Assisted Suicide Problems Cite

By Judy Foreman, Globe Staff, 02/24/00

Physician-assisted suicide, which proponents say can be a humane and painless way to aid terminally ill patients, is often fraught with complications and long delays before death occurs, some researchers say.

A sobering new Dutch study of 649 cases, published in today's New England Journal of Medicine, shows that "complications" occurred in 7 percent of cases of assisted suicide and "problems with completion" (delays of hours to days before death) occurred in 16 percent. The rates of such problems were less - 3 and 6 percent, respectively - with euthanasia, or "mercy killing," which is not a crime in the Netherlands.

According to an editorial in the New England Journal, the study has far-reaching implications for the end-of-life debate in America, which until now has focused on physicians prescribing lethal doses of drugs to help terminally ill patients end their own lives, not on outright euthanasia, which is illegal in this country.

Published in conjunction with two other new studies on physician-assisted suicide in Oregon, the only state in which the practice is legal under certain conditions, the Dutch research will "come as a shock" to many in America, said the editorial written by Dr. Sherwin B. Nuland, the Yale University doctor who wrote the groundbreaking 1994 book, "How We Die."

In the editorial, Nuland contends that the disturbing rate of complications may dismay Americans "who have never considered that the procedures involved in physician-assisted suicide and euthanasia might sometimes add to the suffering they are meant to alleviate and might also preclude the tranquil death being sought."

If doctors are going to become involved in ending lives, at least they should learn to do it right, Nuland argues. "Doctors are unprepared to end life," he wrote. "If this is a burden to be taken on and if the medical profession accepts it as falling within the realm of individual conscience, then thorough training in techniques must be made available."

In the Dutch study, done by Dr. Johanna H. Groenewoud and others at Erasmus University in Rotterdam, doctors often had to step in to complete the process when assisted suicide failed.

The new research may force Americans to confront the issue of euthanasia, notes Dr. William Breitbart, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center in New York.

Breitbart said he fears the debate will now hinge on "how best to kill people, rather than stepping back and debating how best can we prevent the suffering and despondency that leads patients to ask physicians to kill them as the only way to stop the suffering."

George Annas, professor of health law at Boston University School of Medicine, agrees. "If we're going to do it, let's not botch it," Annas said. He added, "I am not one who thinks we should start training doctors to kill people."

But if physicians are going to assist in suicide, they should be present, he said. "And if they're going to be present, they have to be ready to actually kill the patient if the patient experiences significant pain or suffering in the process of dying."

In the Dutch study, the most common "technical problems" were trouble finding a vein in which to inject lethal drugs and difficulty administering an oral medication. Vomiting and muscle spasms were also frequent complications.

The two Oregon studies focused on doctors' and patients' experiences in that state since physician-assisted suicide was legalized in 1997.

One study - led by Dr. Linda Ganzini, director of geriatric psychiatry at the Portland Veterans Administration Medical Center - was a survey of more than 2,600 Oregon physicians, about 5 percent of whom had received requests for lethal prescriptions since October 1997. The physicians honored one in every six of those requests, and one in 10 of those requests actually resulted in suicide.

Strikingly, 46 percent of patients who received palliative care, such as medication to alleviate pain and nausea, changed their minds about suicide.

Ganzini also found that most patients who completed suicide were receiving palliative care and that 81 percent were in hospice care. "It doesn't appear that patients die by suicide because they lack palliative care, but despite it," she said in a prepared statement.

This suggests, Ganzini said in a telephone interview, that some terminally ill patients have reasons for suicide, such as a desire for autonomy and to control the manner of their deaths, that may not be solved by palliative care.

The other Oregon study, led by Amy D. Sullivan of the Oregon Health Division in Portland, focused on 27 patients who died after ingesting lethal medications in 1999.

These 27 patients represent a small number relative to all patients who died in Oregon in 1999, the researchers noted, although they do represent an increase over the 16 patients who used Oregon's Death with Dignity Act the year before.

Nancy Dorfman, president of the Greater Boston Hemlock Society, which favors laws such as the one in Oregon that allow physicians to assist in suicide, said the two Oregon studies suggest "the fears that had been expressed before this law was passed don't seem to have materialized."

Unlike the Dutch study, neither of the Oregon studies noted any complications with assisted suicide, but, as Nuland says in his editorial, this may be because researchers did not ask. In one previous American study, researchers found that 15 percent of attempts at physician-assisted suicide failed.

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