Guidelines for Physicians in Navigating Aid-in-Dying Requests

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Navigating aid-in-dying requests is new territory for many physicians.
Navigating aid-in-dying requests is new territory for many physicians.

A perspective article published in the New England Journal of Medicine outlined guidelines for the many challenges physicians may encounter regarding aid-in-dying requests from patients. 

Navigating physician aid-in-dying (PAD) requests is “new territory” for many physicians. Given that 18.2% of the US population now lives in jurisdictions where PAD is legal, physicians are more likely than ever to encounter requests for assisted suicide. Many patients may broach the topic indirectly, seeking information or asking the physician's stance, for example. In these cases, author Bernard Lo, MD, president and CEO of The Greenwall Foundation, suggested that the physician clarify the patient's motivations before moving forward, to allow for transparent discussion. Dr Lo emphasized the importance of discussing all available end-of-life options; study data indicate that after palliative care is intensified, 46% of patients who have requested PAD change their minds.

PAD is a divisive topic in the medical community, and even physicians who support the practice may only do so conditionally. Many support PAD for cases of “unremitting pain” but not for cases of “perceived loss of autonomy [or] dignity.” Additionally, many practitioners lack experience with PAD and may hesitate in determining the appropriate medication to prescribe. For these physicians, along with those who oppose PAD, co-management of patient care or referral to a colleague may be desirable. The author urged those opposed to PAD to remain open to discussing the process with patients, as such conversations may help the patient in “[finding] reasons to…live.”

As a final matter of concern, physicians should respect the deeply personal nature of end-of-life decisions and carefully navigate these conversations with patients. Dr Lo cautioned against physicians raising the topic themselves, lest the patient assume that they are being recommended the practice. However, per transparency, Dr Lo also believes that physicians who are asked about PAD should respond with their stance, including if they would be willing to write a prescription for a lethal medication dose. Physicians should act carefully in reconciling their duties as providers with any personal stance and above all maintain transparent communication with each patient to identify the best possible treatment course. 

Reference

Lo B. Beyond legalization — dilemmas physicians confront regarding aid in dying. N Engl J Med. 2018;378:2060-2062.

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