DUMMERSTON — It's all about choice.
Choice is what's needed for terminally ill people who are facing death within six months. They need a full range of options to be able to decide for themselves how and when their physical life is to end.
For many, if not most, pain control and palliative and hospice care are their choice, followed by a natural death.
For some, for whom certain kinds of cancer or a disease like ALS (amyotrophic lateral sclerosis, or Lou Gehrig's disease) can be extremely physically and/or emotionally painful, a prescription medication to control the timing and manner of their death may be the desired option.
It's for people like these that a “death with dignity” bill is now being considered in the legislature.
More than a decade of experience in Oregon tells us that a law of this kind works well. Over a 12-year period in Oregon, 460 patients took medication to hasten their death, a yearly average of 38 in a state with six times the population of Vermont. Many others who were granted prescriptions didn't use them but were comforted by their being available if needed.
It's interesting, too, to note that more than 90 percent of the patients using medication under the Death with Dignity Act were enrolled in Hospice in 2009, a substantial increase over the 20 percent of dying patients in Hospice in 1993 before the Oregon law was passed.
A 2004 study of the Oregon law by the Vermont Legislative Council concluded that the law operates without abuse and, to all appearances, actually enhances care at the end of life.
The bill now before the Vermont Legislature, H.274, has actually been under consideration since 2003 in four legislative sessions. It's written very carefully and deliberately to make sure it works as intended and isn't abused.
To exercise the death with dignity choice, a doctor must determine that patient is terminally ill with less than six months to live, has capacity, and is acting voluntarily. The patient must then make a written and two oral requests to his or her physician for the medication. The second oral request is to occur 15 days after the first.
The written request must be signed and dated by the patient and witnessed by two people who attest that the patient understands what he or she is requesting and appears to be free from duress or undue influence.
It's important to note that neither of the witnesses can be a physician caring for the patient, a counselor who has provided counseling to the patient, a close relative of the patient, anyone who might benefit from the patient's death, or an owner, operator, or employee of a facility where the patient is receiving care.
The patient's written request can be completed only after he or she gets a second opinion on his or her diagnosis and prognosis. The bill emphasizes that no one can make any of the requests except the patient himself or herself.
The physician's duties beyond those already noted are detailed and specific. The physician must be a Vermont resident and must provide his diagnosis and prognosis in writing. He or she must explain the range of possible results and probable result of taking the medication and explain all feasible end-of-life services including comfort care, hospice care, and pain control.
The physician must refer the patient for a second opinion on the diagnosis and prognosis. If there is any question that the patient may have impaired judgment due to a mental disorder or disease, the patient must be referred for counseling. The patient must also be referred for a palliative care consultation and hospice services.
A recommendation must be made that a family member or someone with whom the patient has a significant relationship be contacted, and the physician must counsel the patient about the importance of having someone present when he or she takes the medication.
The physician, further, must inform the patient that he or she can change his or her mind at any time. Before writing the prescription, the physician must verify that the patient is making an informed decision. This verification must indicate that all of the required legal steps have been taken and documentation of them must be included in the patient's medical record. After the patient makes the last of the three required requests, the two oral and one written, the physician must wait 48 hours before writing the prescription. When the prescription is written, it's to be delivered to a pharmacist who has agreed to dispense it unless the physician is licensed to dispense the medication directly and agrees to do so.
The patient, finally, must self-administer the medication.
The physician may sign the patient's death certificate and must file a report with the State Health Department.
Other sections of the law have to do with definitions, safe disposal of unused medications, immunities, health care facility exception, liabilities and penalties, the form of the patient's written request, and a section that specifies that this bill does not allow a physician or anyone else to end a person's life by lethal injection, mercy killing, or active euthanasia.
This section also specifies that actions within the law are not considered suicide, assisted suicide, mercy killing, or homicide.
H.274 has 41 sponsors in the House, including Windham County representatives David Deen, Sarah Edwards, Ann Manwaring, Richard Marek, Mike Mrowicki, and Carolyn Partridge. It also is supported by Gov. Peter Shumlin.
H.274 can be readily accessed through the website www.patientchoices.org. Click on “How It Works” and “Decades of Data.” Also available on this site is an excellent summary of the bill, and the 2004 Vermont Legislative Council Study of the Oregon law.