Better end-of-life care

The people of Maine are beginning to think more seriously about the care of the terminally ill. The major cause for this discussion is the formation of two important new groups in the state — the Maine Consortium for Palliative Care and Hospice and Mainers for Death with Dignity. The first is working to educate the public and health care providers about better end-of-life care. The second is working to give dying patients a broader ranger of options at the end of their lives.

Some think these movements must work in opposition, but it is also possible that their work is complementary. Every time representatives from either group speak about assisted dying, they point out that, presently, patients do not have the final say in how they die. Every time representatives from either group speak about hospice and pain control, they remind us that Maine badly needs to work on improving these crucial care measures. As seen in Oregon, the only state with a death with dignity law, hospice, palliative care and physician assisted dying are working together.

Since the passage of the Oregon Death With Dignity Act in 1994, there have been constant and substantial improvements to end-of-life care. Examples of these improvements include:

Hospice usage in the state increased by 20 percent between 1993 and 1995 (Annals of Internal Medicine 1998; 128:567-568).

Oregon is a leader in the nation in the use of medical morphine to control pain. Between 1994 and 1996, the use of medical morphine to control pain in Oregon increased by 70 percent (Annals of Internal Medicine 1998; 128:567-568).

Oregon has the lowest in-hospital death rate in the country, meaning most Oregonians die at home with their loved ones beside them. In 1996, nearly 70 percent of Oregonians were able to die at home. (Annals of Internal Medicine 1998; 128:567-568).

According to a newspaper report on the status of end-of-life care, “End-of-life issues are sailing right on the surface of dialogue and action in Oregon’s medical community.” (The Oregonian, June 8, 1995).

In the first case of its kind in the nation, the Oregon Board of Medical Examiners disciplined a physician for underprescribing pain medications and for disregarding the comfort of his patients. (The Oregonian, Sept. 2, 1999).

These improvements are a direct result of the passage of the Oregon Death with Dignity Act, a fact which has been chronicled by newspapers nationwide, both friendly and unfriendly to the law.

While some organizations outside the health care arena may try to portray the consortium and Mainers for Death with Dignity as opponents in order to promote their political or social views, a practical look shows that they share common ground in their focus on the dying person’s best interests.

The consortium, a group of health care providers, hopes to improve the skills of physicians in the use of pain medication and to increase the use of hospice by both physicians and the public. Mainers for Death with Dignity is a citizens’ group seeking to provide mentally competent, terminally ill adults the right to request assistance in dying when other options have failed. This group seeks to carry compassion all the way to an end that home care, hospice, hospitals and physicians cannot legally go today.

These two groups are not natural opponents. As it has been demonstrated in Oregon, it is hoped that these two movements for better end-of-life care can work together, and not be divided in Maine. We, the people of Maine, very much need to improve the growth and support of hospice, and the use of palliative and pain care. Along with all these improvements, we also need to respect the dying person who wants no other therapeutic choice than a quiet and painless death.

The Maine Death with Dignity Act is purposefully written very cautiously and with many safeguards. The proposed law requires two medical opinions certifying the patient’s terminal condition. It requires that a physician provide the patient with information on alternatives for pain and symptom management. There are two required waiting periods, the first of 15 days and another of 48 hours in order to encourage reflection and deliberation. The law also requires an examination by a psychiatrist or a psychologist to assure competency and to avoid cases of clinical depression. Only after meeting these safeguards can a patient receive a prescription for a drug that will peacefully and compassionately end life.

Hospice care seeks neither to hasten nor to prolong the dying process but to provide to patient and to family pallative care, comfort and support. Hospice also respects and supports a patient’s rights to any and all legal options. In the coming months the voters of Maine will have the chance to make legal the choice for assisted dying by adopting the Death with Dignity Act. Let’s support the Maine consortium but let’s not stop there. Let’s give those patients who would like this option the ability to close their lives with inner calm and personal intergrity.

Dorothy Melanson, R.N. lives in Falmouth.