TALKING TO YOUR DOCTOR ABOUT ASSISTED DYING

By Thomas A. Preston, M.D.

 

All of us would like to die peacefully, but we can’t do it alone.  If you want at least some control about how you die, start talking to your family and doctors and make your goals known. The three major medical strategies for peaceful dying are:

 

(1) Keep the dying phase short.

 

(2) Get optimal palliative (comfort) care.

 

(3) Prepare for assisted dying, if indicated.

 

If you are dying, first and foremost, let your doctors know that you understand your condition and wish to avoid any treatment designed to prolong your life.  A good way to start this dialogue is with a Physician Orders for Life-Sustaining Treatment (POLST) form that summarizes your end-of-life wishes and requires a physician’s signature. 

 

Next, take your POLST form, living will (called a “directive to physician” in Washington State), and durable power of attorney for healthcare and discuss the major points with your doctors.  You might say to your doctor, “I know I am dying, and I appreciate all you have done to help me.  But now my goal is to die peacefully.  It’s all right for you not to use treatments to prolong my life anymore.”

 

Another approach is to write or type a “statement for your doctor” in which you state your wish to avoid life-prolonging treatments, and then write, “I give you permission not to prolong my life.”  A simple statement like that will give you the necessary understanding with most doctors.

 

If any doctor hesitates or disagrees with any stipulation, give your reasons for and feelings about what you are requesting.  Tell your doctors you expect their compliance with your end-of-life requests for medical treatment.  If you cannot reach agreement with one or more doctors now, you may need to work around them or even get a new doctor.

 

If you want aggressive palliative care (pain or symptom control) at the end, let your doctor know your preference between relief of pain or alertness, if the amount of drugs necessary for complete relief of pain would cause loss of awareness or coma.  For example, you could ask your doctor, “If I am having a lot of pain or uncontrolled symptoms such as shortness of breath, will you be willing to give me enough painkillers to make me comfortable, even if it takes so much it knocks me out?”  Your doctor may answer, “Yes, of course,” but you have to ask the question to get the doctor’s commitment.  By doing so, you are signaling a desire for him to let you determine when and how much pain medicine or sedation is enough, on an ongoing basis.  Otherwise, he might assume you want the least amount of painkiller possible so as to avoid drowsiness or development of tolerance to the drug.  And don’t worry about broaching the subject in advance; both you and your doctor have a better chance of doing it right if you have had prior discussions.

 

If you become terminally ill and you want the option of hastening death by fasting or total sedation (also known as palliative sedation), say so in clear language.  If you just hint at what you want, you probably won’t get it.  If you say something like, “Doctor, if things get really tough for me and you can’t control the pain, do you think you could give me something stronger?,” the doctor may not understand what you are asking. 

 

Tell your doctor how far you want to go toward unconsciousness to avoid suffering.  Ask her if she will be ready and willing to give you enough painkillers or sedatives to eliminate hunger or thirst if you elect to stop eating and drinking.  Ask her if she will be willing to sedate you to unconsciousness if that is necessary to stop suffering.  Ask her if she will honor the same request of your attorney-in-fact, or your family, if you become incapable of making decisions.  If she says, “Let’s talk about that when the time comes,” tell her “No, we need to discuss it now.”

 

Make all these requests clear in advance with your family and caregivers.  If you get hospice care, ask the hospice nurse the same questions at your first meeting.  And remember, medical professionals don’t like to commit to anything in advance, so they may hedge their answers.  By your question, they will know your wish and so will be more likely to honor it as the time approaches.

 

If you want the option of using medication to hasten death, you must plan in advance; you can’t wait until just before you want to do it.  Talk to the important people in your life about your plans and goals.  Many physicians will not want to talk about it, but you must sound out your doctor about his willingness to help you.  If you already know your doctor is against helping in this way, get another one.  Physicians who oppose this form of assisted dying are less likely to give you optimal aggressive palliative care if they think you want to “overdose.” 

 

If your doctor seems sympathetic, ask if he will be willing to prescribe the necessary drugs or refer you to a physician who will do so.  Keep in mind that even doctors sympathetic to your plan will avoid discussing the subject and will deflect your request if they can.  I recently talked to a patient whose doctor had said he would write the prescription if and when the patient wanted it.  Every time the patient asked for the prescription the doctor said something like, “Oh, yes, sure, but we’ll be able to keep things under control and I think you’ll do fine.  First, let’s see how it goes.”  He never got the prescription. 

 

You have to be specific and forceful in your request.  How you frame the request is critical.  No doctor wants to be obligated in advance to giving you a prescription for lethal medications, or clearly agree to do so in a manner that could be held against him later if a controversy arose over what he did. 

 

If you say to your doctor, “I want a prescription so I can end it all when I want to,” you are making that physician complicit in your intended act, and she will not comply.  She is much more likely to comply if you say, “I want to live as long as possible, but I do fear a bad end even with the good care I know I’ll get.  Having some pills will give me the security I need, even though I’ll almost certainly never take them.”  This approach helps the doctor deal with it because she is prescribing for your comfort, not for the specific purpose of ending life.

 

Most importantly, get connected with a case manager from Compassion & Choices.  These are the people who know how to work with medical professionals and can help you achieve a peaceful, humane death.  Dying peacefully takes a little work.  To have a good death, you need to be your own forceful advocate.

 

Compassion & Choices of Washington

http://www.compassionandchoices.org/wa

Phone:206.256.1636  Toll Free: 1.877.222.2816

Email: wa@compassionandchoices.org

 

Compassion & Choices (National Services)

http://www.compassionandchoices.org

Toll Free: 1.800.247.7421

Email: clientsupport@compassionandchoices.org