4/11/2019

1

Legal Update on

MAID, VSED & PSU

in the United States

Thaddeus Mason PopeHarvard Medical School

Annual Bioethics Conference

April 11, 2019

Nothing

to disclose

Defining death

Controlling death

Last resort

options6

1 2

3 4

5 6

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2

High dose opioids

Stopping life-sustaining therapy

Voluntarily stopping eating & drinking

Palliative sedation to unconsciousness

Medical aid in dying

Voluntary active euthanasia

Most accepted

Least accepted

High dose opioids

Stop life-sustaining therapy

Voluntarily stopping eating & drinking

Palliative sedation to unconsciousness

Medical aid in dying

Voluntary active euthanasiaWell-settled for decades

High dose opioids

Stop life-sustaining therapy

Voluntarily stopping eating & drinking

Palliative sedation to unconsciousness

Medical aid in dying

Voluntary active euthanasia

7 8

9 10

11 12

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3

VAE(but see CA NL)

Will not discuss

Definitely accepted

Definitely not accepted

High dose opioids

Stop life-sustaining therapy

Voluntarily stopping eating & drinking

Palliative sedation to unconsciousness

Medical aid in dying

Voluntary active euthanasia

Roadmap

MAID

VSED

PSU

13 14

15 16

17 18

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4

MAID

End-of-life

option

For small

number of

patients

19 20

21 22

23 24

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5

Who Adults> 18 years old

Decisional

capacity

Terminally ill

6-mo prognosis

WhatAsk & receive

prescription

drug

25 26

27 28

29 30

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6

Self-administer

to hasten death

Early efforts

1988 California

1991 Washington

1992 California

1994 Michigan

BUTLegalize both

euthanasia

and MAID

MAIDSelf ingestion

Patient takes the

final overt act

1994(1997)

31 32

33 34

35 36

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• OR 1994 Numerous

safeguards

Multiple requests

Multiple screenings

Prescribing MD

Consulting MD

Mental health MD

Voluntary

Informed

Enduring

37 38

39 40

41 42

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Model followed

2008 WA

2013 Vermont

43 44

45 46

47 48

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2015

2016• CO

2017

49 50

51 52

53 54

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10

2018

2019

8 statutes~22% population

55 56

57 58

59 60

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>50 years

of combined

experience

Ongoing

>20 bills (2019)

BUT

CriticismOregon

Model

CACODCHI

NJORVTWA

61 62

63 64

65 66

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12

Nearly identical

Successful

No evidence

of abuse

BUT Tooprotective

Unduly

restrict

access

Eligibility

criteria

Process

requirements

67 68

69 70

71 72

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13

Eligibility

criteria

Adult

Terminally ill

Capacity

1 Adult

18+

73 74

75 76

77 78

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14

Assure

voluntary

& informed

BUTAllow minors

to make other

healthcare

decisions

2

79 80

81 82

83 84

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Terminal

illness

“death within

six months”

Matches

hospice

eligibilityBUT

Temporally

strictunbearable

suffering

85 86

87 88

89 90

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• OR 1994

HB 2232

Reasonably

predictable

3Capacity

“solely and directly

by the individual . . .

not . . . advance

directive”

91 92

93 94

95 96

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BUT

Terminal →

no capacity

Capacity →

not terminal

Advance

requests

97 98

99 100

101 102

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Push to

expand

eligibility

Push to

reduce

procedures

115 day

waiting

periodbetween requests

20 days

Assure

request

enduring

103 104

105 106

107 108

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19

BUT Undue

burdenCannot wait that long

2Self

ingest

Physician

only prescribes

Patient

administers

109 110

111 112

113 114

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20

Helps

assure

voluntaryBUT

Lose

ability Complications

8%

115 116

117 118

119 120

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Avoid with clinician

administration

3Attending +

consulting

clinician

MD or DO

BUT Access

problems

121 122

123 124

125 126

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22

NPs

Extend to

Eligibility

criteria

Process

requirements

OR model

statutes

limit access

127 128

129 130

131 132

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23

133

Why need

a statute

Across USA, since

1800s, helping

someone commit

suicide is a crime

“assisted

suicide

prohibitions

are deeply

rooted in our

nation’s legal

history”

Minnesota

Chapter 609

Criminal Code

“Whoever . . . assists

another in taking the

other’s life may be

sentenced to . . . 15

years . . . $30,000”609.215

133 134

135 136

137 138

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MAID = AS

AS = felony

MAID = felony

CACODCHI

NJORVTWA

BUT Criminal

prohibition

MAID

MT SCT

But b/c consent def.

139 140

141 142

143 144

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No MAID

statuteBUT

Considered

legal

“consent of

the victim. . .

is a defense”Mont. Code Ann. 45-2-211 2009

145 146

147 148

149 150

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Patient consent

Not prohibitedH.B. 284

No MAID

prohibition

No need

explicit

authorization

N.C. Med J.

2019

80(2):128

151 152

153 154

155 156

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VSED

BUT

We need

another EOL

exit option

MAID

157 158

159 160

161 162

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10/56 Even in

MAID

jurisdictions

Cannot satisfy

eligibility

conditions

What is

VSED

Voluntarily

Stopping

Eating &

Drinking

3

163 164

165 166

167 168

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Physiologically

able to take food

& fluid by mouth

Voluntary,

deliberate

decision to stop

Intent

death from

dehydration >80% at 14d

>50% at 8d

Patient

experience

169 170

171 172

173 174

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VSED is not

starvation

Dehydration

is complete

& controlled

VSED

peaceful

1st person

narrativesBooks

175 176

177 178

179 180

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Books

FilmsFilms - Dying Wish

181 182

183 184

185 186

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Phyllis

SchacterTED talks

Not only 1st person narratives

Objective

evidence

187 188

189 190

191 192

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100 Oregon

nurses cared for

VSED patients

Most deaths

“peaceful, with

little suffering”

195

Professional society endorsements

• Other med assn

193 194

195 196

197 198

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Austrian Palliative Society (OPG)

AMDA

PALTC

March 9

202

Clinical guidance

199 200

201 202

203 204

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Legal

status

No statutes

Little caselaw

Cinderalla pic again

BUTNo need for

direct, explicit

authority

205 206

207 208

209 210

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Already legal

under

existing rules

Right to refuse

treatment

Well established

4 decades

VentDialysis

CPRAntibioticsFeed tube

Right to refuse

treatment

VSED Not DIY

211 212

213 214

215 216

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Part of broader treatmentplan

Supervised

by licensed

healthcare

professionals

Recognized as

healthcare by

medical

profession

More position

statements

More clinical

guidelines

PAVSEDPalliated & Assisted

Voluntarily Stopping

Eating and Drinkinghighlights medical role

217 218

219 220

221 222

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Recap Oral N&H =

“treatment”

Right to refuse

treatment

VSED BUT

Oral N&H =

“treatment”

“Basic” care

223 224

225 226

227 228

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That’s

okay

Does not matter

whether food &

fluid is “medical

treatment”

Right to refuse

any intervention

(medical or not)

Right to refuse

unwanted contact

any

Chief Justice

Rehnquist“bodily integrity is

violated . . . by

sticking spoon in your

mouth . . . sticking

a needle in your arm”

229 230

231 232

233 234

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Force feeding is a battery

In sum

You can refuse this

Can you also refuse this?

Can you also refuse this?

Consensus

is “yes”

235 236

237 238

239 240

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BUTLess clear

Advance

VSED

Advance

directive now

for VSED later

Complete AD, today

Direct VSED

in future

241 242

243 244

245 246

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At a point

you specify

Lose capacity

before life

intolerable

Advantage

247 248

249 250

251 252

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Death not

hastened until

point you find

life intolerable

Premature

dying

Avoid

Is a VSED

directive

enforceable?

Generally,

yes

Right to refuse

treatment

VSED

Seemingly

bad

precedent

253 254

255 256

257 258

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44

Margot Bentley

Facility refuses to honor

259 260

261 262

263 264

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Family loses

Probably meant this

Nora Harris

265 266

267 268

269 270

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Family unable

to enforce

VSED directive

BUT Fixable

problems

Be clear on

the “what”

If you mean hand feeding, say “hand feeding”

271 272

273 274

275 276

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“If I am suffering from advanced dementia . . .

I do NOT want

to be fed by hand”

Bigger

problem

Incapacitated

veto

No hand feeding

even if “appear to

cooperate in being

fed by opening

my mouth”

277 278

279 280

281 282

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Ulysses clause

Whose

wishes do

we respect?

Prior self

Current selfor

VSED Ulysses

clauses are

unwelcome

AMDA

PALTC

Vote Mar. 9

Duties to

current self

are primary

283 284

285 286

287 288

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Margot - stage 7 Alzheimer’s

PSU

Cinderalla pic again

Terminal sedation

Continuous deep sedation

Palliative sedation

Controlled sedation

289 290

291 292

293 294

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Total sedation

DegreeMild Deep

Unconscious

DurationTemp PermRespite ContinuousIntermittent

PSU makes

Pt depend

on CANH

Pt usually

refuses

CANH

SufferingIntolerable

Refractory

Last resort only

295 296

297 298

299 300

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51

Legal

status

No statutes

Little caselaw

BUTDouble effect doctrine

Intent = death

Intent = relieve suffering

Means = death

Means = unconscious

301 302

303 304

305 306

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Justice quote

1997 “patient . . . suffering

from a terminal illness

and . . . experiencing

great pain has

no legal barriers . . .

. . . to obtaining

medication . . . to

alleviate that suffering,

even to the point of

causing unconsciousness

and hastening death”

Hargett

v.

Vitas

(Alameda

Sup. Ct. 2014)

1-10 days

Physical suffering

Typically

307 308

309 310

311 312

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Less clear

>10 days

Existential suffering

MAID

VSED

PSU

317

Thaddeus Mason Pope, JD, PhD Director, Health Law InstituteMitchell Hamline School of Law875 Summit Avenue Saint Paul, Minnesota 55105T 651-695-7661C 310-270-3618E Thaddeus.Pope@mitchellhamline.eduW www.thaddeuspope.comB medicalfutility.blogspot.com

Materials discussed

in this presentation

are available at

http://thaddeuspope.com

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Medical Futility Blog Since 2007, I have been blogging, almost daily, to

medicalfutility.blogspot.com. This blog focuses

on reporting and discussing legislative, judicial,

regulatory, medical, and other developments

concerning end-of-life medical treatment

conflicts. The blog has received over 4 million

direct visits. Plus, it is redistributed through

WestlawNext, Bioethics.net, and others.

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VSED

Whether, When and How to Honor Advance VSED Requests for End-Stage Dementia Patients, 19(1) AMERICAN JOURNAL OF BIOETHICS (2019).

Voluntarily Stopping Eating and Drinking Is Legal—and Ethical—for Terminally Ill Patients Looking to Hasten Death, ASCO POST (June 25, 2018).

Voluntarily Stopping Eating and Drinking: Clinical, Psychiatric, Ethical and Legal Aspects, 178 JAMA INTERNAL MEDICINE 123-127 (2018) (with Timothy Quill, Linda Ganzini, Bob Truog).

Voluntarily Stopping Eating and Drinking (VSED) to Hasten Death: May Clinicians Legally Support Patients to VSED? 15 BMC MEDICINE 187 (Oct. 2017).

Voluntarily Stopping Eating and Drinking, 6(2) NARRATIVE INQUIRY IN BIOETHICS 75-126 (2016) (symposium editor).

Prospective Autonomy and Dementia: Ulysses Contracts for VSED, 12(3) JOURNAL OF BIOETHICAL INQUIRY 389-394 (2015).

Legal Briefing: Voluntarily Stopping Eating and Drinking, 25(1) JOURNAL OF CLINICAL ETHICS 68-80 (2014) (with Amanda West).

Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life, 17(2) WIDENER LAW REVIEW 363-428 (2011) (with Lindsey Anderson).

MAIDTHE RIGHT TO DIE: THE LAW OF END-OF-LIFE DECISIONMAKING (3d ed. Wolters Kluwer Law & Business) (with Alan Meisel & Kathy L. Cerminara) (2019).

Medical Aid in Dying in Hawaii: Appropriate Safeguards or Unmanageable Obstacles? HEALTH AFFAIRS BLOG (August 2018) (with Mara Buchbinder).

Legal History of Medical Aid in Dying: Physician Assisted Death in U.S. Courts and Legislatures, 48(2) NEW MEXICO LAW REVIEW 267-301 (2018).

Safeguards, in PHYSICIAN-ASSISTED DEATH: SCANNING THE LANDSCAPE 5-2 to 5-4 (National Academies of Science Engineering & Medicine 2018).

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Medical Aid in Dying: When Legal Safeguards Become Burdensome Obstacles, ASCO POST (Dec. 25, 2017).

Oregon Shows that Assisted Suicide Can Work Sensibly and Fairly, 15(2) FINAL EXIT NETWORK NEWSLETTER 7 (May 2016).

Clinical Criteria for Physician Aid-in-Dying, 19(3) JOURNAL OF PALLIATIVE MEDICINE 259-262 (2016) (with David Orentlicher & Ben Rich).

The Changing Legal Climate for Physician Aid-in-Dying, 311(11) JAMA 1107-08 (2014) (with David Orentlicher and Ben A. Rich).

Oregon Shows that Assisted Suicide Can Work Sensibly and Fairly, NEW YORK TIMES -ROOM FOR DEBATE, Oct. 7, 2014.

Legal Briefing: Medical Futility and Assisted Suicide, 20(3) J. CLINICAL ETHICS 274-86 (2009).

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Thaddeus Mason Pope, JD, PhD Director, Health Law InstituteMitchell Hamline School of Law875 Summit Avenue Saint Paul, Minnesota 55105T 651-695-7661C 310-270-3618E Thaddeus.Pope@mitchellhamline.eduW www.thaddeuspope.comB medicalfutility.blogspot.com

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