Approved by the Board of Directors
Suffering near the end of life arises from many sources including relentless pain, depression, loss of sense of self, loss of control and dignity, fear of the future, and/or fear of being a burden upon others. A primary goal of the American Academy of Hospice and Palliative Medicine (AAHPM) is to promote the development, use, and availability of palliative care to relieve patient suffering and to enhance quality of life while upholding respect for patients' and families' values and goals.
Excellent medical care, including state-of-the-art palliative care, can control most symptoms and augment patients' psychosocial and spiritual resources to relieve most suffering near the end of life. On occasion, however, severe suffering persists; in such a circumstance a patient may ask his physician for assistance in ending his life by providing Physician-assisted Death (PAD). PAD is defined as a physician providing, at the patient's request, a lethal medication that the patient can take by his own hand to end otherwise intolerable suffering. The term PAD is utilized in this document with the belief that it captures the essence of the process in a more accurately descriptive fashion than the more emotionally charged designation Physician-assisted Suicide. Subject to safeguards, PAD has been legal and carefully studied in Oregon since 1997. In all other states, PAD remains prohibited by law, although there is an underground practice that remains largely unstudied.
Situations in which PAD is requested are particularly challenging for physicians and other healthcare practitioners because they raise significant clinical, ethical and legal issues.Statement
When a request for assistance in hastening death is made by a patient, AAHPM strongly recommends that medical practitioners carefully scrutinize the sources of fear and suffering leading to the request with the goal of addressing these sources without hastening death. A systematic approach is essential.
Evaluation of requests:
Initial responses to requests for hastened death:
When unacceptable suffering persists, despite thorough evaluation, exploration, and provision of standard palliative care interventions as outlined above, a search for common ground is essential. In these situations, the benefits and burdens of the following alternatives should be considered:
Despite all potential alternatives, some patients may persist in their request specifically for PAD. The AAHPM recognizes that deep disagreement persists regarding the morality of PAD. Sincere, compassionate, morally conscientious individuals stand on either side of this debate. AAHPM takes a position of "studied neutrality" on the subject of whether PAD should be legally regulated or prohibited, believing its members should instead continue to strive to find the proper response to those patients whose suffering becomes intolerable despite the best possible palliative care. Whether or not legalization occurs, AAHPM supports intense efforts to alleviate suffering and to reduce any perceived need for PAD.
For physicians practicing in regions where PAD is legal, AAHPM advises great caution before instituting PAD including assurance that:
Whenever PAD is being considered by a patient with his or her physician, patients should continue to receive the best possible palliative care. Although many hospice and palliative care practitioners find it morally unacceptable to participate in PAD even where legal, neither a person requesting PAD nor his family should be deprived of any other measure of ongoing palliative care during the dying process and period of bereavement. The most essential response to the request for PAD in the practice of palliative care is to attempt to clearly understand the request, to intensify palliative care treatments with the intent to relieve suffering, and to search with the patient for mutually acceptable approaches without violating any party's fundamental values.References
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Okie S, "Physician-Assisted Suicide-Oregon and Beyond." NEJM 2005; 352 (16):1627-1630.
Quill TE, Battin MP.eds. Physician-Assisted Dying, The Case for Palliative Care and Patient Choice. Baltimore: Johns Hopkins University Press, 2004.
Quill TE, Byock I. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. Ann Intern Med 2000; 132:408-414.
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