The Hospice e-News

What the Media Said about End-of-Life Care This Week

Week of May 1, 2006

…a service of Florida Hospices and Palliative Care

 

 

 

JAMA ARTICLE EXAMINES ROLE OF PAS IN MEDICAL PRACTICE

 

In “Physician-Assisted Suicide,” in the current issue of JAMA, author Lawrence O. Costin, JD, LLD, examines the history and role of physician-assisted suicide.  He traces the history of the movement from the early 1990s, citing a Supreme Court ruling which “did not find a constitutionally protected liberty interest in physician-assisted suicide,” but which did invite “state experimentation.”  Costin discusses three factors that have had significant bearing on the issue.

 

In his first topic, Oregon’s Death With Dignity Act (DWD), Costin briefly describes the DWD Act as one that “authorizes an attending physician to prescribe medications that will assist in a patient’s suicide, but only under tightly controlled circumstances.”  He lists those circumstances as an incurable, irreversible disease with a prognosis of less than six months, a voluntary, informed request on the part of the patient, referral to counseling if the patient’s judgment may be impaired, the examination of the patient and the review of the records by a consulting physician.  He also cites Oregon Department of Human Services statistics that show that, at the end of 2005, 246 persons out of 390 who had obtained prescriptions had used them.

 

Costin next looks at the Controlled Substances Act (CSA), whose objective is “controlling the legitimate and illegitimate traffic in controlled substances,” and its place in medical practice.  Medical practice is regulated by the CSA, in part, by requiring physicians to register to prescribe controlled substances.  Ashcroft threatened physicians who prescribed controlled substances for the purpose of suicide with losing their federal registration, which would “severely restrict a physician’s ability to practice,” and make Oregon’s DWD Act “virtually unworkable.”  Costin says, “There is little doubt that the federal government could set national standards for medical practice,” and that “Congress could constitutionally proscribe physician-assisted suicide, but the CSA does not authorize the attorney general to do so.”

 

Costin’s third factor is Gonzales v Oregon, the DEA’s most recent challenge to the DWD Act.  Costin says that the Court applied administrative law principles to the case, the issue of which is “whether the CSA authorizes the attorney general to determine that physician-assisted suicide is not a legitimate medical practice and therefore subject to criminal sanctions.”  Using those principles, which are for “examining the activities of administrative agencies such as the Department of Justice,” the Supreme Court found that the attorney general’s ruling did not deserve “deference,” meaning that the Court “would not give any special weight to the attorney general’s views in the case.”

 

Without deference, the article says, “An agency’s interpretation is entitled to respect only to the extent that it has persuasive power.”  Costin says that the majority opinion, written by Justice Kennedy, “found the attorney general’s claim that using controlled substances for physician-assisted suicide is a federal crime to be unpersuasive.”  Beyond prohibiting physicians from acting as drug “pushers,” the CSA “does not regulate medical practice.”

 

Costin says that “Gonzales v Oregon is a case about the practice and boundaries of medicine and the appropriate locus of public health regulation under American federalism,” and also “poses profound questions about the physician’s role in the care of patients at the end of life.”  The case “raises the issue of the limits that should be placed on medical practice and who should set them.”  Costin sees the decision as exhibiting “respect for medical decisions and professional self-regulation.”  Physicians, he says, “should make decisions in accordance with the wishes of fully informed patients.  This vision of clinical autonomy and a private sphere between patient and physician requires local regulation guided by medical standards.  Clinical freedom is inconsistent with federal policing of medical judgments for criminal justice purposes.”

 

Costin notes that Justice Scalia’s dissent in the case points out that nearly all states proscribe physician-assisted suicide and adds, “The US and state supreme courts have found that physician-assisted suicide is not part of the history and tradition of the United States and, therefore, does not warrant constitutional protection.”  But Costin believes that the court upheld the Oregon law because of its “discomfort with federal intrusion into intimate matters,” and because it “seeks to facilitate innovative state experiments and humane medical care at the end of life.”

 

Costin concludes by saying , “In many ways, discussion of physician-assisted suicide masks a far more important problem – the need to reliably and safely achieve effective relief of pain and suffering near the end of life.  Multiple forces have stood in the way of effective palliative care such as physician training (stressing intervention over palliation), a rescue imperative, and the burgeoning development and promotion of life-saving technologies.  Physicians have also feared criminal or civil liability for hastening a patient’s death.  Commenting on Gonzales v Oregon, President George W. Bush expressed disappointment at the erosion of a ‘culture of life.’  However, deep caring and relief of suffering by physicians at the bedside of dying patients may be a far greater affirmation of life.  Modern medicine must evolve to constructively support patients in the dying process – a time of incomparable meaning and importance to the human condition.”  (JAMA, 2006;295:1941-1943)

 

 

DOCTOR FIGHTS PAIN – HIS OWN AND OTHERS’

 

Dr. Howard Heit, once “an up-and-coming gastroenterologist,” switched to the practice of pain medicine after an automobile accident left him with continuous neck and head pain that was 100 times worse than a leg cramp.  Profiled in a Washington Post article, Heit, now practicing in Fairfax, Virginia, was one of the doctors who worked with the DEA on guidelines for prescribing narcotics.  Heit wrote in the journal Pain Medicine about the DEA’s withdrawal of the FAQ from their website, saying, “It now is apparent to me that the spirit of cooperation that existed between the DEA and the pain community to achieve the goal of balance has broken down.  The DEA seems to have ignored the input and needs of the healthcare professionals and pain patients who actually prescribe, dispense, and use [prescription opioids].”

 

Though Heit no longer uses opioids for his own pain, the article says, “As the showdown between pain doctors and prosecutors stiffened several years ago, he felt obliged to get more actively involved in defense of opioid treatment despite the potential risk to his practice.”  That was when he joined the group of physicians, hospice workers and others in collaborating with the DEA on writing the guidelines.

 

But unlike many other physicians, Heit still prescribes large doses of opioids for his pain patients.  Since he shares the concern of the DEA and others about the diversion of such drugs, the first “order of business” for his patients on their visits to him is for him to check their vials of drugs to see how many they have taken since their last visit.  He also believes in activity as an analgesic and, since he is confined to a wheelchair, his own history and condition give him credibility with patients.

 

It also gives him credibility with federal agents.  DEA liaison and policy chief Patricia Good, with whom Heit worked on the Frequently Asked Questions document that was pulled, was impressed with the way Heit ran a tight ship in terms of prescription narcotics, with his dedication to patients and with his willingness to cooperate, and even argue with, the DEA.

 

Heit’s practice has 250-300 patients and, in addition, he teaches at Georgetown University School of Medicine, is a regular speaker at pain and addiction conferences, writes extensively and consults for some major pharmaceutical houses that produce opioids.  His patients include a number of success stories, the most notable a young woman with two ruptured disks in her neck.  She declined surgery when other doctors recommended it to her and instead, on her boyfriend’s advice, saw Heit.  Treatment with OxyContin improved her condition “markedly” and, while she was still on OxyContin, she got married and got pregnant.  She knew she’d have to have the medication to get through the pregnancy, the article says, and was concerned about the possibility of the baby being born addicted.

 

Heit was present at the birth to examine the newborn for any signs of addiction and found none.  While Heit is the kind of doctor one might expect to attend such a birth, he had a special reason for attending this one.  The patient was his daughter-in-law, Jamie Heit, and the baby was his first granddaughter, Lilly.  (The Washington Post, 4/23)

 

 

RESEARCH AND RESOURCE NOTES

 

*  PainAid, at www.painfoundation.org, is an online community for discussion and the sharing of personal stories by and for people living with pain and their caregivers.  This is a free service that offers chats, forums and online information resources on topics ranging from illness-specific pain and treatments to financial issues such as disability and workers’ compensation.  Participants may “ask-the-expert” and forward questions to licensed healthcare professionals.  (American Pain Foundation Website, 4/2006)

 

*  Bioethics Forum, a new, online, free service of The Hastings Report, looks at the AIDS epidemic after 25 years.  The lead-in to an article says, “For all the ethical fieldwork they do, if AIDS activists did not exist, health care ethics would have to invent them.”  The article is online at www.bioethicsforum.org.  (Bioethics Forum Website)

 

*  The current issue of PainAdvocacyCommunity is online at the Partners Against Pain website at www.partnersagainstpain.com/painadvocacycommunity/pdfs/Vol0604.pdf.  The article contains information on a 12-module AMA pain management program that is available at www.ama-cmeonline.com.  There is a review of the American Society for Pain Management Nursing’s Pain Assessment in the Non-Verbal Patient.  A section for healthcare professionals has a Medical Education Resource Catalog with information on tools to assess pain.  “In the Spotlight” is a report on a new assessment by the Intercultural Cancer Council on disparities of care in the medically underserved community.  (PainAdvocacyCommunity, 4/2006)

 

*  Meeting the Challenge of Chronic Illness, by Robert L. Kane, Reinhard Priester, and Annette M. Totten, is reviewed in the current JAMA issue by Jennifer L. Wolfe of the Johns Hopkins Bloomberg School of Public Health.  The reviewer says the book “masterfully synthesizes a voluminous evidence base to articulate the underpinnings and implications of the chronic care dilemma in the United States.”  The book is “comprehensive, well-referenced, and sophisticated in its analysis,” and “the lucid narrative makes it accessible to a variety of audiences, from the general public to policy makers, practitioners, and researchers in the field” (JAMA, 2006; 295:1951-1952)

 

 

OTHER NOTES

 

*  Oklahoma Attorney General Drew Edmondson (D) announced Oklahoma Palliative Care Week, which focuses attention on end-of-life care issues.  During the news conference, Edmondson said that discussion of end-of-life wishes is “not the kind of dinnertime conversation most people look forward to,” but it must be done to keep the fate of terminally ill patients out of the courts.  Edmondson also announced “the reconstitution of the unfunded Attorney Generals End-of-Life Care Task Force for another year.”  (Journal Record Legislative Report, 4/25; The Daily Oklahoman, 4/25)

 

*  Former New York Mayor Rudy Guiliani, whose father died a painful death of prostate cancer 25 years ago, is chairman of Rx Action Alliance, a “national coalition of groups seeking access to prescription drugs for those who need them and prevention of abuse and diversion of such drugs.”  Of his own experience with prostate cancer, Guiliani said, “I’ve never really experienced long-term difficult pain, but I have been the beneficiary of medical science.”  (The Kansas City Star, 4/27)

 

*  Dr. Ira Byock, of Dartmouth-Hitchcock Medical Center, has been named New Hampshire’s “Top Doc” of 2005 in end-of-life care by New Hampshire Magazine.  The New Hampshire Partnership for End-of-Life Care lobbied for the inclusion of the end-of-life category in the “top docs” issue, and Byock is featured on this month’s cover.  (New Hampshire Magazine, 4/2006; E-mail from Dr. Patrick Clary, Medical Director of Seacoast Hospice)

 

*  Writing in The Daily Standard, author Wesley J. Smith says that the Swiss organization which facilitates suicide, Dignitas, “is just about done with pretense” – the pretense  contemporary suicide advocates that “’aid in dying’ is merely to be a safety valve, a last resort only available to imminently dying patients for whom nothing else can be done to alleviate suffering.”  Smith cites the London Sunday Times Magazine as saying that Ludwig Minelli, founder of Dignitas, plans to “create a chain of death centers ‘to end the lives of people with illnesses and mental conditions such as chronic depression.’”  Smith also briefly reports on several other persons and organizations that believe in the right to commit suicide.  Smith says, “Which camp one decides best represents the overall euthanasia movement doesn't really matter.  Once assisted suicide is accepted in law and culture, the premises of radical autonomy and allowing killing to alleviate human suffering would conjoin, unleashing the irresistible power of logic that would push us inexorably toward the humanist nirvana of death on demand.”  At HNN press time, the article is online at www.weeklystandard.com/Content/Public/Articles/000/000/012/124abkbr.asp.  (The Daily Standard, 4/27)

 

Thanks to Yvonne J. Corbeil for contributions.

 

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