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Different Kinds of Death: A Primer On Problems At the End Of Life

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Jerry Brown recently signed legislation legalizing physician-assisted suicide for patients at the end of life. When I recently talked with the FRIENDS of IPFW about my work on Advance Care Planning in Indiana, this issue came up. I was talking about the POST (Physician Order for Scope of Treatment) form in Indiana and they asked if it would lead down the path to euthanasia. My initial thought was, “Well, of course not,” but then I got to thinking. Why is this question coming up anyway?

The best I can come up with is that it’s the consequence of two cultural artifacts.


On the one hand, we still treat discussions of death as though we’re superstitious about them: avoiding and delaying discussions, and denying our need to deal with where we’re headed. And so there are decisions to be made, but we’re perpetually unprepared to make them.


On the other hand, we can now keep the body working in ways and for lengths of time unimagined in the past. Our ability to do this has changed the landscape of dying from one of battle to one of decisions. From a struggle to survive at all costs, to a weighing of the benefits and burdens.


The need to resolve this tension has produced two parallel movements: Advance Care Planning and Death with Dignity.


Advance Care Planning


The legal mandate to recognize the Physician Order for Scope of Treatment (POST) form in Indiana, which I’vewrittenaboutextensively, fits within the broader national movement to improve Advance Care Planning. Anytime I talk with my family, my friends, my physician, or my health care team about what I want if they have to make decisions for me, I’m Advance Care Planning.


Advance Care Planning can take many forms.


A signed statement of patient preferences is a type of living will. In Indiana, living wills rarely, if ever, reach the level of legal enforcement because they require a physician to verify in writing that a patient is near death.


Appointing a specific individual to make healthcare decisions for you requires assigning a health care representative (pdf). Every adult person in Indiana should have one of these, because Indiana statutes make surrogate decision-making into committee work if no specific individual is identified.


Working with a health care team to identify appropriate medical orders at the patient’s or the incapacitated patient’s family’s request, can lead to the placement of a Do-Not-Resuscitate (or Allow-Natural-Death) Order or a POST form (pdf).  


Death With Dignity


The key distinction between physician-assisted suicide and euthanasia is who administers the medications. In euthanasia, it is the physician. In physician-assisted suicide, it is the patient.

Since the court decisions regarding Karen Ann Quinlan, Nancy Cruzan, Elizabeth Bouvia, and Larry McAfee, there has been a recognized right of patients to refuse unwanted medical care. Patients have the right to refuse medical treatments they do not want, even if it will lead to their death.


The Death With Dignity movement pushes for physician-assisted dying. Beyond the stark refusal or treatment, they work for Acts like those in Oregon, Vermont, and Washington, which allow physicians to provide prescriptions to patients who request assistance in committing suicide.


When a physician provides such a prescription, when they enable a patient to take their own life using medical means, this is physician-assisted suicide. In these cases, the physician acts as a kind of gatekeeper for the medications necessary for medical suicide. It’s important, however, to distinguish PAS from euthanasia.


Roughly, euthanasia has come to mean “mercy killing”. When we talk about a physician administering a lethal cocktail of medications, we’re talking about euthanasia. The key distinction between physician-assisted suicide and euthanasia is who administers the medications. In euthanasia, it is the physician. In physician-assisted suicide, it is the patient.


Advance Care Planning and Death With Dignity


Advance Care Planning and Death With Dignity are parallel, but independent, reactions to our efforts to resolve our difficulties in dealing with the end of life. They are independent because one does not depend upon, or draw upon, the other.


Advance Care Planning makes just as much sense in Indiana, where physician-assisted suicide remains illegal, as it does in Oregon, where it is legal. Advance Care Planning aims to help patients make their wishes known, to help patients direct their care from the medical alternatives available.


To support Advance Care Planning (like the POST form in Indiana) works to dispel the superstitious avoidance of talking about end of life. It commits us to respecting patient decisions about their care, and nothing more.

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