Posted on: Saturday, January 22, 2005

ISLAND VOICES

By Leonard R. Howard, M.D.

The Legislature is barely in session but the letters to the editor and the local columnists are beating the drums for physician-assisted suicide (PAS) and physician-assisted death (PAD).

The controversy continues, and I once again find myself urging the people of Hawai'i to speak out against those who would ignore the advances made in end-of-life care in the past five years.

There is no reason in modern-day medicine for anyone to die the agonizing death that seems to be the main reason for the proposed PAS legislation. The treatment of pain today is better than it has ever been before.

The world has changed since the governor's blue-ribbon commission released its report in 1998.

In 2001, the Joint Commission on Accreditation of Hospitals added a requirement that accredited hospitals have a pain management service, with physicians who specialize in the various methods of controlling pain. Palliative care (comfort care) has become a certified medical specialty in the last two years. The hospice concept is now found in all states and offers specialized care to the dying in home, hospital or hospice setting.

The Hawai'i Medical Association continues to support the American Medical Association policy opposing both PAS and PAD.

We strongly support the various efforts to improve pain management and end-of-life care that will eliminate the horror stories of terminal suffering that we have all heard, but usually happened five or 10 years ago to a family member.

The American Medical Association said it very well: "Although for some patients it might appear compassionate to intentionally cause death, institutionalizing physician-assisted suicide as a medical treatment would put many more patients at serious risk for unwanted and unnecessary death. Rather than recognize any right to physician-assisted suicide, our society instead should recognize the urgent necessity of extending to all patients the palliative care they need and to redouble our efforts to provide such care to all."

The power to assist in intentionally taking the life of a patient is counter to and fundamentally incompatible with the physician's role as healer. It would be difficult or impossible to control, and would pose serious societal risks.

It is a power that most healthcare professionals do not want.

A brief filed by the AMA holds that "The right to control one's medical treatment is among the most important rights that the law affords each person. This includes the right to have unwanted life-prolonging treatment withheld or withdrawn and to have all medication necessary to alleviate physical pain, even where such medication would hasten death. Through these means, patients can avoid entrapment in a prolonged, painful or overly medicalized dying process."

Hawai'i currently has the best Uniform Medical Decision-maker Law in the country. What we should be doing is educating our people about this law and how they can control what happens in the dying process.

In "Decisions Near the End of Life," it is proposed that instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients cannot be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought, including specialty consultation, hospice care, pastoral support, family counseling and other modalities.

Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy and good communication.

As with so many other problems in our society, education is the answer — both education of our physicians and nurses who deal with dying patients, and education of our patients so that all present legal avenues are utilized to control their own dying process as much as is possible without crossing ethical and moral boundaries.

I encourage all physicians to become more competent in end-of-life care so you will be comfortable when your favorite patient enters the dying process. After all is said, just remember that we are going to die under the same circumstances that we create for our patients today. To be able to deal with our patient's mortality, we, their physicians, must come to grips with our own mortality.

That time will come for each of us.

Leonard R. Howard, M.D., is past president of Hawaii Medical Association and director of the Education in Palliative and End-of-life Care program in Hawai'i. He wrote this article for The Advertiser.