The day assisted dying became legal: choices

As a supporter of assisted dying (AD) I ask myself  – ‘What will I actually do if it becomes legal?’ I haven’t travelled to Oregon or Washington state to see how it works, nor have I talked to doctors or nurses who are involved, but I think it is important to anticipate one’s response. After all, a recent NEJM paper described in a routine, academic, matter of fact way, how a ‘Death with dignity’ programme was rolled out in a Seattle cancer centre. If AD is legalised in the UK, any doctor who works in the field of cancer or palliative care will be touched by it in some way. The degree of involvement will depend on some of the thought process that I explore in this post.

For those who oppose AD it will be relatively simple – if a patient asks about AD you will make it clear that you do not ‘do that’. But it will be necessary to refer the patient on to a colleague who does. To refuse would be to obstruct the patient’s access to a legal therapeutic option. There are parallels with abortion here.

What about those who are ambivalent? This is probably the majority. When the day comes, will it be necessary to make a choice, to be an ADer or non-ADer? Will it be necessary to register that preference, for the sake of transparency? Perhaps it will be possible to avoid making that choice for a few months, a year…until a patient asks you to help them. If you are not completely ‘anti-’ but you have no wish to be involved in assessing them and certifying the terminal nature of their illness, you will again have to refer on. Over time you may be persuaded by the conviction of your patients, and begin to recognise that by referring on and leaving such distasteful tasks to others you are separating yourself from the patient’s journey too forcefully. You might conclude that it is cowardly, in a way, to ‘wash your hands’ of them when the going gets tough and they ask for your signature on the piece of paper, the document, the booklet…whatever it is. You may review your position, and change, finally accepting that ‘Yes, quite a few patients have asked me now, AD is a fact of life, why should I make their progress any more difficult than it is already?’ Others will remain intellectually neutral, but for good reasons they will continue to maintain clear blue water between their own practice and AD. That will be perfectly understandable. I can foresee many doctors adopting this approach.

And what about doctors like me who instinctively support AD? This is where I get nervous. If, a month after the law is passed, a patient whom I have recently diagnosed with terminal cancer (a common enough event) sits down in my clinic and says, ‘When the time comes I want an assisted death. How do I arrange it?’ – I will have to do everything in my power to facilitate it. To do otherwise would be hypocritical. So, I might have to decide that I am happy to be one of the signatories, but not so happy to prescribe the fatal dose. Or I might decide to push myself through that discomfort barrier, propelled by a self-imposed reluctance to abdicate my professional responsibility to care for the patient, and volunteer to be physically involved in the prescription and administration of the fatal dose. If I do that I must prepare myself for the experience of being with someone who is not imminently dying, who is still independent, in the last hour of their life. I will have to remain strong and unflustered (the last thing they will want to see is a nervous clinician) as they arrive, confirm their identity, take to a bed, gather their family around them, reach for the ‘milky drink’, and expire. Am I ready for that? Are you?

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