This Slope Ain’t Slippery

My dear heart sister NP weighed in on my I-1000 post with a common concern:

I’m curious to see other readers’ comments on this, as well as your responses, Dana.

My concern with this initiative would be who makes the decision and when. While there are wonderful people in this world who want the best for their families, there are also people in this world who might make the decision prematurely, perhaps despite the patients’ wishes, and instead of preserving the dignity of a loved one would, in fact, be committing murder.

I’m not speaking from a religious/spiritual place here, although my spiritual views do have an influence on how I feel.

Maybe I watch too much Law & Order, but I can see so many people taking advantage of this Initiative, rather than using it the way it was intended: to preserve human dignity.

And with something like illness or injury, there are so many factors in determining quality of life, and so many varying degrees of “how sick s/he is,” I don’t know how a piece of legislature could be written in order to benefit those who would use it wisely, but protect those whose families would use it unwisely.

Back in my reading-too-many-books-by-profilers days, I had the same concern. I don’t anymore, but I can understand why caring, loving people like NP would.

No human endeavor will ever be perfect, and no piece of legislation can prevent all abuses. But I-1000 comes as close as possible. It is, in fact, so restrictive that it wouldn’t have saved my grandmother from a long, lingering, undignified death.

Here’s what the law requires (.pdf):

RESTRICTED ELIGIBILITY to those adult residents of the state who are:
• Suffering from a terminal illness, less than six months to live (verified by two physicians)
• Mentally capable (verified by two physicians)
• Making the request voluntarily —no coercion (verified by two physicians)

WAITING PERIODS
• At least a 15-day waiting period has taken place between the patient’s initial oral request and the subsequent written request
• No less than 48 hours shall elapse between the patient’s written request and the writing of the prescription

WRITTEN REQUEST
• Must be signed and dated by the terminally ill patient
• Must be witnessed by at least two people who attest the patient is capable and acting voluntarily, and not being coerced to sign the request
• At least one of the witnesses shall not be the patient’s attending physician, a relative, or owner, operator, or employee of a health care facility where the patient is a resident or getting medical treatment
• Patient may rescind the request at any time and in any manner

THE ATTENDING PHYSICIAN’S RESPONSIBILITIES
• To determine whether the patient has a terminal disease, is capable of making decisions, has made the request voluntarily, and is a resident of Washington
• To inform the patient of diagnosis, prognosis, risk of taking the medication to be prescribed, feasible alternatives including comfort care, hospice care, and pain control
• To refer the patient to a consulting physician for confirmation of diagnosis and determination patient is acting voluntarily
• To refer to a mental health professional if the patient may be suffering from psychological disorder
• To recommend that the patient notify next of kin
• To complete all required documents

Those requirements make it very nearly impossible for greedy or nefarious family members (or insurance companies, for that matter) to usher anyone into the Great Beyond who doesn’t have their bags packed and are eager to go. It also limits the dangers of false positives – a patient being told they have six months to live and will die in horrible agony, only to discover later that the diagnosing physician was a nitwit who couldn’t tell a benign lump from a man-eating tumor.

You might remember, too, that Oregon horrified the country about a decade ago by enacting just such a law as this. I dimly recall the hoardes of screaming fundies proclaiming the end of life as we know it. Oregon, they predicted, would turn into a state full of murdering Nazis. People would be offed in droves. Eugenics couldn’t be far behind. God would smite them. And so on.

There’s a good reason they’ve turned their attention to gay marriage. Oregon failed to install gas chambers. Droves of elderly, ill and inconvenient people failed to be murdered by plotting doctors and selfish family members. Quite the opposite, in fact, as my dear state discovered when they looked to Oregon for some indication of what to expect:

The Washington State Psychological Association found that “the quality and specificity of 10 years of comprehensive annual reports from the Oregon Department of Health on the implementation and regulation of the Oregon Death With Dignity Act and related research and data analyses do not show evidence of abuse, neglect, manipulation of, or pressure on patients in vulnerable groups in the state of Oregon. The data do not show evidence of a slippery slope toward less stringent guidelines and regulation.” They further found that, “Patients choose aid in dying because of a desire for autonomy and the wish to avoid loss of dignity and control, not because of a poor mental state, lack of resources or social support.” And that “the law has had a positive effect in terms of significant improvements in palliative care for all Oregonians, e.g. increased hospice referrals, advanced pain management, more home deaths, improved physician education and training in end-of-life care and detection of depression, and more open discussions among patients, doctors, and families about dying.”

Well, well. Imagine that. Giving people options actually improves matters for all. Shhh, don’t tell the fundies – they still can’t wrap their heads around the idea that the best way to prevent abortions is to educate people about sex and then give them good contraceptives. If we tell them that enacting a Death With Dignity law actually leads to better care for those who choose to stick it out until the bitter end, their heads might explode.

I’m not worried about slippery slopes for the above reasons. Much the opposite, in fact – I’m concerned that worries about slippery slopes have forced the laws to be too restrictive. Alzheimer’s patients are rarely coherent enough in their last six months of life to meet the criteria for such a law. And so they’re condemned to a horrific death. I’d like to see language that addressed that. An Alzheimer’s patient, or anyone else suffering a disease that will remove their ability to think long before it removes their ability to breathe, should be able to designate a person to decide these end-of-life issues for them before the disease progresses too far. They should be able to put together a legal instrument that states at what point treatment should stop, and life brought to a gentle end.

The same goes for those people like Dan Savage’s mother, whose condition deteriorates so quickly that they have hours, not weeks, to live. If those last hours would be unremitting agony, they should also have the option of saying, “End it now.”

But even a highly restrictive law is better than the current state of affairs. At least some terminally ill patients would be able to choose a more positive death.

My mind got changed for good on this many years ago, when I read a Reader’s Digest article by a physician who, without benefit of a Death with Dignity law, prescribed powerful drugs to a cancer patient and explained to her just what dosage would be fatal. They tusseled over it for quite some time before the doctor gave in, and then he watched in fascination as her fear and depression fled. Armed with her bottle, she went on to make the most of her last few months, spending time with the family, traveling, squeezing every last drop of enjoyment out of life. When the pain grew too great, and treatment no longer helped, she gathered her family around her and chose the instant of her death. She ended on a high note.

We won’t all be so lucky. But the option should be there, should we ever need it. And as Oregon has demonstrated, we need not fear sliding down the slope. It’s not slippery at all.

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I-1000 Has My Vote

I’ve never understood why we treat our pets better than people.

I grew up with a black cat named Stinker Annie. She was my boon companion and my protector. When I was a baby, she watched over me like I was her own: my mother tells me that every time I cried, she’d run to get my mom, and then run back to me and meow a message that help was on the way. Once, believing Mom was hurting rather than helping me, she jumped on Mom’s back with claws out, attempting to save me. She was there for every moment of my life, one of my best friends.

She developed stomach cancer when I was eight or ten. We knew something was wrong when she started sneezing blood. We took her to the vet, who diagnosed the cancer and informed us there was nothing we could do. There wasn’t any kitty chemo in those days. We were going to lose her. Did we want to euthanize?

No. Not yet. She wasn’t yet in obvious pain. She still ran and played and cuddled. We took her home, and spoiled her rotten, and kept a sharp eye out for signs of distress. She lived on for nearly a year before she started showing signs of discomfort, and the cancer may have spread to her brain, because she started having “senior moments.” She couldn’t take care of herself anymore. She didn’t seem to be enjoying life. So we packed her into the car and headed off to the shelter to have the deed done. We cried, and she cried, and it was one of the most horrible things we’ve ever had to do. Mom wouldn’t let me be there at the end, but she was. Stinker Annie ended her life with the people who had loved her best, before the pain got too much to bear.

Years later, I watched another cat die in screaming agony because its owner couldn’t accept the inevitable. Months of suffering, followed by a horrific night where the poor thing never stopped howling until its final breath.

I bring up this study in contrasts because humans have no choice. Legally, we are required to force our loved ones to stick it out until the bitter end, no matter that the quality of life is nonexistent, no matter that pain medication is worthless when the pain exceeds the capacity of all but lethal doses to ease.

I’ve always been horrified by the fact that we can’t legally end human life when it’s become intolerable, but we’d consider it abuse not to euthanize a pet in the same situation.

After my grandmother died of a combination of Alzheimer’s and breast cancer, my mom called me. “Promise me you’ll shoot me if this happens to me,” she begged. “Don’t let me die like this.” I don’t know that I’d shoot her, but there are “accidents” that could happen. In the stress of taking care of an Alzheimer’s patient, I might measure a dose of medication wrong. I might forget to secure a dangerous drug, and she in her dementia might overdose herself. I’ll find a way to keep the spirit if not the letter of the promise I made her: that I’ll let her end her life on a high note, before things get really awful. When there’s no hope of a cure, when there’s no possibility of dying in anything but pain and humiliation, mind destroyed, there’s no greater act of love than to let things end gracefully before it comes to that nasty pass.

I’ll treat her with the same love and respect with which we’ve treated our pets, and I know she’ll do the same for me, whether or not it’s legal. We both believe that life is far more than just breathing. It’s quality, not quantity, that matters.

If I’m lucky, and Washington State voters wise, that choice for us will be legal.

If Initiative 1000 is approved, a doctor can do what vets do every day: let a decision be made, and if that decision is to end the suffering, then provide the means to do so. The religion-blind, of course, won’t see what a blessing that choice is. They won’t understand the relief people like my mom and I would feel at knowing we won’t have to break the law, strike out on our own, to ensure that our loved one’s death is as easy and painless as possible. My mom and I can live a little easier if we know that we can choose to die with our minds still intact. The diagnosis won’t bring as much fear if we know we have the choice to end life before the disease gets really bad, and that we won’t be committing a crime by opting for euthanasia. Knowing this, we’ll be able to squeeze every drop of good life out of us before going in to that good night.

Life is precious. My mother and I know that. We also know that life is a lot more than breathing and a beating heart. Life is too precious to waste its last hours on pain and fear and insensibility.

If you love life, if you value life, as something more than a technicality, vote Yes on Initiative 1000. Allow people the same dignity and respect we show for pets. Allow them a choice.

(Tip o’ the shot glass to Dan Savage by way of Pharyngula.)