The following is a letter that was sent to all the Vermont House of Representative Members as they considered Physician Assisted Suicide by Robert L. Orleck, Pharmacist.
Re: An act relating to patient choice and control at end of life. (S77)
I am a pharmacist who has practiced retail pharmacy in Vermont for many years. I hope you will read and consider my perspective.
- Secobarbital use problems in Physician Assisted Suicide
The drug that is most often used in Oregon and will most likely be the drug used if Vermont adopts a similar law is “secobarbital” and my these comments will be directed to that drug.
There is no question that secobarbital, if taken in sufficient quantity can cause death. There are many variables (patient age, sex, weight, overall medical condition, recent food or other medications ingested, individual sensitivity to medication and more) that will necessitate differing amounts of the drug. Potential tolerance must be taken into account. However, physicians have not been schooled on how to take the many patient variables into account when writing a lethal prescription. They will make mistakes which will cause patient suffering. In some cases, this shortcoming will result in prescriptions written that are insufficient to cause death. The patient will not die but will experience exaggerated responses to the drug because they are receiving a larger dose than is recommended for “intended” purposes.
Patient medication dosing compliance has been such a problem that the practice of pharmacy has evolved over the years to require that pharmacist offer each patient getting a prescription the opportunity to be counseled on its use. Even the simplest instructions and directions can create major compliance problems for some people. It is not uncommon that there is a caregiver to handle the patient’s medication to insure compliance. This is even more needed with the elderly. In nursing homes and other extended care facilities, nurses use established procedures to insure the patient is compliant. It is not difficult to imagine any of these above described persons getting a lethal dose of medication and having major difficulty in taking it. Yet the Oregon law, recognizing possible coercive problems, requires the medication to be administered by the patient without assistance. As naively understandable as that rationale might be, it leaves most patients very vulnerable to some real and serious practical dangers.
It is reasonable to assume the patient who has received a lethal prescription will have their mind filled with many thoughts as they prepare to surrender their life. If they would have had compliance problems without such a stress, it is not difficult to imagine that the problem is compounded by their state of mind. There are physical limitations some have as well that would affect compliance. Many patients for no apparent reason have swallowing problems when it comes to medication and others have certain neurologic illnesses that create swallowing difficulties. Others may have problems using their hands. They may have tremors or severe weakness that while they may be able to begin taking the drug, they may not be able to complete the ingestion of the total lethal dose.
Can there be any doubt that there will be botched suicide attempts? If a physician is not present to deal with the complications which of course might require them to finish the job (something that would be unacceptable at least at this point in time), there will be much suffering that will come from these botched suicide attempts. If the patient does not die, there will be exaggerated reactions or major side effects from the drug. Imagine the effect on a family member who might be there alone with a patient who experiencing such a scenario.
If not dosed properly the patient might have problems such as gasping or muscle spasms causing them to suffer greatly. They may lose consciousness before they complete the dosing. They may then awake experiencing some of the many major side effects of the drug. The drug may cause them to feel panic or terror. It can cause confusion. They can experience orthostatic hypotension, fall and hit their head. They may end up in a coma and not die at all from the drug.
The drug can cause them to vomit. They can inhale the vomitus causing much suffering and complications. If they vomit before the medication is absorbed they may now not have the sufficient death dose and the major side effects can kick in. Vomiting is not an uncommon side effect for many drugs including secobarbital. It is possible that the person who starts to ingest this medication is already feeling ill and if cancer is involved, has nausea and other physical upsets in the first place. It is not hard to imagine that they would begin to take the medication, gag, possibly swallow some or all of it then gets so sick before the drug kills them that they vomit. In their weakened state they may be unable to deal with the vomiting, some will aspirate the fluids that come up. This can create pneumonia and at a minimum will cause much suffering and distress. They might even die from this violent reaction after much suffering. They may have an allergic reaction to the medication resulting in difficulty breathing, rashes, edema and suffering, all happening without them dying. Some people experience agitation, irritability or excitability and even increased sensitivity to pain. Others may lapse into a coma and linger and suffer for a prolonged period.
Strange reactions have occurred to people under the influence of large doses of this drug. There are cases where an individual has gotten out of bed and has “sleep driven” a car or has done other unconscious activities. If taken with alcohol or other drugs, these side effects can be more exaggerated. You may be aware of drugs such as amphetamines that can cause hyperactivity in some and in others can cause sedation. People do have varying responses to different drugs and that is a very real possibility for those who take drugs like secobarbital, get an overdose, don’t die and then become conscious.
The death envisioned by the Oregon law is one of an effective, humane, quick and final departure. This will not be the case, however. Many will fail in their suicide attempt. They will botch it and it will result in great suffering. It will prolong a life of misery and may result in the person not ever dying from the use of the medication. It will be more than the patient who will suffer. Families will be devastated when this happens when they see their love one linger in such a way. The effects on the health care workers are hard to imagine.
It really is hard to cause death sometimes. There will be those times when the body will not allow it to happen. The lungs and heart will keep working, the drug will wear off and the horror of the overdose side effects will begin. Then what will the loved ones who are with the patient do?
- S77 as amended by the Cummings Amendment benefits dying patients!
The Cummings Amendment has resulted in the S77 that has come over to the House for consideration. This amended bill, as passed by the Senate creates real benefits for a dying patient. Under the current state of the law, physicians are apprehensive about aggressively treating pain, even for terminal patients. They fear that they might be improperly accused of intentionally killing their patient who might die of an overdose, either intentionally or not. If the Senate’s passed version of S77 becomes law, it would free the physician to aggressively treat the symptoms of the patient without fear of legal action against them. In such a situation the matter is then not about suicide but about taking care of a dying patient.
The bi-partisan vote in the Senate shows the value of deliberation for complex issues. Some states do it by voter referendum. Deciding such far reaching matters in that way is dangerous and irresponsible. It is good that Vermont did it its way. With voter referendum it is “yes’ or “no” without an opportunity to make needed changes along the way. There is no ability to deal with unconsidered effects and their consequences. With committee consideration and floor debate that can include amendments, all sides of the bill can be considered and adjusted to get a bill that is less likely to be flawed. That was the very result in this case. Through that process something good has come from an original offering that even proponents know has serious flaws both legally, ethically and factually.
- Reasons why Oregon law cannot be relied on to support S77
Oregon took the dangerous path and the law was enacted by an emotion driven, heavily funded voter referendum, the process by which careful consideration of facts and implications were removed from the equation. So then, how are the flaws to be handled that have and will show up. Basically by creating a reporting system that casts a blind eye to any problems and complications. In that way the law is made to appear the way it was intended to appear to the voters. Only a “head in the sand” (one that does not investigate) analysis could report that there were no or few serious problems. A close examination of the years that Oregon has allowed the patient to choose to die reveals this. Even so, there are still reports of horrific events that surface. Once the patient has received this life ending permission and lethal medication, the system seems to have no resources and definitely has no desire to look for any problems surrounding the matter. Even the death certificate does not carry the fact that the patient chose suicide but lists the underlying disease as the cause of death.
In 2012 there were 77 Oregon patients who requested a lethal prescription and died. (It is curious that Vermont’s introduced bill is numbered S 77). In 64 of those cases it was not known if a health care provider was present or not when the medication was taken. However it was known that there was no provider present when 66 of these 77 died. It was also reported as unknown whether any of these 66 experienced complications. It is also very curious that it is unknown how many minutes it took from ingestion to unconsciousness and from unconsciousness to death. So when you hear anyone say there have been no problems or complications with people in Oregon, think about these unknown numbers. They just do not know! This is because no one is talking and the deceased cannot. You have heard it said that “dead men tell no lies”. Well, they cannot tell the truth either of how real and intense their pain and suffering was after they took the lethal dose but before they died. The suffering these people experience does cry out from statistics that have been kept and it is reasonable to predict that a large percentage had serious complications from the point of ingestion to the point of death.
There was and is nothing meaningful in place in Oregon to monitor and report complications! The report should have an explanation of how cases are monitored and report what truly happened, good or bad. Yet there are those who would have us believe such a law will be good for the dying in Vermont because Oregon has had the law for some time and has had no problems. But they have had major problems, they will in the future and so will Vermont. Who will suffer the most? There will be many people dying horrific deaths in Vermont if the Oregon type bill is passed. They will be the ones to suffer along with their loved ones and healthcare providers.
In the Netherlands, assisted-suicide complications and problems are not uncommon. One Dutch study found that, because of problems or complications, doctors in the Netherlands felt compelled to intervene (by giving a lethal injection) in 18% of cases.(21) This led Dr. Sherwin Nuland of Yale University of Medicine to question the credibility of Oregon’s lack of reported complications. Nuland, who favors physician-assisted suicide, noted that the Dutch have had years of practice to learn ways to overcome complications, yet complications are still reported. “The Dutch findings seem more credible [than the Oregon reports],” see http://www.patientsrightscouncil.org/site/oregon-ten-years/ (note-it would be instructive for our legislators to read the entire post that is on-line)
In that same post a member of the British Parliament when considering the Oregon report; “…questioned the lack of reported complications associated with assisted suicide in Oregon. After hearing witnesses from Oregon claim that there had been no complications (other than “regurgitation”) associated with more than 200 assisted-suicide deaths, Lord McColl of Dulwich, a surgeon, questioned that assertion. He said that, in his practice as a physician, “if any surgeon or physician had told me that he did 200 procedures without any complications, I knew he possibly needed counseling and had no insight. We come here and I am told there are no complications. There is something strange going on.“(23)”
While so many states have considered physician assisted suicide, no state legislature has ever passed such a law and for good reason. When they deliberate and consider all aspects, they find such an approach to dying is unworkable and fraught with danger. Senator Dick Sears from Bennington stated that even a “first year law student” could see legal problems with the bill. Vermont is facing serious issues of “elder abuse” which have implications for this law. There are so many other legal and social issues that adequate discussion here would not be practical. I am sure that others will discuss those.
- Medical realities and facts need to be seriously considered.
What should be most compelling is that there are medical realities and facts that cry out to be heard over the moving and sincere but uninformed emotional clamor to adopt the Oregon modeled bill. The reality is that the AMA (American Medical Association), most nurses, pharmacists and other health care workers are opposed to an Oregon type bill. Their thinking and feelings should be valued in the decision making process. They are the ones on the front line and they see the human price to be paid. Physicians engage in the “practice of medicine”. By simple word analysis, “medical practice” is a term that lacks definiteness of result. Yet we want to thrust them into roles they are ill equipped to perform and that are against their calling to the healing profession. There is no certainty even on how long a patient has to live. The six month to live requirement is nothing but a guess that so many times is very wrong. Doctors should not be forced to make life and death decisions on what amounts an educated guess. While I would suppose they would get better at it the more they do, physicians do not even know how to use drugs to cause death nor do manufactures make drugs for that purpose.
Even the Food Drug & Cosmetic Act defines drugs by their intended use as “articles intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease”. Over hundreds of years this has been the mission of medicine and the medical community has become better and better at meeting its goals. It would be very wrong to reject that mission and instead of helping the patient to have a good natural end to life, to create a system that encourages patients to have a bad end to life by killing themselves.
Most health care workers believe their role is not to assist in the death of patients, they are not trained to assist in the killing of patients, nor do they have the necessary tools to effectively kill the patient. As earlier stated, physicians have not been trained for such an end result and don’t know how to dose for the many variables in age, weight, sensitivity or whatever, of the patient. No such courses are taught in medical school nor are there any continuing education programs. Neither physicians nor pharmacists know how to deal with the lethal prescriptions and with what to do when things go wrong.
- Original S 77 safeguards are in reality hurdles!
The original S77 language would provide the ability to get a lethal dose of secobarbital (the most likely drug to be used) if the patient is given and cooperates with certain so-called safeguards before they get the prescription. Those safeguards, some realize, are really nothing more than hurdles that a patient must clear before they can get this particular drug. When scrutinized, it can be seen that these safeguards do not provide protection against medical diagnostic error. They do not lead to certainty in the prognosis and time a patient has remaining. Nor do they actually provide protection against coercive action. The application of the law allows and seems to encourage the final act to be done without any scrutiny by law enforcement to insure that a patient has not been murdered. There is nothing in the law to monitor or prevent the patient from experiencing complications that large percentage of them will suffer when taking this medication on their own.
- What would the original S 77 provide for a dying patient?
So when distilled down to the basics, implementation of such a law would only add one thing to the patient’s ability to choose suicide as their final act. That is the adding of one substance to the choice of the pharmaceutical substances that could be used to kill themselves. Little is gained that is not already possible for a patient other than having a physician writing a prescription for secobarbital. Much is lost by having the State endorse the act of with all the implications including the wrong message that is sent to troubled teens in a troubled society.
Some may think that the final act of dying simply involves getting the prescription, taking a pill, closing one’s eyes and dying. Some may not be aware that the quantity of the drug secobarbital on average will require the contents of up to 100 of the bitter tasting capsules. This prescription can then sit around unattended for months before the patient, if ever, decides to use it. The more time that goes by the more the supposed safeguards are diminished. A patient could even go past the six month criteria for length of life, still have the medication and could use it to take their life. At the time it was prescribed they might not have been clinically depressed but later when using the drug that might have changed. It is not hard to think of problem after problem resulting from such dangerous, unattended drugs being around. Imagine a child getting hold of the drug (packaged in a non-childproof bottle at the request of the patient).
- Current end of life procedures
End of life medical care has come so far. There are many drugs in the physician’s armentarium to keep the patient comfortable during the dying process. A dying patient (say one dying of cancer) can receive large doses of morphine. How much? The drug literature is reluctant to limit the dose except for giving sufficient dose that will alleviate the pain for that patient. Even with large doses, a patient can be made pain free and they can still function mentally. Beyond that level, there is even the possibility of sufficiently dosing a patient to unconsciousness and keeping him there until he dies. All should be able to agree in this situation that if a terminal patient dies when symptomatically heavily dosed, they were dying in any event and the treatment was legal, humane and ethical. Such an approach is made possible by the just passed Senate version of S77.
Such available effective treatment, free from high incidences of complications, obviates the need for the dangerous and in many cases ineffective dosing with secobarbital, where unmonitored patients can experience as a result, a very painful and disturbing death. It should make one wonder why there would be a desire to implement such a potentially barbaric procedure to bring the patient’s life to an end. There are answers to why but they are most likely based on economic considerations since it is much cheaper to provide a lethal dose to a patient than providing them caring and complete treatment until natural death. Of course most of the Oregon type bill supporters are not driven by that consideration but they are deceived and honestly believed this choice will bring dignity at death. Nothing could be further from the truth. There will be horrible outcomes from allowing death to occur in this manner.
- There is a slippery slope!
Once passed, subsequent legislation expanding the scope to euthanasia is possible. If offered today it would fail but after physician assisted suicide is passed, if offered (and it most likely will be) it will be easier to pass. After physician assisted suicide it is likely that there will be attempts to expand it to not only voluntary euthanasia but to involuntary euthanasia as evidenced by how proponents have proceeded in other countries. Consider other areas where passage has led elsewhere: First a civil union law is passed then expanded to same sex marriage. The battle raged about civil union for years but it was much easier to expand the law to marriage once civil union was on the books. One only needs to look at the Netherlands to see how the progression is happening. Consider abortion. It progressed to partial birth abortion then to the practice of allowing survivors of abortion to die after birth to discussions now of allowing a certain period of time by which the parent can decide after delivery to terminate the life of the infant.
There are so many problems with the physician assisted suicide law that was envisioned by S77 that, if passed into law, there will be a need for remedial legislation in the years to come. So the door will be left open for expansion as we move down the line. If a defective bill is passed, any curative legislation most likely will not receive the same scrutiny as this bill has received over the past 10 years. Why is this likely? Because it will be the only way that a guaranteed death will occur so to have a “successful” completion of the physician assisted suicide. Then while at it, why not extend it to child or disabled euthanasia? Our society will have become so desensitized to the killing that we will have morphed from a one that values life to one that bases life’s continuance on some subjective evaluation by some unknown person or group, based on computer statistics, as to whether there is sufficient quality of life for that person to continue to live. All economies have downturns and the need to cut costs and this is an area that will become ripe for modification since the people who are in the group most likely to be using this law or having it used on them are ones whose medical costs are the highest. Insurance companies will be able to deny certain other medical treatments more easily when the option of assisted suicide is one that is medically accepted.
What a cold, uncaring world such thinking envisions.