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A new study led by a researcher at the San Francisco Veterans Affairs Medical Center (SFVAMC) has found that most physicians whose patients request help in ending their life deal with those requests alone, absent any advice or discussion from their colleagues.
Researchers interviewed 20 physicians in Seattle and San Francisco who have received at least one request from a terminally ill patient for help in committing suicide. The results, which were published in the March issue of the Archives of Internal Medicine, showed that half of physicians helped a patient end his or her life; the other half had not.
The most surprising finding is that physicians rarely discuss these often heart-wrenching suicide consultations with other physicians. "Most physicians who received these requests really dealt with them alone," says lead author Jeffrey Kohlwes, MD, MPH, University of California at San Francisco assistant clinical professor, and physician in general internal medicine at SFVAMC. "They perceived an unspoken code of silence on the topic amongst their colleagues," Kohlwes says.
The physicians reported the most difficulty in coping with requests from patients who wanted to die because they felt their lives had lost meaning, not for reasons related to physical pain and suffering. The researchers recommended that physicians who care for terminally ill patients do the following:
Researchers also pointed to the need for the medical profession to support doctors by encouraging discussion of requests for help with suicide. Although physician-assisted suicide is illegal in every state except Oregon, physicians who care for terminally ill patients receive suicide requests with some regularity. Some guidelines have been written to assist physicians in dealing with those requests, but there has not been much documentation of the different ways in which physicians handle suicide requests from their patients.
Aside from its illegality, the topic of physician-assisted suicide is considered taboo among physicians, a perspective that dates back to a passage of the Hippocratic oath, which admonishes "give no deadly medicine to anyone if asked." A few of the physicians also said they were worried about becoming publicly known as the "local Kevorkian," Kohlwes says.
The isolation experienced by these physicians creates a heavy emotional burden, Kohlwes says. Four of the physicians cried during the interviews, a response that Kohlwes says "seemed more related to a lack of processing their actions rather than any regrets over their actions."
"Somehow the medical community needs to create an environment where these physicians can discuss their decision-making process," he says, suggesting physicians should try to avoid the moral debate over physician-assisted suicide and instead discuss the processes they use to handle those requests. "Improving the professional dialogue will improve care, and hopefully obviate the need for many assisted deaths," he said.
Although physical and psychological suffering were reasons given by many patients for wanting to end their lives, some physicians in the survey said patients frequently cite more existential reasons. "Many terminally ill patients feel that their meaningful lives are over because they are no longer able to do the things they love, such as interacting with loved ones, being active, and generally being in control of their lives," he says. "Physicians reported that these existential cases were the most difficult for them to intervene in."
The physicians in the study who felt most comfortable managing this existential suffering favored open discussions with the patient, and tended to view their discussions with the patient as a therapeutic tool rather than an avenue to some other intervention, Kohlwes says.
The good news, says Kohlwes, is that most requests for a physician’s assistance in suicide can be successfully handled simply by treating either physical pain or depression. "Most physicians we interviewed used those requests as a warning flag to aggressively treat a patient’s physical discomfort, and in many cases they felt this was effective," he adds.
Most physicians in the study reported treating their patients with antidepressants, which another study has shown to reduce terminal patient requests for suicide.