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  • Strange Deathbedfellows
  • Linda Ganzini (bio)

In 1998 I was hired by a local health care system to evaluate the mental health of enrolled patients who requested lethal prescriptions under Oregon's newly implemented Death with Dignity Act. I drove to the trailer home of my first patient, a man in his sixties tethered to an oxygen tank for his chronic pulmonary disease who was recently diagnosed with advanced lung cancer. He told me about his abusive, alcoholic stepfather and how he left his family and church at age sixteen, determined never again to be subjugated in any relationship. But in a life marked by an avoidance of intimate relationships, he corresponded regularly with his nephew and was proud to leave him a small inheritance. He shared with me his delight at the morning's newspaper comics, particularly those focused on family life.

A hospice intake nurse had come to his home a few days earlier. She had upbraided him for smoking while using supplemental oxygen. He judged her bossy and domineering. Thirty minutes into the intake, he fired her, then notified hospice that he did not need their services. He wanted to die in his trailer, alone. To be observed in such a dependent state during his final moments was anathema to him. All of his providers were very uncomfortable with this plan. "Surely he's depressed?" I was repeatedly asked. But after careful negotiations, he agreed for his physician to be present when he ingested a barbiturate, provided the doctor left as soon as he became unconscious. His final words to the physician were "Turn out the lights and lock the door."

Since then, I have been privileged to interview more than fifty Oregonians who requested legalized, physician-assisted death, as well as their family members, physicians, and hospice providers. These people prize independence, autonomy, self-sufficiency, and control. They want to leave this world in the driver's seat, and they anticipate a dying process that is incompatible with this goal.

When talking to a variety of audiences about my experience around Oregon's law, I am often asked, "How and why do hospices allow physician-assisted death to happen?" I respond, "How can they prevent it?" Even among hospices that "prohibit" participation, patients live at home and receive lethal prescriptions from their physicians, who may not be affiliated with the hospice. Some patients never tell their hospice providers of their plans. A few fear obstruction, but others believe the decision is private, not medical.

In this issue, Courtney Campbell and Jessica Cox share a thoughtful, nuanced view into the policies and practices of Oregon's hospices on physician-assisted death. Hospices strive to respect self-determination and to avoid abandoning the patient, but will not participate in directly hastening his or her death. Their policies govern how employees discuss physician-assisted death with clients or facilitate access to information about choices, as well as whether hospice providers may attend the death. Hospices' moral accommodation of this practice is matched by the patients' psychological accommodation to hospice itself. Since 1998, I have observed that hospice providers have learned not to overwhelm patients interested in physician-assisted death with care, but instead to work on respectful engagement that underscores patients' preferences. Compassion and Choices of Oregon, an organization that assists most patients who choose physician-assisted death, encourages hospice enrollment by emphasizing that good symptom management maximizes self-determination and that patients have control over how much hospice is involved. As noted by Campbell and Cox, 95 percent of Oregonians who die with physician assistance are now enrolled in hospice, and they don't fire their hospice providers nearly as often as they once did.

Campbell and Cox state that the high rates of hospice enrollment among those who request physician-assisted death have been given as evidence that patients are not making this choice as a result of poor medical care and that the practice is engaged in responsibly. I would add that hospice is the single most effective means of allowing patients to reconsider physician-assisted death, not by taking the issue head on, but by slowly chipping away at the patients' fears of dependence and care...

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