The Vermont House approved a measure allowing physicians the ability to prescribe life-ending medications to some terminally ill patients seeking to end their lives. Vermont is set to become the fourth state allowing the legislation known as ”Death with Dignity,” following Oregon, Washington and Montana.
“By a 75-65 roll call vote, the House approved a bill largely that copies a law passed by Oregon voters in 1997 for three years and then shifts to a system with less government monitoring,” The Associated Press reports.
This marks the first time this type of legislation has been moved to passage by a legislature. With safeguards similar to the Oregon bill, patients seeking the prescription barbiturates must first state their intentions three times- once in writing. A second opinion from a physician indicating a patient has less than six months to live and proof of sanity, are mandatory. Patients must wait 48 hours before filling the prescriptions.
“It’s an important step for terminally ill Vermont patients,” Dick Walters, president of Patient Choices-Vermont, said after the vote. “It’s a big step forward for the region and for the country as a whole,” the AP reports.
Come 2016, changes advocated by some of the state senators seeking less government involvement during the process will go into effect, including less monitoring from physicians.
“It’s huge,” said lobbyist Michael Sirotkin, who for years has been involved with the issue in Vermont. “I think it’s going to have a major effect on other states’ willingness to vote on this,” he told USA Today.
But not all lawmakers approved of the bill’s passage. ”There can never be a dignified death using a handful of pills or a lethal cocktail,” said Rep. Carolyn Branagan, a Republican from Georgia, VT.
Other opponents were concerned about the radical changes the bill underwent while in the Senate. ”We are passing a bill that has not been vetted,” said Rep. Paul Poirier, an Independent from Barre. “Do we want to pass a bill … just accepting 100 percent what the Senate did overnight?”
“The Illinois POLST form is a step in the right direction,” said Mary F. Mulcahy, a co-founder of Life Matters Media and practicing oncologist at Northwestern University, while lecturing physicians about the form Thursday at Northwestern Memorial Hospital.
In March, the Illinois POLST form was released to the public, an effort headed by the POLST Paradigm and theChicago End-of-Life Care Coalition. This update to the Illinois DNR advance directive aims to improve the quality of life for patients at end of life.
POLSTs, Physicians Orders for Life Sustaining Treatment, are more detailed than conventional living wills and advance directives. These forms give patients the freedom to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across state care settings and direct doctors to provide or withhold lifesaving treatments.
The form should be adjusted over time to fit each patient’s prognosis. “This is not a one-time thing, as patients progress the form can change,” Mulcahy said. “There should be shared decision-making between physicians and patients.” To be valid, the form must be signed by the attending physician.
In the U.S., the average patient visits the hospital more than 30 times and meets nine different physicians during the last six months of life. These patients could benefit from having their medical wishes written down and on hand; the convenience helps cut through the chaos and confusion prevalent in care settings.
POLST was developed in Oregon in the 1990s, and now 14 states have POLST programs. Twenty-eight states are considering the use of such forms.
“Hopefully this form will change the culture and get people talking and preparing for the end of life,” Mulcahy said.
Palliative care expert Andrew Thurston, M.D., agreed. “I think this is great. My hope for the POLST form is that it will clarify patients’ wishes for their end of life care, and that it helps doctors more effectively communicate with their patients,” said Thurston. “We need more open discussion, and with easier language, this form helps.”
The Vermont House will soon vote on a more stringent version of the Senate legislation known as “Death with Dignity.” The House legislation would grant physicians the ability to prescribe life-ending drugs to some terminally ill patients; however, the bill has more caveats, such as mandatory hospice enrollment.
But with a 7 to 4 vote, the House Human Services committee backed a new bill restoring much of the process the Senate version eliminated, such as the requirements for both oral and written requests, and a 48-hour waiting period before filling a prescription. Furthermore, it requires every prospective patient to have an advanced directive and be enrolled in hospice, VPR’s Bob Kinzel reports.
“We have all of the safeguards that they have in Oregon. We have a 15-year track record in Oregon with this law,” said Rochester Rep. Sandy Haas, a Democrat who helped overhaul the Senate’s bill.
Oregon mandates patients verbally request life-ending drugs to their physicians, followed by a 15-day waiting period and then another verbal request. Patients also must submit written requests. Then, they wait 48-hours before picking up the barbiturates.
“That bill was about doctors. The bill we passed this morning is about patients,” Haas said. “The Senate bill purports to be immunity for doctors for malpractice, basically for misprescribing, for confusing patients about what happens.”
Republican Rep. Anne Donahue from Northfield, said she worries the new version will make it easier for families to coerce loved ones into committing suicide. “A person can then wait a month or two or three or more before actually taking (the drugs),” Donahue said. “And at that point there’s absolutely no protection about coercion, family pressures, financial pressures and even whether a person still has the capacity to make that decision.”
Donahue said she favors how the Senate version limited the ability of the state to intervene once an individual committed to end his or her life. “I think that the direction that the Senate went made a huge amount of sense and didn’t have the intrusion on rights and the intrusion of the state actually sanctioning suicide,” Donahue said.
A possible vote is set for Tuesday. If passed, the bill would be kicked back to the Senate for a vote. This is the farthest this Oregon-style legislation has advanced in Vermont. Last year, a bill came before the full Senate, but it failed.
For the first time in Connecticut’s history, the General Assembly’s Public Health Committee allowed a legislative hearing about a physician-assisted suicide bill.
H.B. 6645 aims to allow physicians the ability to prescribe life-ending medications at the request of mentally competent, terminally ill patients. Patients would have to self-administer the drug.
Connecticut’sCBS affiliate reports that because Democratic State Sen. Ed Meyer of Guilford received so many phone calls supporting “Death with Dignity,” he chose to author the bill, which he insists is both compassionate and cautious.
“The bill that we’re hearing today, for example, requires two different physicians to certify under oath that the person is terminally ill, likely to die within six months and is mentally competent to make an informed decision about ending his or her life,” Meyer told WCBS 880.
Washington, Oregon and Montana have already approved the legislation known as “Death with Dignity.”
“If the legislators see the bill as providing a choice, an intelligent choice for people making an informed decision to end their life and end the misery and pain they’re going through at the end of life, I think the bill will go forward,” Meyer said.
However, the bill faces strong opposition from religious and social organizations, such as the Family Institute of Connecticut and Second Thoughts Connecticut. Such opposition could hold-up the bill’s passage.
“We will be killing our vulnerable parents and grandparents through public policy,” said Teresa Wells, a nursing home administrator, according to the Hartford Courant.
The Catholic Church has also been a vocal critic. The Church cites the lack of wait time between the necessary oral and written requests for drugs. Other states require a 15 day wait.
Meyer said he remains open to suggestions.
Proponents of the bill argue it would ensure individual freedoms at the end of life. “The deep yearning for increasing autonomy for patients themselves to have a voice, I think now it’s reaching a tipping point all across the world,” Compassion and Choices’ Barbara Coombs Lee told CBS. “I think the Baby Boomer generation has something to do with that.”
A similar bill was proposed in 2009, but it failed to garner a hearing. Connecticut has banned assisted suicide since the late 1960s.
Read the bill at Connecticut’s General Assembly Web site
The Vermont Senate Health and Welfare committee unanimously approved the bill known as “Death with Dignity,” which would allow some terminally ill patients to end their lives with prescription barbiturates, Vermont Public Radio reports.
More than 300 people gathered in the Vermont Statehouse Tuesday to voice opinions on the proposed “Death with Dignity.” The law would allow terminally ill patients to end their lives with prescription drugs.
Patients expected to live no longer than six months or less could be given a prescription for a lethal dose of barbiturates. Two physicians are needed to agree upon life expectancy. Patients also must declare their wish to die three times, once in writing, within a 15-day period.
The joint session of the Senate Health and Welfare and Judiciary committees heard testimony from both sides of the issue. The Judiciary committee has not yet voted.
Judy Murphy, who still mourns the loss of a friend who she said starved herself to death to end her suffering, came to support the act. ”Not everyone would make that choice to die. But many, including myself, would have great comfort in knowing that that option is possible,” Murphy said. “She should have had the choice of death with dignity,” WCAX reports.
“The bill simply offers end-of-life choice,” said another supporter, William Wilson. “Its presence alone is comforting,” USA Today reports.
Lynn Caulfield, a registered nurse, disagreed. ”It is a sad day in Vermont when our lawyers are asking health care professionals to help human beings to die rather than extending compassionate and respectful care to ease pain and suffering,” she said.
The act still needs to pass the House and Senate before being sent to Democratic Gov. Peter Shumlin for approval.
Earlier on Tuesday, Vermont Public Radioreported the Senate Health and Welfare Committee heard from Attorney General Bill Sorrell and former Gov. Madeleine Kunin,both support the bill.
Some opponents of the act say they fear suicide’s definition will change, including Guy Page from Barre. He asked his twenty-something son, who he said struggled with suicidal thoughts as a teenager, about his thoughts on the bill.
“His response shocked me. Shaking with anger and fear he said ‘What hypocrites. Everyday my teachers tell me that killing myself is never an option. But here they are saying that suicide is ‘okay’,” Page said.
In November, Massachusetts voted against allowing physicians to prescribe life-ending drugs to terminally ill patients. Question 2, known as “Death with Dignity,” faced strong opposition from prominent physicians and the Roman Catholic Church.
Physician-assisted suicide is legal in Oregon and Washington.
The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve end of life care in Illinois, is on its way to implementation. Health care professionals met at Rush University Medical Center this week to discuss the form’s development and strategies for raising public awareness.
Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center, provided the audience with hypothetical scenarios the POLST program form could remedy.
POLST program forms are more detailed than conventional living wills or other advance directives. They allow people to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for people who are likely in their last year of life. They can follow patients across in-state care settings and direct doctors to provide or withhold life-sustaining treatment in emergency situations.
The forms aim to more quickly direct doctors to a person’s wishes and eliminate confusion about what patients would want in the case that they are medically incapacitated and unable to communicate their wishes. The forms provide instructions in the case of a cardiopulmonary arrest (the person has no pulse and is not breathing), the degree of medical intervention they would want in a pre-arrest situation (the person has a pulse and/or is breathing), and whether or not they would want artificial nutrition if their medical illness prevented them from taking in adequate oral nutrition.
How a POLST form could help
A 67-year-old man is sent to the emergency room with chest pain and shortness of breath. He is also confused. The cardiologist says that a cardiac catheterization with angiogram and a stent are needed. The nurse tells the physician that there is a DNR order on his chart. Should the physician send the patient for an angiogram? It’s not clear.
If that patient had a POLST form that indicates DNR in case of full cardiac arrest but an order for full treatment in a pre-arrest emergency, the physician would immediately know what to do. The patient would be sent for the angiogram.
An 85-year-old man is admitted to the emergency room with severe pneumonia. He’s hypoxic, confused and refusing the ventilator. There is a DNR order on the charts. The physician feels that DNR doesn’t apply to this potentially reversible condition but the nurses disagree. He receives full resuscitation.
If that same patient had a POLST form indicating no CPR in the case of arrest and a preference for comfort care, the physician and nurses would have clear instructions. He would not have undergone full resuscitation, but would have been maintained in comfort with noninvasive maneuvers. .
A 59-year-old woman who is being treated for breast cancer is admitted to the emergency room for sepsis. She is transferred to intensive care and receives oxygen and maximum vasopressors. She has a DNR order on the charts. The staff are concerned that they are violating her wishes.
If she had a POLST form indicating no CPR in the case of arrest but limited interventions in addition to comfort measures, the staff may feel more comfortable treating her as they are doing and spend less time deliberating.
The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve the quality of end of life care, is on its way to Illinois. Health care professionals met at Rush University Medical Center Thursday to discuss the form’s development and strategies for raising public awareness.
The Chicago End-of-Life Care Coalition sponsored the discussion led by Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center.
POLST program forms are more detailed than conventional living wills or other advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across in-state care settings and direct doctors to provide or withhold life saving treatment in emergency situations.
For instance, an individual may choose to decline resuscitation efforts, but of for artificial nutrition. An individual may choose artificial nutrition with set limits or permanent placement.
“POLST improves on the existing uniform DNR form,” said Goldstein. “POLSTs are medical orders and have to be followed by all medical care providers.” To be valid, a POLST form must be signed by an attending physician.
Loretta Downs, president of the CECC, told LMM that POLST is essentially about enhancing personal liberty at end of life. “For Illinois, accepting the POLST form is a statement encouraging people to take advantage of their liberty regarding end of life decisions. It empowers the individual to make a clear statement about whether or not he or she wants end of life care and what level of treatments.”
The POLST form will be available in early 2013, a version of the IDPH DNR Uniform Advance Directive. Goldstein said it will be most similar to the California POLST. The final form awaits approval from state health officials and it may be “ultra pink.”
Many in attendance left hopeful that the form would help their patients. Kriston Kurelic, a social worker at Passages Hospice, says she is excited about the form’s implementation. “I’m very interested in the changes that will happen,” Kurelic said. “It will be very beneficial to long-term care. It will be beneficial to patients and families.”
Christine Nelson, director of nursing at Manor Care, agrees. “I think anything that helps us assess what people’s wishes are more clearly is helpful,” she said. “The only barrier I see is time being taken to explain the form to patients.”
The task of educating patients will likely fall on individual health care providers. Because it is a physician order, it is intended to be accompanied by a meaningful doctor-patient dialogue. Carol Blendowski, a Rainbow Hospice nurse practitioner, says time is what is required to have such conversations, but thinks patients will ultimately find the POLST easy to navigate. “I can see clearly now,” she said. “This form is user friendly.”
POLST was developed in Oregon in the 1990s, and now 15 states have POLST programs. Twenty-eight states are considering the use of POLST forms.
Illinois lawmaker pushes for medical marijuana bill
An Illinois sponsor of a medical marijuana measure says he may have enough votes to pass the bill in the Statehouse, theChicago Tribunereports. Rep. Lou Lang, D-Skokie, says his ”nose count” has him near the 60 votes needed for approval of a three-year trial medical marijuana program called the Compassionate Use of Medical Cannabis Pilot Program Act, which would be a first for Ill.
“If members vote their consciences, I’ll have the votes,” said Lang, who fell short a handful of votes last year, although the Senate approved similar previous legislation in 2010.
This season may be different, however, because three dozen lawmakers in the House and Senate are not coming back in the next General Assembly, making them lame ducks, Ray Long reports. “Their votes are more likely to be up for grabs given that they are not expected to face the voters again.”
CBS Newsreports that advocates of medical marijuana are in Springfield to lobby state lawmakers to approve the use of medical marijuana with strict limitations. The drug would only be prescribed by doctors, in small amounts, to qualifying terminally ill patients or their designated caregivers. Individuals suffering from AIDS, cancer, multiple sclerosis or a “debilitating medical condition” may qualify.
A qualifying patient or caregiver would only be able to legally possess 6 cannabis plants and 2 ounces of dried usable cannabis during a two-week period.
State Rep. Jim Durkin, R-Countryside, opposes the measure because he fears it will make the drug more available. “Just in the last two weeks in DeKalb, there was a 10-pound traffic stop of medical marijuana that came from Oregon,” Durkin said.
The AP reports that Rep. Jim Sacia, R-Freeport, acknowledges that Lang may have enough votes to pass the measure, but the former FBI agent still plans to fight it. “I just see it as a tremendous mistake,” said Sacia.
Lang may bring the measure to vote this week at the General Assembly. He told the AP that there are ”a whole bunch of people who are wavering.” He will work over the weekend before putting the measure to vote, although he may be close to the 60 votes needed.
Medical marijuana supporters have already won local approval for medical use in 18 states and D.C. Voters in Colorado and Washington chose to legalize marijuana, although, the federal government currently lists marijuana as a Schedule I controlled substance, meaning it has no medically accepted use and high potential for abuse.
Chronically ill patients inadequately prepared for the end of life often receive unnecessarily burdensome care, said Dr. Bernard Hammes, keynote speaker at this week’s Illinois Hospital Association Conference. Hammes, of Wisconsin’s Gundersen Lutheran Medical Foundation, developed the program Respecting Choices to teach clinicians about end of life planning.
Hammes maintains that the POLST paradigm is the best program to fix the problem of inadequate end of life treatment, and practitioners should understand POLST as a platform for cultural transformation.
What is POLST?
POLST (Physician Orders for Life-Sustaining Treatment) was developed in Oregon in the 1990s, and 14 states have enacted POLST programs in the years since. The POLST form is now under consideration for use in twenty-eight other states, including Illinois.
POLSTs are more detailed than conventional living wills, and they differ from advance directives. Patients can indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. The forms are intended for patients whose life expectancy is no longer than one year.
“The purpose of POLST is to provide a mechanism to communicate seriously ill patients’ preferences for end of life treatment across treatment settings and to improve the implementation of advance care planning by being more specific,” Hammes said. “POLST works.”
POLSTs do not carry legal weight across state lines, but the forms can act as guidelines for physicians in any care setting. The POLST form is always intended to travel with a patient- whether by ambulance en route to a hospital, or in the instance a patient moves to a long-term care facility.
POLST Coming to Illinois
“There is a national POLST paradigm initiative, there is a task force, I assume that Illinois will become a recognized member,” Hammes told the room of hospice, palliative care, and general practitioners at Northern Illinois University’s Naperville campus.
The Illinois POLST task force is currently working to assemble and educate health workers statewide about the form. The task force is made up of physicians, public health officials, nurses, chaplains and representatives from the Chicago End of Life Care Coalition.
POLSTs may be available in Illinois as early as January of 2013.
Learn more about the POLST form coming to Illinois here.
Massachusetts will vote on whether to allow physicians to prescribe life-ending drugs to terminally ill patients. Question 2 is known as “Death with Dignity,” and the measure will likely pass, even with strong opposition from outspoken patients, prominent physicians and the Roman Catholic Church.
“As a good pro-choice liberal, I ought to support the effort. But as a lifelong disabled person, I cannot,” writesBen Mattlin for The New York Times Op-Ed page.
Author of Miracle Boy Grows Up: How the Disability Rights Revolution Saved My Sanity, Mattlin suffers from spinal muscular atrophy and fears that if Question 2 passes, it will allow for abuse against the elderly and disabled.
“There’s been scant evidence of abuse so far in Oregon, Washington and Montana, the three states where physician-assisted death is already legal, but abuse — whether spousal, child or elder — is notoriously underreported,” he writes. “What’s more, Massachusetts registered nearly 20,000 cases of elder abuse in 2010 alone.”
The initiative, referred to as “Prescribing Medication to End Life,” has a number of restrictions. Patients would have to be determined capable of making and communicating their health care decisions and have at most six months to live. Patients must also express a wish to die on two occasions, 15 days apart. A physician would be required to discuss the option of palliative care.
Mattlin raises the concern of coercion being a threat to the disabled and elderly. Having experienced a life in which eating, breathing and growing brought him pain, he sympathizes with those who may be one ‘talk’ away from ending life.
He writes: “My problem, ultimately, is this: I’ve lived so close to death for so long that I know how thin and porous the border between coercion and free choice is, how easy it is for someone to inadvertently influence you to feel devalued and hopeless — to pressure you ever so slightly but decidedly into being ‘reasonable,’ to unburdening others, to ‘letting go.’ ”
Ezekiel J. Emanuel, former White House adviser, oncologist and professor at the University of Pennsylvania, stated his concerns about “Death with Dignity” in an Op-Ed for The New York Times.
Ezekiel asserts that individuals who choose assisted suicide are not motivated by pain, so logically “Death with Dignity” should be reconsidered as a compassionate act.
“Only 22 percent of patients who died between 1998 and 2009 by assisted suicide … were in pain or afraid of being in pain,” he writes. “Patients themselves say that the primary motive is not to escape physical pain but psychological distress; the main drivers are depression, hopelessness and fear of loss of autonomy and control.”
His advice: focus on the dying process and not death itself.
“Instead of attempting to legalize physician-assisted suicide, we should focus our energies on what really matters: improving care for the dying.”
Earlier this year, Dr. Barbara Rockett, the former president of the Massachusetts Medical Society, criticized the initiative in The Boston Globe: “We as physicians must avoid the so-called slippery slope of attempting to save money by doing less for our patients rather than rendering the proper care to them. To substitute physician-assisted suicide for care represents an abandonment of the patient by the physician.”
Moral concerns from Roman Catholics
The Roman Catholic Church, the largest religious tradition in Massachusetts, also remains a vocal opponent to “Death with Dignity.” Tradition maintains that human life is sacred from conception to death; therefore, hastening death is a mortal sin.
The Globe’sChelsea Conaboyreports, “Catholic archdioceses from across the country contributed tens of thousands of dollars to the Committee Against Physician Assisted Suicide, which raised $900,550 from late April to September.”
According to Boston’s NBC affiliate NECN, Catholics are organizing church by church against “Death with Dignity.” For example, St. Jerome Parish in Weymouth, Mass. is holding workshops encouraging parishioners to vote “no” on the initiative.
Question 2 likely to pass
According to Pew Research, 43 percent of Massachusetts residents identify as Catholics. Massachusetts has a larger percentage of Catholics than any other state.
The high percentage of Catholics is not, however, translating into statewide opposition to Question 2. A Suffolk University poll of likely voters shows 64 percent would vote “yes” and only 27 percent would vote “no.”