Among physicians who had prescribed end-of-life medications, Ganzini said, most of them felt they had acted appropriately, but many were surprised by how emotionally difficult the whole experience was. Some have participated more than once, but most had only received one or two requests.
Receiving physician assistance in ending one's life in Oregon is not as easy as opponents of the state's law might assume. To qualify for the program, a patient must be an Oregon resident, at least 18 years of age, and terminally ill with a prognosis of death within six months or less. In addition, the attending physician must be licensed in Oregon, and must be willing to participate.
"Participation is voluntary for the physician as well as the patient," Darcy Niemeyer from the Oregon Department of Human Services, Health Services, told PT. "Some physicians have employment relationships that prevent them from participating. Some employers--for example, the U.S. Department of Veterans Affairs or hospitals operated by the Catholic Church--will not permit their physicians to participate."
After a patient requests an end-of-life prescription, the request must be repeated at least 15 days later. That request must be followed by a written request that is signed by two witnesses, one of whom may not be related to the patient. A consulting physician is then called to confirm the diagnosis and prognosis and to determine whether or not the patient is able to make and communicate health care decisions for themselves. If the patient is mentally impaired, a psychological examination is ordered.
Before the attending physician may write the end-of-life prescription, the patient must be informed of alternatives, including hospice care and palliative treatments. If the patient persists in requesting the prescription, the physician must wait another 48 hours before writing it and may request that next-of-kin be notified. Finally, the pharmacist who receives the prescription has the right to refuse to fill it.
"For every 10 people who make an explicit request, only one dies by assisted suicide," Ganzini said. "There is a great deal of winnowing at the point of the request. Physicians make interventions that help patients change their minds, the most important being a referral to hospice. What [this] suggests is that, among patients who request suicide, a substantial portion will change their minds with improved palliative care.
"But palliative care cannot give patients the control they want. It's tough to leave this world totally in the driver's seat. Not wanting people to take care of you is particularly frightening for people who want assisted suicide."
Nor is improved hospice care always an alternative. Oregon has one of the highest rates of deaths in hospice of any state, but some patients are not satisfied with that choice. "It turns out that 85% of people who die by assisted suicide in Oregon are in a hospice and have been there for a median of seven weeks," Ganzini said. "It may be that there are ways we can interact with patients before they get into the hospice that will change their attitudes."