Palliative care/physician-assisted dying: alternative or continuing care?

End-of-life care far dying patients has become an issue of importance to physicians as well as patients. The debate centers around whether the option of physician-assisted suicide cuts off, or diminishes the value of, palliative care. This ongoing attention makes the crafting of advance directives from patients detailing their end-of-life choices essential. Equally important is the appointment of a health care surrogate. The surrogate, when the patient is too ill to make decisions, should be empowered to make them in his stead. No American court has found a clinician liable far wrongful death far granting a request to refuse life support. An entirely separate issue is that of legalized physician-assisted suicide. As of this writing, only Oregon has made this legal (see Gonzales v. Oregon). It is likely that this issue will be pursued slowly through the state courts, making advance directives and surrogacy all the more crucial. Keywords: physician-assisted dying; palliative end-of-life care; advance directives; health care surrogates; Gonzales v. Oregon End-of-life care for mortally ill patients became a high-profile issue as the plight of Terri Schiavo again rose to public prominence in 2005. Two recent volumes, although not published during the heat of the recent Schiavo controversy (The case Against Assisted Suicide for the Right to End-of-Life Care, edited by Kathleen Foley, MD, and Herman Henden, MD, and Physician-Assisted Dying: The case for Palliative Care and Patient Choice, edited by Timothy E. Quill, MD, and Margaret P. Battin, PhD) address many of the issues, implied and overt, raised by the Schiavo case. The language of the books' titles is revealing: The Foley title implies that assisted suicide vitiates compassionate end-of-life care, while Quill's avoids the word suicide altogether, emphasizing the connection between assisted dying and palliative care. Quill and Battin (2004), in their introductory remarks, state that they "firmly believe that physician-assisted death should be one-not the only one-but one, of the last-resort options available to a patient facing a hard death ... physician-assisted dying, whether it is called physician-assisted death or physician aid in dying or physician-assisted suicide should be available to patients at the end of life . . . that physician-assisted dying . . . should be safe and legal-and relatively rare" (p. 11). Foley and Henden (2004), on the other hand, believe that legalization of assisted suicide and euthanasia undermines the care provided to patients at life's end (p. 3). According to Foley and Henden, a positive outcome of the debate over assisted suicide has stimulated the medical community, and especially palliative care specialists, to make compassionate end-of-life care standard practice (p. 332 S). At the same time, they also state that the very notion of physician-assisted death, whether legal or not, encourages patients to forgo palliative endof-life care (p. 12). Their argument seems to be based on the premise that physician-assisted death and compassionate end-of-life care are mutually exclusive. Legalization is, at best, only implicit in their focus; the major concern is with the physician assisting a patient to die. It is important to note that neither of these volumes mention, except marginally, advance directives. Advance directives and the appointment of health care surrogates logically bridge the gap between the two positions. The compassionate physician would be hard-pressed to ignore a patient's documented request to cease intravenous feeding, just as the physician favoring assisted dying can be specifically directed by patient directive first to provide palliative care. The 45 contributors to these volumes surely cannot wish for a replay of the Schiavo miseries. And yet, after what has been called "the most important case of clinical ethics in more than a decade" (Hook & Mueller, 2005, p. 1449), the clash continues, even spawning Web sites for the Schiavo principals. …