Special Report
Legalized Physician-Assisted Suicide in Oregon — The Second Year
N Engl J Med 2000; 342:598-604February 24, 2000
- Abstract
Background and Methods
In 1997, Oregon legalized physician-assisted suicide. We have previously reported data on terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. We now report similar data for 1999, obtained from physicians' reports, death certificates, and interviews with physicians. We also report data from interviews with family members.
Results
Information on 33 persons who received prescriptions for lethal medications in 1999 was reported to the Oregon Health Division; 26 died after taking the lethal medications, 5 died from their underlying illnesses, and 2 were alive as of January 1, 2000. One additional patient, who received a prescription in 1998, died after taking the medication in 1999. Thus, 27 patients died after ingesting lethal medications in 1999 (9 per 10,000 deaths in Oregon), as compared with 16 patients in 1998 (6 per 10,000).
The median age of the 27 patients who died in 1999 after taking lethal medications was 71 years. The most frequent underlying illnesses were cancer (in 17 patients), amyotrophic lateral sclerosis (in 4), and chronic obstructive pulmonary disease (in 4). All 27 patients had health insurance, 21 were receiving hospice care, and 13 were college graduates. According to both physicians and family members, patients requested assistance with suicide for several reasons, including loss of autonomy, loss of control of bodily functions, an inability to participate in activities that make life enjoyable, and a determination to control the manner of death.
Conclusions
In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die.
Media in This Article
Table 1
Demographic and Clinical Characteristics of 43 Patients in Oregon Who Died by Physician-Assisted Suicide in 1998 and 1999.Table 2
Characteristics of Patients Who Died by Physician-Assisted Suicide in 1998 and 1999, as Reported by Their Physicians.Article Activity
- Article
In 1997, Oregon passed the Death with Dignity Act, which legalized physician-assisted suicide.1 With legalization came concern that physician-assisted suicide might be forced on poor, uneducated, or uninsured patients or that it might be disproportionately chosen by patients receiving inadequate care at the end of life.2,3 We have previously reported that in 1998, the first year after implementation of the act, information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division.4 Of the 23, 15 died from taking the lethal medications. According to their physicians, the patients requested assistance with suicide because of concern about loss of autonomy and control of bodily functions, not because of concern about inadequate control of pain or financial loss. We now report on the second year of experience with legalized physician-assisted suicide in Oregon, including information obtained from family members about the reasons for requests for assistance.
Methods
Study Population
Under Oregon law, residents of the state who are 18 years of age or older can request assistance with suicide if they are expected to die within six months, are capable of making and communicating decisions about their health care, and are able to take an oral dose of medication. Patients must voluntarily express the wish to die in the form of two oral requests (made at least 15 days apart) and one witnessed, written request that the attending physician prescribe a lethal medication. A second physician must confirm the diagnosis and prognosis and verify that the patient is capable of making an informed choice. The attending physician must inform the patient about alternative options at the end of life (e.g., hospice care and pain control) and review the risks and results of ingesting the lethal dose of medication.1,5
Data Collection
Physicians who prescribe lethal medications are required to notify the Oregon Health Division and provide documentation that all the legal requirements have been met.1,6 After reviewing the death certificate for each patient who has received a prescription for a lethal medication, we contact the attending physician by telephone to determine whether the patient died as a result of ingesting the lethal medication. If we have not received a death certificate within six months after the receipt of the physician's report, we contact the physician to determine the outcome. For the purpose of this report, we classified patients according to whether they ingested a legally prescribed, lethal dose of medication in 1999 (the second year after the Oregon Death with Dignity Act was passed) or in 1998 (the first year).
In follow-up interviews with physicians, we collect additional information about the process of assisted suicide and the patient's functional status7 before death. We ask why the patient requested a prescription for lethal medication. We also ask whether the patient was concerned about the financial impact of the illness, loss of autonomy, an inability to participate in activities that make life enjoyable, loss of control of bodily functions, and worsening pain. (For reporting forms and questionnaires, see www.ohd.hr.state.or.us/cdpe/chs/pas/pas.htm.)
All Deaths in Oregon in 1998
Using demographic information obtained from death certificates for Oregon residents who died in 1998 (the most recent year for which complete data were available), we compared patients who received prescriptions for lethal medications with other state residents who died from similar diseases. The proportion of deaths from physician-assisted suicide was calculated with the use of total and disease-specific deaths in 1998 as the denominators.
Interviews with Family Members
We interviewed close relatives or friends (subsequently referred to as family members) of patients who died between September 15, 1998, and October 15, 1999, after ingesting lethal medications prescribed by their physicians. We selected this period to minimize inaccurate recall. The interviews were conducted within approximately one year after the death. The attending physician or another health care professional involved in the patient's terminal care identified the most appropriate family member to interview (one per patient). Each family member knew of the patient's request for and use of lethal medication and was involved in the patient's health care decisions. Patients were excluded from the analysis if no family member familiar with the patient's illness and death could be identified or if the family member declined to be interviewed.
Most of the questions asked of family members were analogous to those asked of participating physicians, with additional questions about physical suffering, finances, and hospice care. Since some family members had difficulty separating pain from other aspects of physical suffering (e.g., dyspnea, dysphagia, and the side effects of medication), we did not make this distinction in assessing their responses. Consequently, the physicians' responses to questions about pain are not directly comparable to the family members' responses to questions about physical suffering. Oral informed consent was obtained from all family members who were interviewed.
Both the institutional review board of the Oregon Health Division and the Human Subjects Research Office at the Centers for Disease Control and Prevention determined that our reporting system was part of the routine surveillance and evaluation required by the Oregon Death with Dignity Act and, as such, was not subject to formal review by the institutional review board of either institution.
Statistical Analysis
Categorical variables were compared with use of Pearson's chi-square test and Fisher's exact test. Continuous variables were compared with use of the Wilcoxon rank-sum test. Unadjusted relative risks with 95 percent confidence intervals were calculated for comparisons of patients who died by assisted suicide in 1999 and Oregon residents with similar illnesses who died in 1998. Data from interviews with physicians and family members were compared with use of a corrected McNemar's test for paired proportions. Two-tailed P values that were less than or equal to 0.05 were considered to indicate statistical significance. Statistical calculations were performed with SAS software.8
Results
In 1999, 33 patients received prescriptions for lethal doses of medication; 10 (30 percent) received the prescriptions in November or December. Five of the 33 patients who received prescriptions died from their underlying disease; 2 were alive as of January 1, 2000. Twenty-seven patients died after ingesting the prescribed medications in 1999: 26 of the patients who received prescriptions in 1999 and 1 patient who received a prescription in 1998 but who was alive at the end of 1998. The one other patient who received a prescription in 1998 and who was alive on December 31, 1998, died in 1999 from the underlying disease. In addition, information on one patient who received a prescription late in 1998 was reported in 1999; the patient died in 1998 after taking the lethal medication. Thus, we report here on 24 persons who received prescriptions for lethal medications in 1998 and on 16 who died from taking the medications.
The median age of the 27 patients who died in 1999 was 71 years. They were similar to the 16 patients who died in 1998 with respect to demographic characteristics, underlying illnesses, use of hospice care, and health insurance coverage (Table 1Table 1
Demographic and Clinical Characteristics of 43 Patients in Oregon Who Died by Physician-Assisted Suicide in 1998 and 1999.), although a higher proportion of the patients who died in 1999 were married (44 percent, vs. 12 percent in 1998; P=0.03). Sixty-three percent of the patients who died in 1999 had end-stage cancer — most commonly lung cancer — and 78 percent were enrolled in a hospice program before they died (Table 1).In 1999, the median interval between the first request for assistance with suicide and death was 83 days, as compared with 22 days in 1998 (P=0.006) (Table 2Table 2
Characteristics of Patients Who Died by Physician-Assisted Suicide in 1998 and 1999, as Reported by Their Physicians.). One patient used the prescription more than 6 months after it was written (247 days). Twenty-six patients received prescriptions for a dose of secobarbital that was 9 g or more, usually in conjunction with antiemetic agents; one patient received a prescription for 6 g of phenobarbital. The median interval between ingestion and unconsciousness was 10 minutes (range, 1 to 30), and the mean interval between ingestion and death was 30 minutes (range, 4 minutes to 26 hours). Twenty-four patients died within 4 hours. Three patients died after 11 hours or more. Two of these three patients ingested the entire dose of medicine; the other patient ingested two thirds of the dose, became unconscious after 13 minutes, and died 26 hours later.Twenty-two physicians prescribed lethal medications to 33 persons in 1999. Six of the physicians had also prescribed such medications in 1998. Fourteen of the 22 physicians were in family practice or internal medicine, 5 were oncologists, and 3 were in other specialties. Their median age was 52 years (range, 30 to 78), and they had been in practice for a median of 20 years (range, 1 to 48). According to the physicians' reports, 8 of 26 patients for whom data were available (31 percent) received a prescription from the first physician they asked (Table 2). Of the other 18 patients, 10 (56 percent) asked one other physician, and 8 (44 percent) asked two or three other physicians. Information on one patient was not available.
Comparison with All Deaths in Oregon in 1998
In 1998, a total of 29,281 Oregon residents died, including 6994 who died of cancer and 76 who died of amyotrophic lateral sclerosis. Using these 1998 data for comparison, we estimated that patients who ingested lethal medications in 1999 accounted for 9 of every 10,000 deaths and for 39 of every 10,000 deaths from cancer. In comparison, deaths from physician-assisted suicide in 1998 accounted for 6 of every 10,000 deaths and for 20 of every 10,000 deaths from cancer. The four patients with amyotrophic lateral sclerosis who died by assisted suicide in 1999 accounted for approximately 5 percent of deaths from this disease (none of the patients who died by assisted suicide in 1998 had amyotrophic lateral sclerosis). The patients who died by assisted suicide in 1999 resembled a cohort of 6901 Oregon residents who died from similar underlying illnesses, with respect to age, race, and residence (Table 3Table 3
Characteristics of Patients Who Died by Physician-Assisted Suicide in 1999 and Oregon Residents with Similar Diseases Who Died in 1998.). A higher level of education was associated with an increased likelihood of physician-assisted suicide (P<0.001 by the chi-square test for linear trend). College graduates were more likely to die from physician-assisted suicide than were persons without a high-school education (relative risk, 12.1; 95 percent confidence interval, 3.8 to 38.7; P<0.001).Interviews with Physicians
On the basis of our interviews with physicians in 1999, patients gave multiple reasons for requesting assistance with suicide. Eighteen patients (67 percent) discussed three or more reasons with their physicians: 13 of these patients mentioned loss of autonomy, an inability to participate in activities that make life enjoyable, and loss of control of bodily functions. In 1998, 7 of 16 patients (44 percent) discussed three or more reasons for requesting assistance with suicide, according to their physicians. The most frequently cited reasons in both years were loss of autonomy (cited by 81 percent of patients in 1999 and by 75 percent in 1998) and an inability to participate in activities that make life enjoyable (81 percent in 1999 and 69 percent in 1998) (Table 2). In 1999, seven patients (26 percent) expressed concern about inadequate control of pain as their illness progressed, as compared with two patients (12 percent) in 1998; this difference was not significant (P=0.30). None of the patients cited the cost of treating the illness or prolonging life as a concern.
Interviews with Family Members
Between September 15, 1998, and October 15, 1999, 24 patients died after ingesting a lethal dose of medication. We interviewed family members of 19 of these patients (79 percent): 8 spouses, 2 siblings, 7 children, 1 parent, and 1 close friend. In 18 of the interviews, the discussions went beyond the structured questionnaire. In the case of five patients, interviews with family members were not conducted because the family member was too upset (one), there was no current telephone number for family members (two), or the provider could not identify an appropriate person to contact (two).
Like the physicians, the family members of the 19 patients often cited multiple reasons for the patient's decision to request assistance with suicide (Table 4Table 4
Characteristics of 19 Patients Who Died after Ingesting a Lethal Dose of Medication between September 15, 1998, and October 15, 1999, as Reported by Family Members.). Twelve of the family members (63 percent) noted at least three reasons. Overall, the most frequently cited reasons were concern about loss of control of bod-ily functions (68 percent), loss of autonomy (63 percent), physical suffering (53 percent), an inability to participate in activities that make life enjoyable (47 percent), and concern about being a burden on others (47 percent). Four of 10 patients who were concerned about physical suffering were not reported by their family members to be suffering when the use of a lethal medication was first discussed. The one patient who expressed concern about the financial impact of the illness, according to a family member, was concerned about all the issues except physical suffering. This patient was privately insured and spent only a small amount of money on health-related expenses. One spouse did not believe that any of the factors we asked about in the structured interview contributed to the patient's request for a lethal medication.The physicians for these 19 patients were more likely than family members to cite concern about loss of autonomy and an inability to participate in activities that make life enjoyable (83 percent and 78 percent of physicians, respectively) and cited concern about loss of control of bodily functions about as often (61 percent). When these data were compared for individual patients, the physicians' responses were similar to those of family members, with the exception of responses about pain (asked only of physicians) and physical suffering (asked only of family members), which could not be directly compared.
Family members noted additional factors that were not explicitly addressed in the structured interview. Fourteen of 19 family members stated that the patient was determined to control the circumstances of his or her death. Eleven of these 14 family members and 3 others mentioned the patient's wish to avoid a prolonged death; 4 specifically noted the patient's fear of ending life in a coma and on a respirator, despite having an advance medical directive. Many family members noted that the control of pain improved after the patient was enrolled in a hospice program. Six family members also mentioned how difficult it was to meet the requirements of the Oregon Death with Dignity Act.
Discussion
In 1999, 27 patients died after ingesting lethal medications prescribed under the Oregon Death with Dignity Act, as compared with 16 in 1998. A total of 33 patients received prescriptions for lethal doses of medication, as compared with 24 in 1998. Although concern about possible abuses persists,9-11 our data indicate that poverty, lack of education or health insurance, and poor care at the end of life were not important factors in patients' requests for assistance with suicide. Interviews with physicians and family members indicated that the primary reasons for requesting prescriptions for lethal medications were concern about loss of autonomy, concern about loss of control of bodily functions, an inability to participate in activities that make life enjoyable, physical suffering, and a determination to control the manner of death.
Patients who died by physician-assisted suicide were better educated but otherwise demographically similar to residents of Oregon with similar diseases who died in 1998. The low proportion of married persons in 19984 was not found in 1999. Although most of the patients spent their own funds on some medical expenses (e.g., for prescription drugs), all were insured for most other major medical expenses, often through a combination of Medicare and private supplemental policies.
Many patients who sought assistance with suicide had to ask more than one physician for a prescription for lethal medication. This finding is consistent with reports on the attitudes of physicians and medical students in Oregon toward physician-assisted suicide.12-14 Many physicians in the state are not willing to provide assistance with suicide. Physicians' experiences with the Oregon Death with Dignity Act are examined by Ganzini et al. elsewhere in this issue.14
As best we could determine, all the physicians who provided assistance with suicide complied with the provisions of the Oregon Death with Dignity Act. Although the Oregon Health Division is not a regulatory agency for physicians, it does report any cases of noncompliance to the state Board of Medical Examiners. Underreporting cannot be assessed, and noncompliance is difficult to assess because of the possible repercussions for noncompliant physicians reporting data to the division.
We found that patients' decisions to request assistance with suicide were based on several overlapping factors. Physical suffering was discussed by several family members as a cause of loss of autonomy, an inability to participate in activities that make life enjoyable, or a very poor quality of life. For example, one family member stated, “She would have stuck it out through the pain if she'd thought she'd get better [but believed that when] life has no meaning, it's no use hanging around.” For a patient with amyotrophic lateral sclerosis, the feeling of being trapped by the disease contributed to concern about loss of autonomy. Family members frequently commented on loss of control of bodily functions when discussing loss of autonomy. The reasons for requesting a prescription sometimes overlapped to such an extent that they were difficult to categorize. Asked to cite the reasons for one patient's decision, a family member said, “It was everything; it was nothing.” The responses of physicians and family members were similar and consistently pointed to patients' concern about the quality of life and their wish to have control over how they died.
When family members discussed a patient's concern about physical suffering, they referred to dyspnea and dysphagia, as well as pain. Some patients were concerned that with adequate control of pain, the side effects of the pain medication would make life meaningless. Physical factors, especially dyspnea, have been identified as important predictors of a decrease in the will to live.15 However, among patients in Oregon, concern about physical suffering was not necessarily equivalent to the experience of suffering. Palliative care was available to all the patients who requested assistance with suicide, and three quarters of them received hospice care before they died.
Many family members emphasized that the patient wanted to have control over how he or she died. One woman had purchased poison more than a decade before she died, when her cancer was first diagnosed, so that she would never be without the means of controlling the end of her life, should it become unbearable. Like many of the other patients, she was described as determined to have this kind of control. Another patient was described as a “gutsy woman” who was “determined in her lifetime and determined about [physician-assisted suicide].” Family members expressed profound grief over their loss. However, mixed with this grief was great respect for the patient's choice. One man said about his wife of almost 50 years, “She was my only girl; I didn't want to lose her . . . but she wanted to do this.”
This study was conducted as part of the required surveillance and public health activities of the Oregon Health Division and was supported by division funds.
We are indebted to Dr. Susan Tolle for her comments on the questionnaire for the family interviews; to Dr. Thomas Torok of the Centers for Disease Control and Prevention for his comments on the manuscript; to staff members at Kaiser Permanente Northwest and the Oregon Health Sciences University, as well as participating physicians, for helping us identify family members; and to the family members who shared their thoughts on a very personal subject.
- References
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