Tagged Aid In Dying

Docs In Northwest Tweak Aid-In-Dying Drugs To Prevent Prolonged Deaths

Two years after an abrupt price hike for a lethal drug used by terminally ill patients to end their lives, doctors in the Northwest are once again rethinking aid-in-dying medications — this time because they’re taking too long to work.

The concerned physicians say they’ve come up with yet another alternative to Seconal, the powerful sedative that was the drug of choice under Death with Dignity laws until prices charged by a Canadian company doubled to more than $3,000 per dose.

It’s the third drug mixture recommended by the doctors whose medication protocols help guide decisions for prescribers in the six U.S. states where aid-in-dying is allowed.

The first Seconal alternative turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain. The second drug mix, used 67 times, has led to deaths that stretched out hours in some patients — and up to 31 hours in one case.

“[Twenty percent] of the cases were 3 hours or more before death, which we think is too long,” said Robert Wood, a retired HIV/AIDS researcher who volunteers with the advocacy group End of Life Washington, in an email. “The longest was 31 hours, the next longest 29 hours, the third longest 16 hours and some 8 hours in length.”

Patients and families are told to expect sleep within 10 minutes and death within four hours. When it takes far longer, family members get worried, even distressed, said Dr. Carol Parrot, a retired anesthesiologist who has prescribed drugs for dozens of aid-in-dying patients in Washington.

The doctors say this can be addressed with larger doses of the three drugs they have been using — diazepam, often used to treat anxiety; digoxin, used to treat heart issues; and morphine, a narcotic pain reliever — plus another heart medication, propranolol, in a four-drug cocktail aimed at quickly inducing death, Wood said.

Parrot and Wood are part of a seven-member group of doctors in the Northwest who came up with the three-drug protocol after Valeant Pharmaceuticals Inc., acquired the rights to secobarbital, known as Seconal, in 2015 and raised the price sharply.

“We wanted the new drug regime to be safe, reliable and effective — and cost $500 or less,” said Parrot.

Since 1997, when Oregon’s Death with Dignity law became the first in the nation, doctors had relied on fast-acting, relatively inexpensive barbiturates — either secobarbital or pentobarbital — for patients with terminal diagnoses who sought aid in dying in Oregon, Washington, California, Colorado, Montana and Vermont. The practice also has been approved in Washington, D.C., but is being reviewed by Congress.

Pentobarbital became unavailable after drugmakers blocked its use in U.S. death penalty executions.

Concerns about the overly long deaths surfaced last summer, Parrot said. Nearly all of the problems occurred in patients already taking high doses of opiates.

“We run into patients who are so tolerant or dependent on narcotics that even the astronomically high doses of oral narcotics in our prescription do not stop them from breathing,” she said.

If patients have diseases that slow or alter normal organ function, it can affect the speed and amount of drugs absorbed in the small intestine, metabolized in the liver and sent to the rest of the body. Very large patients, too, may require larger doses.

Deaths aren’t required to be supervised, and no doctor was present with the unidentified patient who took 31 hours to die, so doctors would only be speculating about the reason, Parrot said.

Not all patients — or doctors — experienced overly long deaths with the previous drug mixture. Dr. Lonny Shavelson , a Berkeley, Calif., physician who has supervised two dozen aid-in-dying deaths under California’s new law, said it worked fine.

“My personal experience is I haven’t had long deaths with it,” Shavelson said.

And not all doctors think long deaths are a problem. In Oregon, even with fast-acting barbiturates, time to death has ranged from one minute to 104 hours during the 20 years the law has been in effect, state records show.

“I’ve heard stories where it took quite a number of hours to die, and it was fine,” said Dr. David Grube, an Oregon-based medical director for the advocacy group Compassion & Choices.

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Pat Hansen, 69, of Wenatchee, Wash., chose to end her life with lethal medications under Washington’s aid-in-dying law. Hansen, who had end-stage kidney failure, congestive heart failure and other ailments, went to sleep within minutes after taking the drugs and stopped breathing within 20 minutes, her family said. (Courtesy of Scott Kreiter)

Scott and Amy Kreiter, of Wenatchee, Wash., didn’t know what to expect when Scott’s mother, Patricia Hansen, 69, decided to take the lethal drugs on Dec. 26, 2016. Hansen, a lively woman who once ran a gourmet ice cream business, had endured frequent hospitalizations for end-stage kidney failure, congestive heart failure and other ailments.

“She said, ‘I want to listen to Willie Nelson, I want to play a game of Scrabble, I want to drink a Rob Roy or two, and then I want to be done,’” Scott Kreiter, 47, said.

Hansen proceeded to “kick our butts” at Scrabble, her son said — including fulfilling a goal of getting a triple-word score with a dirty word. Then she mixed the drugs with scotch and drank the solution.

“She didn’t complain. She just took it,” her son recalled. “She said, ‘You thought I’d chicken out, didn’t you?’”

Within two minutes of downing the mixture, Hansen was asleep. Within 20 minutes, her breathing had stopped.

“We thought it would take one to two hours,” Amy Kreiter said. “It if had gone on for hours, we would have thought we did it wrong.”

Critics of aid-in-dying say growing reports of overly long deaths underscore their objections. Dr. David Stevens, CEO of Christian Medical & Dental Associations, which has tried to halt or reverse laws, said coming up with new drug protocols could eventually be a step toward Holland’s practice of allowing euthanasia by lethal injection “so the patient could be killed ‘humanely.’”

“We are heading down that same path,” Stevens said in an email.

But Parrot and other frequent prescribers of aid-in-dying drugs say they are looking for the best way to honor the wishes of patients in states where the practice is allowed. Doctors recently began using the newest drug mixture and will gather data about its effectiveness.

“We’re not experimenting,” Parrot said. “We are working with available drugs to provide dying patients a comfortable, peaceful death that is reliable and safe for them and comforting for their families as well.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

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Right-To-Die Fight Hits National Stage

Opponents of aid-in-dying laws are claiming a small victory. They won the attention of Congress this week in their battle to stop a growing movement that allows terminally ill patients to get doctors’ prescriptions to end their lives.

The Republican-led effort on Capitol Hill to overturn the District of Columbia’s aid-in-dying law could fail by Friday. But advocates worry the campaign will catalyze a broader effort to fully ban the practice, which is legal in six states and being considered in 22 more.

“The D.C. legislation has catapulted the issue of medical aid in dying onto the federal agenda at a time when Congress has the power to enact a ban on this end-of-life care option nationwide — even criminalizing the practice in the six states where this option is currently authorized,” warned Jessica Grennan, national director of political affairs and advocacy for Compassion & Choices, which supports right-to-die laws.

“If that happens, it will set the end-of-life care movement back to the last century,” Grennan said.

No matter how the effort plays out, both sides agree that the debate on Capitol Hill, featuring a Republican moral protest, could be only a taste of what’s to come.

In a vote that hewed closely to party lines, the Republican-controlled House Oversight Committee on Monday approved a bill that would knock down D.C.’s law, which won approval from the mayor and City Council in December. While D.C.’s law mirrors those passed in other states, Congress has unique power to intervene in D.C.’s affairs. Under the Home Rule Act of 1973, Congress has 30 legislative days to overturn any law D.C. passes.

“It’s of deep, personal moral conviction that I stand in opposition” to D.C.’s law, said Rep. Jason Chaffetz of Utah, who chairs the committee, in Monday’s hearing.

The clock is running out on his effort. Republicans in the House and Senate have introduced joint resolutions attempting to block D.C.’s law, but the bills would need to pass the full House and Senate and gain President Donald Trump’s signature. Trump has declined to take a public stance on the matter. If those steps don’t happen by Friday, D.C.’s law will take effect.

Dr. David Stevens, CEO of the Christian Medical & Dental Associations, which opposes medical aid in dying, said even if Republicans fail to overturn D.C.’s law, their efforts may have broader impact.

“As representatives and senators become more educated about the dangers of physician-assisted suicide,” Stevens said, “I wouldn’t be surprised” if members of Congress introduce laws to “prohibit or at least more closely regulate” the practice.

(Courtesy of Amazon.com)

(Courtesy of Amazon.com)

If Congress passes such a law, the only hope for advocates such as Grennan “would be for the Supreme Court to intervene,” she said. But she noted that Trump’s pick for the Supreme Court, Neil Gorsuch, a federal appellate judge on the U.S. Court of Appeals for the 10th Circuit, has published a book against aid-in-dying efforts. The book, she said, notes “the Supreme Court’s power to overturn the state medical aid-in-dying laws.”

Away from Capitol Hill, the aid-in-dying movement has gained steam: The practice is legal in Oregon, Washington, Vermont, Colorado, California and Montana.

Energized by victories in California and Colorado last year, aid-in-dying supporters are pushing ahead to battlegrounds nationwide. So far this year, 21 states have introduced aid-in-dying legislation, according to Compassion & Choices. And in South Dakota, proponents are trying to get the practice approved through a ballot initiative.

Hawaii, Maryland and Maine appear the most likely to pass new legislation this year, said Peg Sandeen, executive director of the Death With Dignity National Center, another national advocacy group.

But opponents have beaten back similar measures in many states in recent years. And in Alabama, South Dakota and New York, they have gone on the offensive, introducing bills to preemptively outlaw the practice or prohibit insurance from paying for the lethal drugs.

Chaffetz, who is leading the charge to overturn D.C.’s law, has enraged Democrats and D.C. officials, who accuse him of overreaching his power by meddling in local affairs. But Chaffetz and fellow House Republicans at Monday’s vote said moral concerns trump local autonomy.

“Only God gets to decide” when a person’s life ends, declared Rep. Paul Mitchell, a Michigan Republican, during the debate.

If Republicans fail this week, they could attack D.C.’s Death With Dignity law in April, when Congress approves D.C.’s proposed budget. D.C. has proposed to spend some local money to build a database tracking the assisted-dying program.

Republican Sen. James Lankford of Oklahoma, who introduced the Senate resolution blocking the bill, also made a legal argument, citing a 1997 law passed under President Clinton that bans the use of federal money for physician-assisted death. Because of that law, Medicare and the Department of Veterans Affairs do not pay for the lethal drugs, so patients must pay out-of-pocket or use private or state-funded insurance. Lankford challenged D.C. to show that its assisted-dying program wouldn’t conflict with that law.

Advocates dismissed that argument. Sandeen, of the Death With Dignity National Center, said D.C.’s program will not use any federal money to help people die. She called the legal argument a “red herring effort,” aimed at distracting attention from politicians’ true reasons for trying to strike down D.C.’s law.

“I’d rather that they said, ‘For religious purposes, I disapprove of this law,’” she said.

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

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