Withdrawal of medication or other life-sustaining treatment is not considered euthanasia. Providing treatment or medication with the intention of easing the pain of a dying patient is acceptable treatment and not euthanasia, even though such treatment or medication may foreseeably hasten the moment of death.

PHYSICIAN-ASSISTED DEATH

  • It is incumbent upon the medical profession to use all means to ensure that dying patients are provided optimal treatment for their pain and other discomfort. This may include the use of more aggressive comfort care measures, including greater reliance on palliative and hospice care, which can alleviate the physical and emotional suffering that dying patients experience.
  • Physicians should recognize the physical, social and existential needs of patients with terminal illness. Involvement of palliative care at early stages of serious life-threatening illness or injury can allow patients and their support system adequate time and information to anticipate choices in care when/if the condition becomes terminal. Emotional suffering should also be addressed by health care professionals with expertise in the psychiatric aspects of terminal illness.
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  • Every effort should be made to encourage advance care planning for patients and their families or support systems prior to disease progression.
  • Requests for physician-assisted death may be a signal to the physician that the patient’s needs are unmet and further evaluation to identify the elements contributing to the patient’s suffering is necessary. Multidisciplinary intervention, including specialty consultation, pastoral care, family counseling and other modalities should be sought as clinically indicated.
  • Further efforts to educate physicians about advanced pain management techniques, both at the undergraduate and graduate levels, are necessary to overcome any shortcomings in this area. Physicians should recognize that courts and regulatory bodies readily distinguish between use of narcotic drugs to relieve pain in dying patients and use in other situations.
  • The principle of patient autonomy requires that physicians must respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics and artificial nutrition and hydration.
  • The professional and societal risks of involving physicians in medical interventions intended to cause patients’ deaths are too great to condone euthanasia. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment including decisions regarding refusing or withdrawing care.
  • In those instances where state law or precedent permits physicians to assist terminal patients to self administer a lethal dose of medication with the intention of physician-assisted death: (1) Physicians and patients should be allowed to pursue options that do not violate either party’s fundamental values; and (2) Adequate protections must be in place to protect both physicians and patients, including but not limited to:
    1. Qualifications of a patient who can participate:
      • Adult, age 18 or older
      • Has the capacity to make medical decisions: able to understand their own condition, articulate their values, weigh risk and benefits
      • Has a confirmed terminal disease that is likely to result in death in 6 months
      • Is a resident of Colorado
      • Makes a voluntary request for aid in dying
      • Has had all feasible end-of-life services, including pain control, palliative care, comfort care and hospice
      • Must be able to self-administer lethal medication
      • Cannot take medication in a public place
    2. Medical Requirements

      • Physician must have the qualified patient request aid in dying directly and in writing.
      • Waiting period between requests.
      • Cannot accept a request through an advanced directive, a power of attorney or other proxy.
      • Must obtain a confirming second opinion on diagnosis of terminal disease and capacity of patient to make a medical decision.
      • Refer for counseling if patient is depressed or has mental health issues that may affect judgment (or requirement for mental health evaluation).
      • Must discuss and document all options for end-of life care, risks /results of taking lethal medication.
      • At the time of prescribing, must document that patient is making an informed decision and that the decision can be rescinded at any time.
    3. Reporting and documentation requirements

      • All discussions, consultations and prescriptions must be part of the patient’s medical record.
      • Physician’s duty to report to specified agency prescription for aid in dying, patient demographics, disease diagnosis, and insurance.
      • Yearly aggregated reports. Individual confidentiality.
      • Prescriptions identified as aid-in-dying medication.
    4. Other

      • Fraud protections: penalties for altering, forging prescriptions or suppressing rescissions.
      • Penalties for coercion from individuals, facilities or insurers to seek aid-in-dying medication.
      • Civil and other immunity for physicians who write prescriptions or who choose not to participate.
      • Requirements for witnesses to written request: must not be the patient’s provider; one cannot be related or a beneficiary.
      • Safe storage of prescribed medication and requirement of return of unused medication.
      • Prohibition of euthanasia.
      • Encourage family notification.

(Adopted by the board of directors, Sept. 16, 2016)