On June 9, the End of Life Option Act (http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520162AB15) went into effect in California. This law allows terminally ill patients to request medications to end their life from physicians. California became the fifth state to allow this option, joining Vermont, Oregon, Washington and Montana. As a geriatric psychiatrist and someone who cares for patients with advanced neurodegenerative diseases, I was struck by the realization that this law will change my practice. Even before this law became reality, I had seen patients who alluded to the fact that they would want to have control over the end of their life and had explored physician-assisted suicide options, including relocating to other states. All of a sudden, the experience gained as a resident, performing capacity consults on medically ill patients who had expressed wanting to die, seemed woefully inadequate. Will many more patients request this option? Will we change the protocol for assessing capacity to make this decision? How about medico-legal implications? And how to draw the line between wanting to end one’s life in dignity, and suicidal ideation born from the intense suffering of psychiatric illness?
In the April editorial of Academic Psychiatry, Balon and colleagues reviewed the current state of medical student and psychiatric resident education in palliative care.1 They found, as had others before them, that a lot more education and research are necessary in this area. Among both healthcare professionals and the general public, the distinction between palliative care and hospice is poorly understood. Specialists who care for patients with neurological diseases or cancer advocate for the palliative care approach to be introduced as part of the initial treatment plan, ideally at the time of diagnosis.2 Palliative care is a team-based approach, focused on alleviating symptoms (importantly, pain) and relieving suffering. Hospice care refers to end-of-life care (typically, last six months) and is also delivered by an interprofessional team, including physicians, nurses, social workers, pharmacists, and chaplains, with an important component being the support for family caregivers.2 Balon et al. posited that “psychiatry itself is a form of palliative care because psychiatric treatments are frequently not curative”.1
In a recent article published in the American Journal of Geriatric Psychiatry, Meier and colleagues3 combed the literature and found 36 studies that defined a good death. They analyzed the perspectives of three stakeholder groups: patients, prebereaved and bereaved family members, and healthcare providers. The top three themes identified as important by all three groups were: preferences for dying process, pain-free status, and emotional well-being.3 The authors ended by highlighting Atul Gawande’s eloquent words: “…our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.”4 In reflecting on this poignant message, it seems to me that there is a crucial role for psychiatry in this national dialogue.
AAP Bulletin – Summer 2016, Page 4 of 7