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POSTED: Sunday, Feb. 22, 2009

Questions remain as Death With Dignity law goes into effect

With less than two weeks remaining before the Death With Dignity Act goes into effect in Washington state, health care providers and patient advocates are busy explaining how the measure will work.

State officials on Friday, Feb. 20, finalized the guidelines for implementation of the new law. It begins March 5, a mere 120 days after Washington voters approved it Nov. 4 after a bruising campaign.

"There's a lot of scrambling going on by a lot of different organizations, including our own," said Robb Miller, executive director of patient advocacy group Compassion & Choices of Washington.

Washington is only the second state in the nation to pass such a law, which opponents see as physician-assisted suicide. It is similar to the Oregon measure that went into effect in 1998 after protracted legal battles.

Approved as Initiative 1000, the Washington measure allows terminally ill adults who are competent and have been told by their doctors they have six months or less to live to ask for a prescription for a lethal dose of medication, which they must be able to take themselves.

But the new law also allows health care providers and pharmacies to opt out, meaning they don't have to participate.

Among those opting out is PeaceHealth, a Catholic health care system that is the parent company of PeaceHealth Medical Group and St. Joseph Hospital, which also oversees Whatcom Hospice.

That has worried some Whatcom County residents, who wonder about the impact of such a large medical provider in the community deciding that it will not allow its employees to help the terminally ill end their lives.

There are 420 licensed doctors who live in Whatcom County. Of that total, 97 are directly employed by PeaceHealth while 400 doctors have visiting privileges at the hospital, according to PeaceHealth representatives.

Miller is working to alleviate residents' fears.

"I'm telling people don't worry so much. We'll help you. Compassion & Choices will help you find someone. There are doctors out there who will help you," Miller said. "It isn't that much of a deterrent to a person who is determined to use the law."

PeaceHealth representatives say the decision to opt out of providing lethal prescriptions doesn't mean the medical provider will refuse to discuss all end-of-life issues with patients. Nor will PeaceHealth abandon them, said Ross Fewing, director of spiritual care and regional ethicist at St. Joseph Hospital.

"We would not in any way, shape or form inhibit or dictate what a physician or patient could talk about," he said.

"All we're saying in our policy is that no PeaceHealth provider can participate in providing those services on PeaceHealth time or on PeaceHealth facilities," Fewing said.

"Obviously, we're not in a position to dictate what people do on their own time or in their own place," he added. "What physicians not affiliated with PeaceHealth do is also private, as long as the medication to hasten death is not taken by the patient on PeaceHealth property."

But PeaceHealth hopes its employees will honor its decision when they're on their own time away from work, Fewing added.

As for Whatcom Hospice, providers will care for clients before they take the medication and after, Fewing said, but they will not be on the premises while the patient takes the dose.

"Our fundamental value is the respect for the sacredness of life, so that's why we take the stand that we do," he said.

PeaceHealth also has facilities in Oregon. The experience in that state shows that while medical groups opting out may make it more difficult for the terminally ill to hasten their deaths, it doesn't stop them. And some Catholic health-care providers are participating.

Of the 341 Oregonians who used the law in the past decade, about 40 were under the care of a Catholic health-care system or a doctor working in one, estimated George Eighmey, executive director of Compassion & Choices of Oregon.

Hospice opting out shouldn't have much of an impact, either, Miller said, referring again to Oregon.

"Almost everybody who uses it is at home," he said. "It's an empty gesture in terms of the actual data that's been collected over the years in Oregon."

Ninety percent of Oregon residents who took lethal medication under that state's Death With Dignity Act died at home, according to the 2007 report compiled by the Department of Human Services. Eighty-eight percent were enrolled in hospice.

"There's no reason to believe people are going to behave that differently here in Washington," Miller said.

WHAT'S NEXT?

If PeaceHealth patients who are terminally ill insist on receiving a lethal prescription, then the medical provider will direct them to the Whatcom County Medical Society.

The society's members, more than 300 doctors, in turn will refer people to additional information and advocates, including Compassion & Choices of Washington. But members decided against keeping a referral list of participating Whatcom County medical providers, such as doctors willing to write a prescription for lethal medication.

"We didn't feel that we should be out there on point maintaining the list ourselves," said Dr. David Lynch, president of the Whatcom County Medical Society.

Lynch said the society has been busy educating members about the law, its requirements and their responsibilities under the measure. It also is encouraging patients to talk to their doctors about the issue.

But the society isn't telling its members whether to participate. Lynch said its doctors have an array of feelings on the matter - from those who believe it is part of compassionate care of patients that should be allowed in some circumstances to those who see it as violating the physicians' Hippocratic oath on the ethical practice of medicine.

It will be up to doctors to decide for themselves, he said.

Lynch also is the medical director for Family Care Network, which will leave it up to individual doctors to decide whether to participate.

The network has 52 physicians and 13 mid-level practitioners such as physician's assistants and nurse practitioners, making it the largest independent medical group in Whatcom County.

Meanwhile, the medical society is telling the public that "very little is going to change" when the measure is enacted, Lynch said.

"Because most people, this isn't what they choose. Most people wouldn't choose it if they felt there were other alternatives that were acceptable to them," he said. "We don't want people to feel abandoned."

One outcome of the law in Oregon that will make opponents and supporters alike happy is that it has increased hospice care, Eighmey said.

Other positives include greater attention to pain management on the part of doctors, and better relationships between doctors and patients and patients and their families as they openly discuss their end-of-life wishes, he added.

"End-of-life care will improve once this law goes into effect," Eighmey said.