Characteristics of Patients Requesting and Receiving Physician-Assisted Death.pdf

Characteristics of Patients Requesting and Receiving Physician-Assisted Death.pdf

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Unformatted text preview: ORIGINAL INVESTIGATION Characteristics of Patients Requesting and Receiving Physician-Assisted Death Diane E. Meier, MD; Carol-Ann Emmons, PhD; Ann Lithe, MA; Sylvan Wallenstein, PhD; R. Sean Morrison, MD Background: Surveys have shown that physicians in the United States report both receiving and honoring re- quests for physician assistance with a hastened death. The characteristics of patients requesting and receiving phy- sician aid in dying are important to the development of public policy. Obiociivo: To determine patient characteristics asso- ciated with acts of physician-assisted suicide. Design: Physicians among specialties involved in care of the seriously ill and responding to a national repre- sentative prevalence survey on physician-assisted sui- cide and euthanasia were asked to describe the demo- graphic and illness characteristics of the most recent patient whose request for assisted dying they refused as well as the most recent request honored. Results: Of 1902 respondents (63% of those surveyed), 379 described 415 instances of their most recent request refused and 80 instances of the most recent request hon- ored. Patients requesting assistance were seriously ill, near death, and had a significant burden of pain and physical discomfort. Nearly half were described as depressed at the time of the request. The majority made the request them- selves, along with family. In multivariate analysis, physi- cians were more likely to honor requests from patients mak- ing a specific request who were in severe pain (odds ratio, 2.4; 95% confidence interval, 1.01-5.7) or discomfort (odds ratio, 6.5; 95% confidence interval, 2.6-16.1), had a life ex- pectancy of less than 1 month (odds ratio, 4.3; 95% con- fidence interval, 1.7-10.8), and were not believed to be de- pressed at the time of the request (odds ratio, 0.2; 95% confidence interval, 0.1-0.5). Conclusion: Persons requesting and receiving assis- tance in dying are seriously ill with little time to live and a high burden of physical suffering. Arch Intern Med. 2003;163:1537-1542 From the Hertzberg Palliative Care Institute, Department of Geriatrics and Adult Development (Drs Meier and Morrison and Ms Litke) and Department of Biomathematical Sciences (Dr Wallenstein), Mount Sinai School of Medicine, New York, NY; and National Opinion Research Center, Chicago, Ill (Dr Emmons). The authors have no relevant financial interest in this article. (REPRINTED) ARCH INTERN MED/ VOL 163, JULY 14, 2003 MID CONTINUED contro- versy, national surveysl'4 suggest that 1 in 5 physi- cians in the United States have received at least 1 re- quest to assist a terminally ill patient to die, and approximately 3% to 18% accede to these requestsM'6 despite legal prohibi- tion against the practice in all states but Oregon. With the exception of surveys focused specifically on oncologists}7 early reports from Oregon after legaliza- tion,‘*'11 and small studies from single states,5'12 little is known about the char- acteristics of patients requesting aid in dying and what patient characteristics are associated with a physician’s decision to honor a request. We previously re- ported results from a national survey of US physicians’ experiences with respect to physician-assisted suicide and eutha- nasia by lethal injection.1 In this article, 1537 we report data from the physician re- spondents’ recall of the characteristics of patients making requests as well as char- acteristics of patients whom they decided to assist. A patient’s request for his or her phy- sician’s assistance in dying is a communi- cation of great distress. Some physicians will explore the reasons for the request, and oth- ers will avoid the subject, but it is a pow- erful communication, and one physicians are not likely to forget. Mostlim1018 but not all2 previous attempts to study the circum- stances surrounding a patient’s request for aid in dying have used the retrospective memories of physician respondents as proxies for the patient’s voice. Reasons for this method include the facts that it is all but impossible to prospectively identify and interview sufficient numbers of seri- ously ill patients who wish aid in dying; that retrospective interviews of family care- ©2003 American Medical Association. All rights reserved. Downloaded From: on 05/21/2017 givers require that physicians identify both deceased pa- tients and families who have either completed or con- templated completing an illegal act; and that physicians are a relatively accessible group for surveys. While the physician as representative of the patient’s perspective is imperfect and may be a biased source of information, it is a feasible means of acquiring population data on this rare practice.1 To this end, using data from a national representa- tive survey (among physician specialists involved in care of the seriously ill) of US physician experiences with re- quests for and acts of physician-assisted death,1 we as- sessed respondents’ descriptions of the characteristics of those of their patients making such requests as well as variables associated with the physicians’ decisions to honor them. @— The survey sample, questionnaire development, and data col- lection procedures are described in detail elsewhere.1 The sample was designed to represent all practicing physicians in the United States in the 10 specialties determined in other studies most likely to receive requests for assisted death?12 We drew a strati- fied probability sample of 3021 doctors of medicine younger than 65 years from the 1996 AMA Physician Master File. Spe— cialists at highest likelihood of receiving requests based on pre- viously reported data were oversampled to maximize report- ing of the events of interest. We mailed the questionnaire to 3021 sampled physicians in August 1996. A series of remailings and telephone remind- ers resulted in 1902 completed questionnaires for analysis (63% response rate). The survey (available from the authors on request) que- ried respondents about experiences they had had with re- quests for and acts of assisting a patient to die, defined as writ- ing a prescription or administering a lethal injection with the primary intention of ending the patient’s life. This terminol- ogy was chosen to avoid widespread variable interpretation of the term euthanasia and its qualifiers (active, passive, volun— tary, involuntary). For the purposes of both the survey and this article, the phrase used in place of “active euthanasia” was “le- thal injection with the primary purpose of ending the patient’s life.” Physicians reporting experience with such requests, re- gardless of their response to the request, were then asked to describe the most recent request that was refused as well as the most recent request that was honored, if any. These descrip- tions of the respondents’ memory of their most recent patient requests are reported herein. Physician respondents were asked to describe the source of the request (patient, patient and family, family member, or other); the nature of the request (prescription, lethal injec- tion, or a nonspecific request for either type of assistance); the primary diagnosis; the physician’s estimate of the patient’s life expectancy; whether the physician believed that the patient was in pain or discomfort; the demographic characteristics of the patient; the patient’s cognitive, affective, and functional state; and the duration of the physician-patient relationship. All ques- tions were closed-end. Physician characteristics associated with receiving and acting on requests for an assisted death were re- ported elsewhere.1 We used x2 tests to compare patient characteristics and demographic variables for patients whose requests were hon- ored or refused. Subsequently, a stepwise logistic regression model to yield predictors of honoring a request was con- structed on the basis of all patient characteristics found to be significant in univariate analysis at a level of P: .15 or below, as well as variables found to be significant predictors in other studies.3‘5‘7‘8‘12 As some physicians reported both a request that was honored and one that was refused, we combined aspects of matched and unmatched studies by means of a procedure described by Moreno et al19 and implemented with PROC PHREG of SAS software (SAS Institute Inc, Cary, NC) as de— scribed by Huberrnan and Langholz.20 Reanalysis excluding the 36 respondents who reported one response of each type had no influence on the results. We excluded from these analyses responses from physicians who stated that they would not honor a patient’s request for a hastened death under any circum- stances. Similar steps were used to create 2 additional multi- variate logistic regression models to identify factors that influ— enced decisions to honor a request specifically for prescription or injection, respectively. The study was approved by the Institutional Review Board of the Mount Sinai School of Medicine, New York, NY. M— SOURCE OF THE SAMPLE The Figure describes the origins of the sample. Of the 3021 eligible physicians surveyed, 1902 (63%) re- sponded by returning a completed survey. Of these, 379 described characteristics of their most recent request for an assisted death. One hundred fifty-five physicians (41%) stated that they would not honor a patient’s request for a hastened death under any circumstances. Of the re- maining 224 physicians who stated that they would be willing to honor a request, we report 260 descriptions of their most recent request: 80 physician descriptions of patients whose requests for assistance in hastening death were honored, as well as 180 physician descriptions of patients whose requests were refused. Thirty-six physi- cians reported 1 request of each type (a request honored and a request refused). CHARACTERISTICS OF PATIENTS MAKING A REQUEST Table I contains physician descriptions of their most recent patient and family requests for assistance in dy- ing. These patients were predominantly male (61%), 46 to 75 years old (5 6%), of white European descent (89%), Christian (78%), and middle class (71%). Almost 50% were college graduates. Almost half (47%) had a pri- mary diagnosis of cancer, and a large number were ex- periencing severe pain (38%) or severe discomfort other than pain (42%). Many were described by their physi- cians as dependent (53%), bedridden (42%), and ex- pected to live less than 1 month (28%). The majority (90%) were lucid, but had experienced a recent deterio- ration in functional status (87%). Almost half (49%) were believed by their physicians to be depressed at the time of their initial request. Most requested a lethal prescrip- tion (52%) vs a lethal injection (25%) or did not specify the type of assistance they wanted (23%). In the major- ity of requests (89%), the patient made the initial re- quest, either alone or with a spouse or other family mem- ber. More than half of these patients (53%) had known (REPRINTED) ARCH INTERN MED/ VOL 163, JULY 14, 2003 1538 ©2003 American Medical Association. All rights reserved. Downloaded From: on 05/21/2017 1996 AMA Physician Master File of 10 Internal Medicine Suhspecialists Likely to Receive Requests for Assistance in Dying l Stratified Random Sample of Physicians (N =3021) l Mail Survey Reminder Telephone Calls Remails l 1902 Physician Respondents (63% ofThose Eligible) l 379 Physicians (20%) Reported 415 Descriptions of Requests for a Hastened Deat 81 Ineligible: 75 Not in Active Practice 6 >65 y Old 1038 Nonrespondents / 155 Physicians Who Would Not Honor a Request for a Hastened Death UnderAny Circumstances Reported 155 Descriptions of Requests for a Hastened Death l l 155 Descriptions of Most Recent Request Refused by Physicians Who Would Nut Hunur a Request for a Hastened Death Under Any Circumstances A \ 224 Physicians Who Would Honor a Request for a Hastened Death Under Some Circumstances Reported 250 Descriptions of Requests for a Hastened Death 180 Descriptions of Most Recent Request Refused A an Descriptions of Most Recent Request Hundred A 46 Nonspecific Requests 29 Requests for Lethal Injection 80 Requests for Lethal Prescription 5 Nonspecific Requests 43 Requests for Lethal Injection 32 Requests for Lethal Prescription 44 Nonspecific Requests 33 Requests for Lethal Injection 103 Requests for Lethal Prescription Patients requesting and/or receiving physician aid in dying, based on a national representative survey of US physicians. the physician to whom the request was directed for a year or more. Characteristics of patients requesting lethal pre- scription as compared with lethal injection are also in Table 1. Multivariate logistic regression (model not shown) with type of request (injection or prescription) as the dependent variable was used to compare patient characteristics. Patients requesting a prescription were less likely to be bedridden (odds ratio, 0.4; 95% confi- dence interval, 0.2-0.8), more likely to have an esti- mated life expectancy of longer than 1 month (odds ra- tio, 4.0; 95% confidence interval, 2.0-8.3), and more likely to have made the request themselves (odds ratio, 4.3; 95% confidence interval, 1.3-14.0). DECISIONS TO HONOR OR REFUSE A REQUEST FOR AID IN DYING FOR ALL PATIENTS Overall, respondents reported 415 requests for aid in dy- ing. Of the 260 requests (63% of total requests) made to physicians who reported that they would, under some conditions, honor such a request, 135 (52% of 260) were made for a prescription, 76 (29%) for an injection, and 49 (19%) for either. Respondents reported honoring 32 requests for prescriptions (40% of 80 requests hon- ored), 43 requests for injections (54%), and 5 nonspe- cific requests for either type of assistance (6%). Independent predictors of having a request for aid in dying honored are given in Table 2. Compared with those making a nonspecific request, specific requests for assistance were significantly more likely to be honored for either prescription or injection. Other independent predictors of a physician’s decision to honor a patient’s request for assistance in dying included severe pain, se- vere physical discomfort, and life expectancy of less than 1 month. Although 21 (26%) of 80 patients receiving as- sistance in dying were believed by their physicians to be depressed when the request was made, physicians were significantly less likely to honor a request if they be- lieved the patient was depressed at the time of the re- quest. Because of how the survey was constructed, loca- tion (home, hospital, or other) at the time of the request was obtained only on honored requests. About 50% of the respondents describing such a patient did not re- spond to that question at all. For this reason (missing data), location at time of request was not included in the regression models. Among the 32 patients who received a lethal prescription, 13 (41%) were at home at the time of the request, none were reported as having been in the hospital, and 19 (59%) of the data points were missing. (REPRINTED) ARCH INTERN MED/ VOL 163, JULY 14, 2003 1539 ©2003 American Medical Association. All rights reserved. Downloaded From: on 05/21/2017 Table 1. Characteristics of Patients in Sample: Overall and by Type of Request No. (%) Requested Requested Total Lethal Lethal Sample* Prescription Injection (n = 415) (n = 215) (n =105) 155 (39) 74 (35) 346 (89) 183 (90) Female sex White race/ethnicity Religion Roman Catholic Other Christian Jewish Other None Age, y 19-45 46-75 >75 Social class Upper Middle Lower Education None or elementary school High school graduate College graduate Primary diagnosis Human immunodeficiency virus Cancer Neurologic disease Other Experiencing severe pain Experiencing severe discomfort other than pain Confused Depressed at time of request Experienced recent deterioration in functional status Dependent for most or all of personal care Bedridden Physicians’ estimate of life expectancy <1 mo 21 m0 Duration of patient-physician relationship <1 mo 1 mo to 1 y >1 y Source of request Patient or patient with family Family only Type of request Lethal prescription Lethal injection Either prescription or injection 39 (10) 202 (49) 313 (87) 217 (53) 173 (42) 114 (28) 294 (72) 68 (19) 100 (28) 191 (53) 361 (89) 46 (1 1) 215 (52) 105 (25) 0 95 (23) 0 0 215 (100) o 105 (100) *Total sample included 215 who requested a lethal prescription, 105 who requested a lethal injection, and 95 who made a nonspecific request. TP<.001 (unadjusted comparisons of lethal prescription vs lethal injection). 1:P=.007 (unadjusted comparison of lethal prescription vs lethal injection). Among the 43 patients who received a lethal injection, 25 (58%) were in the hospital at the time of the request, 3 (7%) were at home, and 15 (35%) of the data points were missing. Table 2. Independent Patient-Related Factors Associated With Physicians Honoring a Request for a Hastened Death* Odds Ratio p 95% Cl Value Type of request’r Prescription Injection Patient depressed at time of request Patient in severe pain Patient in severe discomfort other than pain Patient life expectancy <1 mo 43 1 06 0.2 2.4 6.5 4-440 1 0-1 1 00 0.1 -0.5 1 .01 -5.7 26-161 .002 <.001 <.001 .049 <.001 4.3 1 .7-10.8 .002 Abbreviation: CI, confidence interval. *Responses from physicians who stated that they would not honor a patient‘s request for assistance in dying under any circumstances were excluded from the analysis. TReference category was nonspecific request for prescription or injection. Table 3. Independent Patient-Related Factors Associated With Physicians Honoring a Request for a Hastened Death by Lethal Injection or Lethal Prescription* Odds Ratio 95% CI P Value Lethal Injection Patient depressed at time of request Patient in severe discomfort other 0.1 3.8 0.2-0.4 1 02-144 .002 .04 than pain Patient life expectancy <1 mo 12.9 Lethal Prescription Patient depressed at time of request 0.12 003-05 .004 Patient in severe pain 9.3 22-396 .003 Patient in severe discomfort other 21.4 4.6-100.8 <.001 than pain Duration of physician-patient relationship 30-561 .001 1.1 099-12 .07 Abbreviation: CI, confidence interval. *Responses from physicians who stated that they would not honor a patient‘s request for assistance in dying under any circumstances were excluded from the analysis. DECISIONS TO HONOR OR REFUSE REQUESTS FOR PATIENTS REQUESTING PRESCRIPTION AND FOR PATIENTS REQUESTING INJECTION We performed 2 subanalyses to identify factors associ- ated with honoring a request for aid in dying for pa- tients requesting a prescription and for patients request- ing an injection (Table 3). In multivariate analyses of patients requesting a prescription, patients with severe pain and severe physical discomfort other than pain were significantly more likely to have their request honored. While 10 (31%) of 32 patients receiving a prescription were reported by their physicians to be depressed at the time of their request, depressed patients were signifi- cantly less likely to have their request honored than pa- tients not described as depressed at the time of the re- quest. For those requesting a lethal injection, patients with severe physical discomfort other than pain and patients with a life expectancy of less than 1 month were signifi- cantly more likely to have their request honored in the multivariate analysis. Again, although 9 (21%) of 43 pa- (REPRINTED) ARCH INTERN MED/ VOL 163, JULY 14, 2003 154-0 ©2003 American Medical Association. All rights reserved. Downloaded From: on 05/21/2017 tients receiving a lethal injection were described as de- pressed at the time of the request, depressed patients were significantly less likely to have their request honored. @— The major finding of this analysis is that patients receiv- ing a physician’s assistance in hastening their death are making specific requests, have a substantial burden of physical pain and distress, and ...
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