Responding to Requests for Physician-Assisted Suicide: Title and subTitle Break"These Are Uncharted Waters for Both of Us . . . "

In July 2002, Paul B. Bascom, MD, and Susan W. Tolle, MD, explored the case of Mr G, a 47-year-old nursing home resident with advanced amyotrophic lateral sclerosis (ALS). As he neared death, Mr G asked his physician, Dr R, for physician-assisted suicide (PAS). Dr R did not respond directly to the request, and instead referred Mr G to the nursing home's hospice program. When the hospice social worker, Ms T, relayed back to Dr R that Mr G was still interested in pursuing PAS, Dr R became angry with the hospice staff and chose to withdraw from Mr G's care. The hospice medical director, Dr L, then became Mr G's physician and began to try to understand the context and meaning of Mr G's request.

After reviewing the data demonstrating that the vast majority of PAS requests do not persist when patient concerns are identified and addressed, the authors emphasized the primary need for physicians to explore the motivation behind a patient's request for PAS. The author's described 7 important areas of exploration: (1) expectation and fears, (2) options for end-of-life care, (3) patient goals, (4) family concerns and burdens, (5) suffering or physical symptoms, (6) sense of meaning and quality of life, and (7) symptoms of depression. In Mr G's case, Dr L's exploration identified Mr G's fears of suffocation and uncontrolled symptoms in his last days and his fears of lingering death. Dr L explained to Mr G that any physical symptoms he experienced would be aggressively and effectively treated and that sedation could be used if his pain remained intolerable. Mr G was assured that his wishes to withhold life-prolonging measures would be respected and options of voluntary cessation of hydration and nutrition were discussed. With these assurances, Mr G did not persist with his request for PAS.

Mr G's ALS continued to progress rapidly. On the day he was scheduled to be interviewed for the Perspectives article, he began to weaken further and was unable to participate. Within days, he developed respiratory distress and a morphine infusion was begun. Mr G could still communicate by eye movements and was able to direct the staff to administer morphine at a level that ensured his comfort. His caregivers at the nursing home and several friends from the military remained close by his bedside. He died several days later.

Excerpts of the interviews conducted by a Perspectives editor with Dr R, Dr L, and Ms T further describe the events of Mr G's final days and the potential for all involved in dealing with requests for PAS to provide comfort in a manner consistent with their own values.

Mr G never needed sedation. He just needed to know it was an option. He was very frightened and he needed to know that if at any level he could not tolerate what was happening to him, he could be sedated. Once he knew that, he felt great relief. The nursing home staff wanted to be with him through his death. One of the CNAs [certified nurse assistants] at the nursing home took time off from work to sit by his bed for the last 2 days because Mr G was frightened to be alone.

In the end, I think it worked out well. He died under hospice care. They fulfilled his wishes in terms of the type of care he got. He had a very quick decline and died comfortably. He received very good attention at the nursing home. They treated him with a great deal of compassion and always with as much dignity as possible. I never felt that he had any resentment at all and he made a point to tell me that he still respected me and appreciated the things I'd done for him.

Mr G was very understanding about Dr R's withdrawing from his care. He didn't harbor any resentment. He was not judgmental or angry. He said that people have their beliefs and those need to be respected.