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Doctors Prefer Terminal Sedation to Assisted Suicide
Dec. 6, 2004 - Doctors appear willing to use
intensive treatment to lessen otherwise untreatable pain or other severe
symptoms in dying patients even if the treatment, at least in theory,
risks hastening the dying process Known as "terminal sedation," the
practice involves the use of sedating medications to control a patient's
symptoms even if it results in decreased or complete loss of
consciousness. In contrast to physician-assisted suicide, this may risk,
but does not intend, hastening or causing death.
A majority of physicians in the two University of
Iowa and Yale University studies on end-of-life care, drew a clear line
between terminal sedation and assisted suicide. In addition, physicians'
attitudes were related to two notable factors: their experience in
caring for terminally ill patients and their frequency of attending
religious services.
One study, which focused on internal medicine
physicians, appeared in the October issue of the Journal of Medical
Ethics. The second study, which focused on internal medicine
residents (doctors in training), was published in the September/October
issue of the American Journal of Hospice and Palliative Medicine.
Both studies were led by Lauris Kaldjian, M.D.,
assistant professor of internal medicine in the UI Roy J. and Lucille A.
Carver College of Medicine, and member of the college's Program in
Biomedical Ethics and Medical Humanities. Kaldjian was formerly on the
faculty at Yale University.
"End-of-life care involves many treatment
decisions, some of which are focused on extreme pain and other symptoms
that are very challenging to control," Kaldjian said. "We studied the
specific ethical issues of treatments that control symptoms versus
interventions that intend to cause or hasten death."
The study of internal medicine physicians, who had
been in practice for at least several years, involved 677 Connecticut
members of the American College of Physicians (ACP). The study of
doctors-in-training involved 236 residents in three internal medicine
residency programs in Connecticut. Participants in each study responded
anonymously to questions in a survey. The questions were phrased as
statements, and respondents indicated their agreement or disagreement on
a five-point scale, with "not sure" as a sixth option.
Among the ACP physicians, 78 percent of respondents
supported the use of terminal sedation, while among the residents, 66
percent agreed with the practice. In both groups, about one-third of
respondents supported physician-assisted suicide, in theory, as
"ethically appropriate" in certain circumstances. The practice is legal
only in Oregon, not in Connecticut or other states.
While general attitudes toward end-of-life care
were similar among doctors in training and doctors who had been in
practice, the ACP study revealed more about the roles that palliative
care experience and religious involvement play in physicians' views.
Of the ACP members who supported terminal sedation,
nearly two-thirds of them (62 percent) did not support assisted suicide.
Analysis revealed physicians were more likely to be for terminal
sedation but against assisted suicide if they had either significant
experience with dying patients or frequent religious service attendance.
Among ACP physicians who had cared for one to 10 terminally ill patients
in the past year, 39 percent disagreed with the notion of assisted
suicide. In contrast, among ACP physicians who had cared for 50 or more
terminally ill patients in the past year, 68 percent disagreed with
assisted suicide.
"It was clear from our statistical analysis that
those who had cared for a greater number of terminally patients in the
preceding year were more opposed to assisted suicide and also more
supportive of terminal sedation," Kaldjian said.
"There seemed to be both a greater willingness to
be rigorous in end-of-life care but also less willingness to cross that
line into actually intending death," he added.
Kaldjian said the reasons for this attitude are
open for discussion because the statistical study was descriptive, not
designed to establish cause and effect.
The ACP study also showed that the more frequently
a doctor attended religious services, the more likely he or she was to
disagree with assisted suicide, as shown by these disagreement rates: 30
percent for non-attendees, 33 percent for less-than-monthly attendees,
52 percent for monthly attendees and 76 percent for weekly attendees.
"We found that the more frequently respondents
attended religious services, there was a trend toward less support for
assisted suicide but more support for terminal sedation," Kaldjian said.
"To my knowledge, this is the first study to show such a stepwise
trend."
The association with frequency of religious service
attendance held true no matter what the religious affiliation of the
physician.
Kaldjian said the studies collectively suggest that
physicians do not separate their religious beliefs from decision-making
in end-of-life care.
"We should not be surprised that physicians have
religious beliefs and that, especially in some areas of medicine, these
beliefs are operating in some way," he said. "A physician should not be
seen as any less of a professional because of deeply-held religious
convictions.
"Medical ethics involve not just a patient's
autonomy but also a physician's integrity," he added. "On matters of
such importance as end-of-life care, physicians' integrity must be
respected. Patients should not see themselves as mere consumers of
health care but as partners in a decision-making process with
physicians, who are not mere robots."
The ACP-based study was funded in part by a
dissertation fellowship to Kaldjian from the Graduate School at Yale
University.
University of Iowa Health Care describes the
partnership between the UI Roy J. and Lucille A. Carver College of
Medicine and UI Hospitals and Clinics and the patient care, medical
education and research programs and services they provide. Visit UI
Health Care online at
http://www.uihealthcare.com.
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