Eidelman-WMA EoL Presentation Vatican-Nov2017

11/23/17
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End-of-life decisions:
Compassionate use and conscientious objection
Prof. Leonid A. Eidelman, MD
President-elect, World Medical Association
President, Israeli Medical Association
Vatican 2017
Is Medical Assistance In Dying A Platitudinous
Medical Treatment?
Is Medical Assistance In Dying A
Platitudinous Medical Treatment?
One of the most important factors separating
physicians who do or do not accept PAS and E is
whether they see their actions as similar or
different than other treatments they give their
patients
The main question
Is terminating of life/medical assistance in dying
a regular (banal, platitudinous) medical
intervention like treatment with antibiotics?
or
It is something extraordinary
demanding different attitude
n engl j med 376;14 April 6, 2017
Health care professionals are not conscripts, and in a freely
chosen profession, conscientious objection cannot
override patient care.
n engl j med 376;14 April 6, 2017
By entering a health care profession, the person assumes a
professional obligation… This obligation is not unlimited,
but exemptions are reserved for cases in which there are
substantial risks of permanent injury or death.
n engl j med 376;14 April 6, 2017
…in most cases, professional associations should resist
sanctioning conscientious objection as an acceptable practice.
Unlike conscripted soldiers, health care professionals
voluntarily choose their roles and thus become obligated to
provide, perform, and refer patients for interventions
according to the standards of the profession.
… collectively, the profession — not politicians, judges, or
individual practitioners — sets its contours.
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Pain
“An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.”
Merskey H et al. (Eds) In: Classification of Chronic Pain:
Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 1994:209-212.
International Association for the Study of Pain (IASP) 1994
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Spinal cord stimulation What causes patients to seek end-of-life?
üPain
üDepression
üDyspnea
üNausea and vomiting
ØFrailty, fatigue
ü – treatable
What causes physicians to seek end-of-life of a patient?
qPain
qDepression
qFrailty, fatigue
qDyspnea
qNausea and vomiting
qCough
qFever
qBleeding
qAgitation/delirium/ terminal anguish/restlessness (e.g.
thrashing, plucking, or twitching)
qSecretions accumulated in the oropharynx and upper
airways when patients become too weak to clear their
throat
Ø Rationing and the allocation of resources
OPTIONS AT THE END OF LIFE
FULL CONTINUED
CARE
ACTIVE LIFE
ENDING
PROCEDURES
End-of-Life Decisions in the Netherlands over 25 Years
(1990-2015)
Agnes van der Heide, et al. (Erasmus MC, Utrecht Univ., Amsterdam)
N Engl J Med 2017; 377:492-494
In the Netherlands, physician assistance in dying has been
legally regulated since 2002:
§ physician-assisted suicide
§ euthanasia (physician administers lethal medication
at the explicit request of a patient)
• Both types of assistance are allowed only for patients
who are “suffering unbearably” without any prospect of
relief
Agnes van der Heide, et al. (Erasmus MC, Utrecht Univ., Amsterdam)
N Engl J Med 2017; 377:492-494
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“Such assistance is provided predominantly to patients with
severe disease but increasingly involves older patients and
those with a life expectancy of more than a month”
Agnes van der Heide, Johannes J.M. van Delden, Bregje D. Onwuteaka-Philipsen
End-of-Life Decisions in the Netherlands over 25 Years. NEJM2017;377:492
About half of all requests for physician assistance in dying
were granted in 2015
In 2015 reported 829 cases (4.5%) of euthanasia and 18 cases of
ending of life without explicit patient request
End-of-Life Decisions in the Netherlands over 25 Years
(1990-2015)
Agnes van der Heide, et al. (Erasmus MC, Utrecht Univ., Amsterdam)
N Engl J Med 2017; 377:492-494
In 2015 had:
§ early stage of dementia – 3%
§ psychiatric problems – 3%
Reporting of euthanasia in medical practice in Flanders,
Belgium: cross sectional analysis of reported and unreported cases.
T. Smets et al. BMJ 2010;341:c5174
… the incidence of euthanasia was estimated as
1.9% of all deaths (95% CI 1.6% to 2.3%).
Approximately half (549/1040 (52.8%, 95% CI 43.9%
to 60.5%)) of all estimated cases of euthanasia were
reported to the Federal Control and Evaluation
Committee
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…the ACP (American College of Physicians) believes that the
ethical arguments against legalizing physician-assisted suicide
remain the most compelling.
…It is problematic given the nature of the patient-physician
relationship, affects trust in the relationship and in the
profession and fundamentally alters the medical profession’s
role in society.
Why physicians shouldn’t be involved in
physician assisted death- euthanasia?
• Many requests disappear with symptom control
and psychological support.
• Patients should be sure about medical
professionalism: physicians are trying to heal and
relieve suffering and they are never intentionally
causing harm
• The danger of a slippery slope
– Administration of lethal drugs without absence of
terminal illness, untreated psychiatric diagnoses and
patient consent
Euthanasia and physician assisted suicide
Improve palliative care at the end-of-life
• Patients with severe pain can benefit from better palliative
care as almost all patients can be made physically
comfortable.
Lorenz K, Lynn J. JAMA 2003;289:2282
Euthanasia and physician assisted suicide
Improve palliative care at the end-of-life
• Many suicidal individuals do not want to die; they want to
escape what they perceive as intolerable suffering. When
relief is offered in the form of adequate treatment for
depression, better pain management and palliative care,
the desire for death wanes.
Kheriaty A. First Things. 2015
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Euthanasia and physician assisted suicide
Improve palliative care at the end-of-life
• The International Association for Hospice & Palliative Care
stated that no country or state should consider the
legalization of PAS-E until it ensures universal access to
palliative care services and to appropriate medications,
including opioids for pain and dyspnea.
De Lima L. J Palliat Med 2017;20:8-14
Alternatives to physician assisted
death- euthanasia
• Palliative care
• Social support
• Psychological support
• Physician practicing medicine is constantly trying to heal the
patient and never to harm him/her.
• Healing doesn’t always mean curing, as palliative care is no
longer curing but it is healing suffering.
• The actions of a physician trying to “heal“ suffering require us
to be WITH our patient and never to abandon him/her
• It’s Beneficence, Doing good. VS – euthanasia which is an
unwillingness to do this…unwillingness to stay with the person
and instead a willingness to eliminate the patient altogether-
to make a somebody into a nobody.
(E. Wesley Ely, MD, Vanderbilt University and VA-GRECC- personal communication)
• Causing death means causing absolutely different irreversible
state
Medical Assistance In Dying Is Not A Platitudinous Medical Treatment?
It is different:
PAS and E is different and should
not be performed by doctors
Is Medical Assistance In Dying A
Platitudinous Medical Treatment?