First-year complications with assisted suicide

There may need to be some tinkering with the machinery of death.

Opponents of Washington'ꀙs and Oregon'ꀙs physician-assisted suicide laws had warned that there would be botched procedures leading to drawn-out suffering of terminally ill patients ending their lives. Newly released annual reports on the use of the Death with Dignity laws in Washington and Oregon in 2009 show there were two or three complications in Washington and one in Oregon. It'ꀙs believed that one Washington patient accounted for two of the reported complications.

Leaders of Compassion & Choices, a nonprofit group which sends volunteers to support and monitor patients using the laws, say these complications were minor and that they occurred in a tiny percentage of the total cases. 'ꀜWe'ꀙre concerned because we want this to work well and properly,'ꀝ said Dr. Tom Preston, a retired Seattle cardiologist who serves as Compassion'ꀙs medical director in Washington. 'ꀜThe more we can get information out there on doing it correctly, particularly to doctors, the better it works out.'ꀝ

But the leader of a group that strongly opposes Washington'ꀙs law — approved by 58 percent of voters in a 2008 ballot initiative — has a darker view of these complications. 'ꀜThis is marketed by Compassion and Dr. Preston as a peaceful means of dying,'ꀝ said Eileen Geller, a Seattle hospice nurse who heads True Compassion Advocates, which tries to steer people away from assisted suicide. 'ꀜBut this type of death is cruel and unusual.'ꀝ

One terminally ill Washington patient who took the lethal prescription vomited up part of it because he had swilled six cans of Pepsi, his favorite drink, in the hour before taking the drug, Preston said. He got that information from the patient'ꀙs physician, who wasn'ꀙt there but heard it from people who were present. The patient woke up and fell back asleep several times before finally dying 28 hours later — the longest time to death reported among the 36 Washingtonians who died in 2009 after ingesting the drug.

The other Washington case with complications was a terminally ill woman who swallowed the drug too slowly because she kept stopping to say goodbye to the people around her, Preston said. She fell asleep after drinking less than half the full cocktail, then awakened before later dying. The lethal drug used in assisted dying in Washington and Oregon is either oral secobarbital or pentobarbital, mixed with a sweet-tasting liquid or custard.

The problem in these two cases, Preston said, was the patients refused to have a physician or trained Compassion volunteer present to make sure proper procedures were followed. Compassion counsels patients not to eat for four to five hours beforehand; to take an anti-nausea drug an hour ahead of time; not to take laxatives or ingest acidic beverages such as orange juice; to drink water or soda only at room temperature; and to say goodbyes first and then drink the lethal cocktail down all at once.

Compassion had a volunteer present in 80 percent of the Washington cases where patients ingested the lethal drug last year, and there were no reported complications in those cases, Preston said.

'ꀜWhen we have a trained volunteer present, the average time to sleep is five minutes and the average time to dying is 25 minutes,'ꀝ he said. 'ꀜLike any medical procedure, there'ꀙs a right way to do it. Even when patients and their families have been adequately instructed, it can misfire if there isn'ꀙt someone knowledgable there watching.'ꀝ

In Oregon, there was one reported regurgitation out of the 59 deaths under the law in 2009; there have been 20 out of 460 cases since that state'ꀙs pioneering Death with Dignity law took effect in 1998. Over that entire period, just one patient was reported to have awakened after taking the drug, about four years ago.

According to George Eighmey, Compassion'ꀙs executive director in Oregon, doctors later concluded that patient woke up because he had taken a laxative to mask the bitter taste of the lethal drug, which prevented his body from absorbing the drug quickly enough. When he awoke after being asleep for 65 hours, there were no signs of pain, and he ended up dying of his underlying disease two weeks later.

Oregon reported one Death with Dignity patient last year who took a record 104 hours to die. 'ꀜThe doctors we talked to said it'ꀙs likely she just had a very strong heart,'ꀝ Eighmey said.

There'ꀙs no indication that people who have taken longer to die have suffered, Eighmey said; they look relaxed and sleep soundly. In one case last year, however, family members noticed the patient 'ꀜgrimacing or twitching,'ꀝ he acknowledged. 'ꀜThey were concerned afterward, but the person still died without awakening.'ꀝ

Compassion volunteers inform family members in advance to prepare for an extended vigil. While the average time to death is two hours, Eighmey said, eight or nine of the 460 patients took longer than 10 hours. 'ꀜIt depends on the family whether it'ꀙs uncomfortable or not,'ꀝ he said. 'ꀜYes, some are distressed. But others find it comforting. One family called me after the father took 24 hours to die. They lit candles and held a vigil and said it was good for them and for the father as well. It'ꀙs no different than the dying process in natural death.'ꀝ

Eighmey boasts that last year Compassion had volunteers present during 57 of the 59 assisted-dying cases in Oregon, up from around 80 percent over the previous years. 'ꀜMore and more hospices and medical providers are aware of our organization and appreciate our facilitating that process,'ꀝ he said.

In Washington, there is concern that mandatory physician reporting forms on two of the 63 Washington patients who received lethal medication prescriptions from their doctors weren'ꀙt filed in time for the 2009 annual report. In addition, there were four missing after-death forms from physicians — making it impossible to know whether four of the 47 patients who received the prescription and subsequently died expired from ingesting the lethal drug or from other causes.

'ꀜThe law doesn'ꀙt provide specific enforcement authority but we are calling doctors to ask them if they forgot to send the forms,'ꀝ said Donn Moyer, a spokesman for the Washington Department of Health.

Geller, who also heads a Christian-oriented, right-to-life bereavement group called Consoling Grace, criticized the missing forms as a sign of the dangerous holes in reporting and enforcement under the law. 'ꀜWe don'ꀙt know who died from the medication, and there'ꀙs no penalty for not reporting,'ꀝ she said.

She argues that elderly and disabled people are being pressured by relatives to choose assisted suicide for financial reasons, and that providers are being told they can'ꀙt report this as elder abuse due to the Death with Dignity law. She said she knows of one case last year where a woman suffering from moderate diabetes wanted to stop taking her insulin to qualify for Death with Dignity; when a hospice nurse told her she didn'ꀙt qualify under the requirement that patients be terminally ill with six months to live, a Compassion & Choices volunteer called and berated the nurse.

Geller declined to make the hospice nurse available for an interview, saying the nurse was fearful of retaliation. But Preston called Geller'ꀙs charge against Compassion a 'ꀜbaseless and unsubstantiated claim,'ꀝ saying, 'ꀜwe would never consider working with such a patient except to advise her that she didn'ꀙt qualify under the law.'ꀝ

Overall, Washington'ꀙs experience in the first year of its law was quite comparable to Oregon'ꀙs, according to the state reports. The large majority of patients who received the lethal prescriptions had terminal cancer, were white, had some college education, were covered by health insurance, and were concerned about loss of autonomy, loss of dignity, and inability to participate in activities that made life enjoyable.

One difference was that 72 percent of the Washington patients were enrolled in hospice care, compared with 92 percent in Oregon. Both supporters and opponents of the Death with Dignity law urge terminally ill patients to take advantage of hospice to receive palliative care and pain relief, which may dissuade them from seeking assisted suicide. Experts say awareness and use of hospice and palliative care has increased since Oregon'ꀙs Death with Dignity law took effect.

Critics have said not enough patients undergo psychological evaluations to determine whether they are competent to use the Death with Dignity law. Last year, according to the state reports, doctors ordered evaluations for three Washington patients who later received lethal prescriptions; in Oregon there were none. Preston and Eighmey noted, however, that other patients — three in Washington and five in Oregon — received evaluations and never got the lethal prescriptions. That wasn'ꀙt reported to the states, which only require reporting of cases where patients received the drug.

In one such case, Preston was skeptical about the patient'ꀙs competence but the attending doctor initially was reluctant to order a psychological evaluation because it would take too much time. He ended up ordering the test. 'ꀜThe doctor said it turned out to be very helpful,'ꀝ Preston said. 'ꀜThe patient was too far out of it.'ꀝ