Palliative care doctors mixed on CMA assisted suicide policy shift

The decision by the California Medical Association to drop its decades-old opposition to physician-assisted suicide and adopt a neutral position has sparked mixed reactions from palliative care doctors, who work closely with seriously ill and dying patients. 

One reason for last week's policy shift, according to Medical Association President Dr. Luther F. Cobb, is that palliative care, which focuses on helping alleviate the symptoms of pain and anxiety that accompany serious illness, "isn't always enough." 

"We have a great deal of high-quality… palliative and hospice care and that’s obviously the choice that we would like to see patients utilize at end of life," says Dr. Ted Mazer, speaker of the Medical Association's House of Delegates. "But in some cases, patients are looking for a different option.…they're looking for some more control over their lives."

Dr. Lynette Cederquist, a palliative care specialist in San Diego, agrees with the Medical Association's action. She’s also a plaintiff in a lawsuit that alleges California’s ban on physician-assisted suicide violates the state Constitution. 

"Unfortunately, maybe ten percent of the time, no matter what we do to get a patient comfortable at the end of life, we just can’t," she says. 

Cederquist adds that she sees little distinction between providing a patient with a lethal prescription and the legally-condoned practice known as “palliative sedation.” That’s a last-resort procedure in which a patient is sedated into unconsciousness until he dies. Cederquist says under such sedation, a person can linger for up to a week before passing away.

"The longer that goes on, " she says, "the more exhausting, draining, stressful it is for the family." 

"A sacred moment"

Other palliative care specialists say none of that justifies legalizing physician-assisted suicide. Dr. Vincent Nguyen, who practices in Newport Beach, counts himself in that group.

"End of life is a sacred moment for people and it’s a very scary thing because we only die once," he says, adding that in his two decades  of practice, he’s never considered lethal medication a necessary option.

The typical fears patients have - about pain, losing control or being a burden on family - can be managed with spiritual and emotional counseling and pain medications, all of which are part of the palliative care toolkit, Nguyen says.

Hastening death with a lethal prescription misses the opportunity to make the patient’s final days more meaningful, he maintains. Nguyen also insists that the patients who've asked him for help in expediting death "don't want to die. They just need to be listened to."

"Those of us who practice hospice and palliative care don’t allow people to die in ghoulish ways," says Dr. Ira Byock, who also opposes the Medical Association's new policy. Byock is a pioneer in the palliative care field and author of a book on end-of-life medicine.

"We can control people’s physical distress and we can help people to die in a manner that is gentle, that honors their inherent dignity and that honors the sensitivity of this profoundly personal transition from life for them and their family," he argues.

"People are dying badly"

Byock, who practices palliative care in Torrance, says by changing its position, the Medical Association is obscuring a more fundamental issue.

"People are dying badly," he says. "We should be talking about a public health crisis that surrounds the way Americans are being cared for and facing the end of life."

Byock points in particular to chronically-ill people who - despite their wishes - spend their last weeks in intensive care units, hooked up to life support.  To address this problem, he says that all doctors – from medical students to veteran practitioners – should be required to have training in end of life conversations. 

"State boards of medical examiners continue to give licenses to physicians without testing to ensure that these physicians have mastered the basic knowledge and skills in communication, decision-making and pain assessment and management required to care well for seriously ill people," says Byock. 

Despite the opposition of palliative care physicians such as Byock and Nguyen, the Medical Association's Mazer says opinions about assisted-suicide are changing, with support for the practice growing among doctors and the general public.  

The Association's shift in position comes as state lawmakers are considering SB 128, legislation that would legalize medically-assisted suicide in California. If the bill becomes law, doctors would be able to furnish terminally ill, mentally competent patients with lethal medications. 

By taking a neutral position on the measure, Mazer says the Medical Association is able to work with SB 128's authors to ensure the bill has adequate protections for doctors and patients.