How to cope with a patient who wants to die - Study examines physicians' responses to requests for assisted suicide

Physicians whose patients request help in ending their lives face moral, legal and professional pitfalls in responding to these requests. A new study led by a researcher at the San Francisco Veterans Affairs Medical Center has found that most of these physicians deal with these requests alone, without advice or discussion from their colleagues.

The doctors reported the most difficulty in coping with requests from patients who wanted to die because they felt their lives had lost meaning, not for reasons related to physical pain and suffering.

The researchers recommended that physicians who care for terminally ill patients improve their skills in managing pain and suffering, learn to watch for and treat depression, and strive to communicate openly and clearly. Finally, the medical profession should support these doctors by encouraging discussion of requests for help with suicide, according to the study's lead author Jeffrey Kohlwes, MD, MPH, UCSF assistant clinical professor, and physician in general internal medicine at SFVAMC.

Although physician assisted suicide is illegal in every US state except Oregon, doctors who care for terminally ill patients receive suicide requests with some regularity. Some guidelines have been written to assist doctors in dealing with these requests, but there has not been much documentation of the different ways in which doctors handle suicide requests from their patients.

In the study published in the current issue of the Archives of Internal Medicine, Kohlwes and his colleagues conducted interviews with 20 physicians in Seattle and San Francisco who had received at least one request from a terminally ill patient for help in committing suicide. Half of the participants had helped a patient to end his life; the other half had not.

The most surprising finding, Kohlwes said, is that doctors rarely discuss these often heart-wrenching suicide consultations with other physicians. "Most physicians who received these requests really dealt with them alone. They perceived an unspoken code of silence on the topic amongst their colleagues," he said.

Aside from its illegality, the topic of physician assisted suicide considered taboo among physicians, a perspective that dates back to a passage of the Hippocratic oath, which admonishes "give no deadly medicine to anyone if asked." A few of the doctors also said they were worried about becoming known publicly as the "local Kevorkian," Kohlwes said.

The isolation experienced by these doctors creates a heavy emotional burden, Kohlwes said. Four of the physicians cried during the interviews, a response that Kohlwes said "seemed more related to a lack of processing their actions rather than any regrets over their actions."

"Somehow the medical community needs to create an environment where these physicians can discuss their decision-making process," he said, suggesting that physicians should try to avoid the moral debate over physician-assisted suicide and instead discuss the processes they use to handle these requests.

"Improving the professional dialogue will improve care, and hopefully obviate the need for many assisted deaths," he said.

Although physical and psychological suffering were reasons given by many patients for wanting to end their lives, many doctors in the survey said patients frequently cite more existential reasons, Kohlwes said. "Many terminally ill patients feel that their meaningful lives are over because they are no longer able to do the things they love, such as interacting with loved ones, being active, and generally being in control of their lives," he said.

"Physicians reported that these existential cases were the most difficult for them to intervene in," he said. Most doctors are well trained in how to treat disease, but receive very little training in handling end-of-life situations, Kohlwes explained.

The doctors in the study who felt most comfortable managing this existential suffering favored open discussions with the patient, and tended to view their discussions with the patient as a therapeutic tool rather than an avenue to some other intervention, he said.

The good news, according to Kohlwes, is that most requests for a doctor's assistance in suicide can be successfully handled simply by treating either physical pain or depression. "Most physicians we interviewed used these requests as a warning flag to aggressively treat a patient's physical discomfort, and in many cases they felt this was effective," he said. Most doctors in the study reported treating their patients with anti-depressants, which another study has shown to reduce terminal patient requests for suicide.

Without delving into the moral debate over physician assisted suicide, Kohlwes said he hopes the study will foster discussion among doctors over how best to handle these patient requests, and how to improve medical education on end-of-life care in general.

Co-authors on the study included Robert Pearlman, MD, MPH, professor of medicine and medical history and ethics at University of Washington and VA Puget Sound Health Care System; Thomas Koepsell, MD, MPH, professor of health services and epidemiology at University of Washington; and Lorna Rhodes, PhD, professor of medical anthropology at University of Washington.