Sharon Quick: Overall patient safety more than cosmetic need

By Sharon Quick, M.D., M.A.

How important is patient safety? Two Washington state bills pertaining to elective medical treatments have opposing views.

ESSB 5050 wisely requires breast implant information prior to surgical consent because women believe time and information are lacking to make informed decisions. Risks include device failure, cosmetic problems, diseases and cancer. The bill supports the current standard, which includes four meetings with health professionals and signing over 20 documents two weeks prior to surgery.

By contrast, ESSB 5179 demolishes safeguards for the terminally ill to obtain lethal prescriptions. It chops the waiting period for lethal drugs from 15 to seven days and allows: nurse practitioners and physician assistants to determine eligibility and write lethal prescriptions; less qualified practitioners to perform mental health evaluations; consent form completion before two practitioners have agreed; mailing lethal drugs; and an indirect supervisory role between the two evaluating practitioners that compromises the integrity of the second opinion. The waiting period may start before either practitioner has evaluated the patient, making same-day death possible.

How can one bill require extensive consent processes for a cosmetic medical procedure with mostly risks that aren’t life-threatening, while another bill limits the consent process and diminishes safeguards for a procedure intended to cause immediate death? The difference in treatment unfairly disregards patient safety in one group of people, the terminally ill. The proposals in ESSB 5179 ignore palliative care possibilities, current deficiencies in safeguards and the vulnerability of terminally ill patients.

Proponents of ESSB 5179 suggest that shortening the waiting period to obtain lethal drugs is needed to end “intractable” pain. Two problems arise with this argument. First, pain is not “intractable.” Multiple medications, nerve blocks and other interventions including pain management consultation make end-of-life care effective in managing pain and other symptoms. Temporary sedation can eliminate symptoms in rare cases where usual measures are inadequate. Though studies show that some doctors lack knowledge about palliative care possibilities, lethal drugs should never be a solution for lack of education. Secondly, patients in significant pain cannot provide valid consent for lethal drugs.

Some want to rush lethal drugs to patients nearing death so they can die in the manner they choose. However, hallmark symptoms for patients approaching death include brain dysfunction and the inability to ingest liquids. As a result, lethal prescriptions would be dangerous and consent invalid at this time.

Of the 2,704 patients who have received lethal drugs since 2009 in Washington, 476 physicians’ forms and 264 patient consent forms are missing from the Washington Department of Health records. The problem seems to be worsening, as about half of the legally required missing forms are from the last three years in which reports are available. Why does this bill propose to further reduce safeguards when hundreds of Washington residents have received lethal drugs without documentation of consent or a terminal diagnosis?

A wish to die requires thorough evaluation. It is often a plea for help or assurance of self-value in the face of new disabilities. The terminally ill frequently have a compromised capacity to choose, with good/bad days, declining cognition, depression, coercion risk, etc. If such deficits are not recognized and a request for lethal drugs fulfilled, then that person’s autonomy is violated. Such vulnerable patients risk ingesting lethal drugs, not realizing that with time and support they may not want to hasten death. Depression and impaired capacity to choose often go unrecognized by doctors. Evidence suggests depressed patients are getting lethal drugs. Allowing providers with less expertise to prescribe lethal drugs will worsen this.

The terminally ill need loving care, not abandonment to a lethal prescription. Without an adequate waiting period or sufficient provider expertise, patients are deprived of proper evaluation, treatment and time for mind changes. While ESSB 5050 rightly prioritizes safety and time for decision-making, ESSB 5179 exhibits reckless disregard for patient safety–violating the core medical ethic to do no harm. Why are we discriminating against the terminally ill? Do disabilities make their lives less valuable?

Sharon Quick, M.D., M.A. (Bioethics) is president of Physicians for Compassionate Care Education Foundation. She is a retired pediatric anesthesiologist/critical care physician residing in Bonney Lake, Washington.