FAST FACT AND CONCEPT #156: Evaluating Requests for Hastened Death

Authors: Tim Quill, MD and Robert Arnold, MD

A patient’s request to a health care professional to help hasten death is not uncommon. The motivation for this request is usually a combination of relentless physical symptoms, progressive debility, in combination with a loss of sense of self, loss of control, fear of the future, and fear of being a burden on others. Some physicians are frightened by these requests, feeling that they are being asked to cross unacceptable professional boundaries. Others may be tempted to quickly accede, imagining that they would want the same thing in the patient’s shoes. But requests for a hastened death may provide an entree into a patient’s experience of suffering, and may lead to opportunities for more effective treatment if fully evaluated. In general, the clinician should carefully clarify, explore, evaluate, intensify treatment, and support the patient to ensure a full understanding of the request and to ensure that all alternatives have been considered before responding. This Fast Fact provides guidance on how to evaluate and initially respond to a patient who raises the topic of a hastened death. A subsequent Fast Fact will explore how to respond when the request for a hastened death persists after a full evaluation and search for alternatives.

1. Clarify which question is being asked before responding. Is the patient simply having thoughts about ending his life (very common), or is he exploring the possibility of a hastened death in the future if his condition deteriorates, or is he exploring your willingness to assist right now. (1;2)

2. Support the patient, and reinforce your commitment to trying to find a mutually acceptable solution for the patient’s problem and to continue to work through the process. This does not mean violating fundamental values, but it does mean searching in earnest with the patient and family to find a way to approach the dilemma. (3) Attend to your own support by discussing the patient with trusted colleagues and/or with your multidisciplinary team.

3. Evaluate the patient’s decision-making capacity. Is he seeing his medical condition clearly? Is the request proportionate to the level of unrelieved suffering? Are there dominating aspects of anhedonia, worthlessness and guilt, or is the capacity for pleasure and joy preserved in some small ways? Is this request consistent with the patient’s past values? Get help from an experienced psychiatrist or psychologist if you are unsure. (4)

4. Explore the many potential dimensions that may contribute to the patient’s “unbearable” suffering to be sure you (and the patient) fully understand its underlying cause(s). Sometimes in may be an unrelenting physical symptom, other times feelings of depression, or a family or spiritual crisis, or perhaps a combination of many factors. (1;2)

5. Respond to the associated emotions, which may be strong and conflicted. Try to empathically imagine what the patient is going through and asking for. Distinguish your own feelings and reactions from those of the patient.

6. Intensify treatment of any potentially reversible elements of the patient’s suffering. Depending on the patient’s circumstances, offer to increase treatment of pain or other physical symptoms, consider biological or interpersonal treatment of depression; see if an appropriate and acceptable spiritual counselor is available. Be creative and brainstorm potential solutions with your multidisciplinary team. (1;2)

7. Respond directly to the request for hastened death only after this multidimensional evaluation has been completed. If the patient has full decision-making capacity and all alternative approaches to the patient’s unbearable suffering have been fully considered, then re-explore exactly what is being requested, and look for mutually acceptable ways to potentially respond. (5) Note that many patients may be looking for the potential of an escape they will never use, but a smaller number will be looking for a way to hasten death in the present.

References

1. Quill TE. Doctor, I want to die. Will you help me? JAMA 1993; 270:870-873.
2. Block SD, Billings JA. Patient requests to hasten death: Evaluation and management in terminal care. Arch Intern Med 1994; 154:2039-2047.
3. Quill TE, Cassel CK. Nonabandonment: A central obligation for physicians. Ann Intern Med 1995; 122:368-374.
4. Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. Ann Intern Med 2000; 132:209-218.
5. Quill TE, Lo, Brock DW. Palliative options of last resort: A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997; 278:1099-2104.

Copyright/Referencing Information: Users are free to d ownload and distribute Fast Facts for educational purposes only. Citation for referencing: Quill T and Arnold R. Fast Facts and Concepts #156 Evaluating requests for hastened death. May 2006. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

State laws often provide guidelines for certification of medical information. Certification and completion of death certificates is usually the primary responsibility of the physician. However, in some states, death may be certified by the attending physician or attending Advanced Practice Registered Nurse (APRN). In the absence of these individuals, or with the approval of the attending physician or APRN, certification may be completed and signed by an associate physician or APRN, registered nurse, a physician assistant, chief medical officer of the institution or pathologist if the state law provides this option. The medical examiner or coroner investigates certain types of deaths and completes the cause of death for these specific cases. Since laws vary for each state, it is best to reference instructions regarding who may be an acceptable certifier.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Interpersonal and Professional Communication Skills

Keyword(s): Ethics, law, policy, health systems; communication; psychosocial and spiritual experience