When patients ask you to hasten death, look closer
Most fears can be calmed with open discussion
For various reasons — pain, fear, or control —patients sometimes consider ending their lives; occasionally, they even ask their doctors for help. But ethicists say, before responding to the question as asked, physicians first should look at what might be going on behind the question.
First of all, nurses who care for the dying say intractable pain is not always the reason that requests for hastened death arise, according to one study.
According to hospice nurses whose experiences were reported in a 2003 New England Journal of Medicine article,1 patients chose to stop eating and drinking for reasons that included being ready to die, the belief that continuing to live was pointless, and a sense of poor quality of life, as well as wanting to control the manner of death. Unbearable physical suffering did not appear to be an important reason for patients choosing suicide.
"I don't know the exact number, but I can tell you that requests for hastened death are not very common," says Christina Puchalski, MD, MS, founder and director of the George Washington Institute for Spirituality and Health (GWISH), and author of "A Time for Listening and Caring: Spirituality and the Care of the Chronically Ill and Dying."
"I find the request comes out of a deep fear of the unknown, and when patients find out that most of what they're fearful of can be handled, they don't have that fear anymore."
Honesty, clear answers douse fears
Puchalski, who says she would not feel comfortable participating in a physician-assisted suicide, says when people talk about patients wanting to hasten death, they sometimes are lumping in anecdotes of patients in terminal pain asking that their morphine levels be increased to a point of terminal sedation.
"That's not the same thing," she says.
But physicians should also counsel patients who ask for terminal sedation, Puchalski suggests, because they might not truly want to miss the time they have left — and she knows this from experience.
When her fiancé was dying of cancer more than a decade ago, he told her that he planned to stockpile medications (he, too, was a physician) so that he could end his life when he decided it was time.
"I was very upset about that, but it was out of my hands," she says now. "On the evening he died, I said, 'Eric, you can ask for morphine to help calm your breathing,' but he said no, that he wanted to be alert for this moment. So really, nobody knows how they'll feel about death until they get there."
There are things that physicians and nurses who work in hospice can do to help a patient who asks for a hastened death to have a clearer idea of what to expect.
"I explain what hospice is to begin with, to get to what the issues are and get to what they're fearful of," Puchalski says. "And usually, when I explain what hospice is, they don't have that fear anymore."
When patients are facing death, in addition to fearing death itself, they often are gripped with worries about their loved ones, questions about life after death, concerns that they will feel they are choking, suffocating, or in terrible pain, she adds.
"Dying is not easy, but being born is not easy, either," says Puchalski. "In our culture, there's a sense that if you can't participate fully in life anymore, to just put yourself out of your misery.
"But what is needed is a reframing, that dying is a natural part of life, and that dying is not a medical problem. It's a natural, sacred part of people's lives, a time of a lot of richness and for significant relationships."
When possible, the patient, physician, and family should have discussions about dying, hospice, and care options long before death is imminent. If assisted suicide is brought up, the physician should be as clear and specific as possible about what he or she is able to do for the patient, as well as any personal principles that apply.
Infrequently, physicians and patients find they cannot agree on key issues surrounding medicine's role in the process of dying. Even the idea of conscious sedation has a duality about it — the patient's pain is muted by unconsciousness, yet the patient does not die from the sedation (except in occasional cases); the patient is pain-free, but is unable to experience the "issues" involved in dying, Puchalski adds.
"We need to have more conversations with patients and talk with people about what's going on," she says. "There's a lot we can help people with. We can talk to them about their unfinished dreams, about what they want to finish.
"It's how you are living while you're dying that gives life meaning."
- Ganzini L, Goy ER, Miller LL, et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. NEJM 2003; 349:359-365.
For more information:
- Christina Puchalski, MD, director, George Washington Institute for Spirituality and Health, Washington, DC. Phone: (202) 496-6409. E-mail: firstname.lastname@example.org.