Oregon's experience: evaluating the record

Neurology ethics at the end of life

Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.

A Comparison of Physician-Assisted/Death-With-Dignity-Act Death and Suicide Patterns in Older Adult Women and Men

OBJECTIVE

To examine Oregon's Death-with-Dignity-Act (DWDA) death and suicide patterns among women age 65 and older, relative to patterns among same-age men, as a way to assess DWDA's impact on older adult women, a group considered vulnerable.

DESIGN

Oregon's 1998-2018 DWDA- and suicide-mortality rates and confidence intervals were calculated.

RESULTS

Between 1998 and 2018 women age 65 and older represented 46% of DWDA deaths and 16.3% of suicides in their age group. Among women age 65 and older DWDA and suicide mortality increased whereas among same-age men DWDA deaths increased and suicides declined. DWDA deaths were the most common form (52.7%) of self-initiated death for older adult women, and firearm suicides (65.7%) for older adult men.

CONCLUSION

Legalization has a substantial impact on older adult women's engagement in self-initiated death. In Switzerland and in Oregon, where assisted suicide/medical-aid-in-dying (MAID) is legal and where assisted-suicide/MAID and suicide comparative-studies have been conducted, older adult women avoid self-initiated death except when physician-approved. Older adult women's substantial representation among assisted-suicide/MAID decedents, relative to suicide, may be a clue of their empowerment to determine the time of their death, when hastened-death assistance is permitted; or of their vulnerability to seeking a medicalized self-initiated death, when in need of care.

Why People Think They Might Hasten Their Death When Faced With Irremediable Health Conditions Compared to Why They Actually Do so

This study surveys the differences of relatively healthy proponents of end-of-life choices and people with irremediable health conditions having already made the decision to hasten their deaths on what each group considers important in influencing a desire to hasten death. Psychosocial factors were more important than physical ones for both groups; but those contemplating what might influence them to hasten their deaths in the future thought pain and feeling ill would be much bigger factors than they turned out to be for those deciding to do so. Those having decided to hasten their deaths cited the lack of any further viable medical treatments and having to live in a nursing home as bigger factors. Identifying these psychosocial factors influencing a desire for a hastened death suggests that caregivers and medical providers may want to review what compassionate understanding and support looks like for people wanting to hasten their death.

Attitudes of nurses toward patient-directed dying: a pilot study

Patient-directed dying (PDD) will be an increasingly common issue faced by healthcare professionals. Nevertheless, few studies have explored nurses' attitudes toward PDD. This pilot project sets out to fill the gap regarding nurses' attitudes and values regarding PDD and perceptions of consistency or inconsistency with the American Nurses Association (2001) Code of Ethics for Nurses With Interpretive Statements (The Code). Thirteen subjects self-selected from a population of registrants attending a national ethics conference by completing an anonymous descriptive survey. The majority of subjects noted that their personal and professional values related to PDD are in agreement (regardless of their specific position). The subjects were divided on whether PDD is ethically consistent with The Code. Despite being unsure if PDD is ethically consistent with The Code, these nurses found relief of suffering to be a more compelling rationale for PDD over patient autonomy. This study offers insight into key social and professional issues in which further research is needed and offers many avenues for further investigation.