2. “Physician-assisted Suicide (PAS), n. – orig. U.S. suicide carried
out with the assistance of a physician (whose role is typically to
provide a lethal dose of a drug at the explicit, voluntary request
of a mentally competent patient considered to be incurable)”
(Oxford University Press, 2013)

3. • An Aging Population
• Legislation allowing for patients to choose end-of-life
care preferences has helped lead to this discussion
• PAS is Tied to Other Healthcare Debates
– Desire for more Autonomy
– High End-of-life Care Costs
– Difficulty Obtaining Insurance Coverage for the Terminally
Ill
• Patient Concerns Include
– Desire to Reduce Pain & Suffering
– Desire to Die with Dignity
– History of Inadequate Pain Control

4. (United States Census Bureau, 2010)

5. • Physician Prescribes or Provides
the Means
• Patient Administers Lethal
Medication
• Legal in 3 U.S. States
• Request Process & Wait Period
• Physician Administers Lethal
Medication
• Active or Passive
• Currently Not Legal in the U.S.
• No Determined Process

6. 5th
Century B.C. to 1st
Century B.C. – Ancient Greeks and Romans often complied with
voluntary death requests while still abiding by the Hippocratic Oath
1984 - Advance care directives begin to be recognized
1984 - The Netherlands Supreme Court approves voluntary euthanasia and physician-
assisted suicide under strict conditions.
1984 - American Medical Association adopts the formal position that with informed
consent, a physician can withhold or withdraw treatment from a patient who is close
to death, and may also discontinue life support of a patient in a permanent coma.
June 4, 1990 - Dr. Jack Kevorkian assists in the death of Janet Adkins, a middle-aged
woman with Alzheimer’s disease. Kevorkian subsequently flaunts the Michigan
legislature’s attempts to stop him from assisting in additional suicides.
(ProCon.org, 2012)

7. 1990 - Congress passes the Patient Self-Determination Act, requiring hospitals that
receive federal funds to tell patients that they have a right to demand or refuse
treatment. It takes effect the next year.
1997 - Oregon Death With Dignity Act Passed- becoming the first law in American
history permitting physician assisted suicide.
1998 - Dr. Kevorkian shares a video on national television of him administering a lethal
injection to Thomas Youk, a man suffering from Lou Gehrig’s disease. He was
convicted for the murder of Youk and is sentenced to 10-25 years in prison.
2008 - Luxembourg legalizes physician assisted suicide and euthanasia.
2008 - Washington becomes the second state to legalize physician-assisted suicide.
2012 - Massachusetts voters rejected the Death with Dignity ballot by less than
60,000 votes.
(ProCon.org, 2012)

8. Year Case / Law Description
1976 In re Quinlan Right to remove person in a vegetative state from
ventilator
1990 Cruzan v. Director
Missouri Department of
Health
Right for states to grant families the right to remove
feeding tubes from a person in a vegetative state
1990 Patient Self-
Determination Act
Health care facilities must provide information to
patients about advance directives
1997 Oregon Death with Dignity
Act
Allows terminally ill Oregon residents to obtain and
use prescriptions from their physicians for self-
administered, lethal medications
2008 Washington Death with
Dignity Act
Allows terminally ill Washington residents to obtain
and use prescriptions from their physicians for self-
administered, lethal medications
(Guido, 2009)

9. • Dr. Jack Kevorkian (1928-2011)
– Nicknamed “Dr. Death”
– Pathologist in Pontiac, MI
• 1980s: Developed PAS Machine
• 1990: Janet Adkins
– Alzheimer's Patient granted
PAS
– Charges Dropped
• 1998: Thomas Youk
– Lou Gehrig’s Patient
– Administered by Kevorkian &
Aired on “60 minutes”
– Found Guilty of murder
• 10-25yr sentence
• Served 8 yrs.
(Hosseini, 2012)

10. • Believed Pt.’s Right to Avoid Prolonged & Painful Death
– Should Die with Dignity
– Wanted to be charged and arrested to bring about a
national debate
• Poll on Kevorkian’s Punishment (Hosseini, 2012)
– 39% Felt he should not be punished
– 27% Felt he should be charged with a lesser crime
– 19% Felt the charges were appropriate
• Brief Videos On Dr. Kevorkian
– Information on Dr. Kevorkian
– 60 Minutes Tape of Thomas Youk (Graphic)
(Hosseini, 2012)

11. • Opposed by the U.S. Supreme Court
• Legal in only 3 States
• Legal in 4 other Countries
– Belgium
– Luxembourg
– Netherlands
– Switzerland
(ProCon.org, 2012)

12. Montana*
Oregon - 1994
Washington - 2008
Nevada
Utah
Wyoming
(ProCon.org, 2012)

13. • 1997 in Oregon
• First Person Received legal PAS in 1998
– Mid-80s with Metastatic Breast Cancer to the Lungs
• Requirements
– ≥ 18 yrs.
– Resident of Oregon
– Legally/medically competent
– Terminal illness with ≤ 6 mos. to live
– Two oral requests & one written (two witnesses)
– Confirmed diagnosis by two physicians
• Annual Report 2012
– PAS only accounted for 23.5 deaths per 10,000 total deaths
– 673 patients have died under the DWDA
(Hendin, Foley, & White, 1998)
(Oregon Public Health Division, 2012)

14. (Oregon Public Health Division, 2012)

15. • Death with Dignity National
Center in Oregon
• Exit International (Australia)
• Euthanasia Research &
Guidance Organization
(ERGO)
• World Federation of Right
to Die Societies
• Final Exit Network
• American Nurses
Association (ANA)
• American Medical
Association (AMA)
• Care Not Killing
• Not Dead Yet
• Roman Catholic Church
• United States Conference of
Catholic Bishops

16. • Most Common Reasons Loss
of Autonomy
– Decreased Ability
– Loss of Dignity
– Fear of Adequate Pain Control
• Other Reasons
– Right to end life on own terms
– Prolonging the unavoidable
– Less medical bills
– Don’t want to be a burden to
family
• “Slippery Slope” belief that
PAS will move onto disabled
and more vulnerable
populations
• Perceived as murder
• Against Religion
• Reductions in medical
coverage for elderly &
terminally ill as a result of
legalizing PAS
• Forced PAS in the future
(Guido, 2009: Hosseini, 2012; ProCon.org,
2012)

17. (Lachman, 2010)

18. • By 2020, 2.5 Million Aged ≥ 65 yr. will die each
year
• In 2008 Medicare Spent $55 billion on End-of-
life care during the last two months of
patients’ lives.
– Estimated that 20-30% of these expenses had very
little health impact.
– 18-20% of patients spend their final days in an ICU
which can be painful & expensive
(CBS News, 2009)

19. • Available Options Include
– Withdrawal of Treatment
• Removing Ventilator & Feeding Tube
• Chemo & Medications
– Advance Directives
• Living Will
• DNR
• Power of Attorney
– Hospice Care
– Palliative/Terminal Sedation
– PAS (Only where it is legal)

20. • “Presents a Moral/Ethical Dilemma” Cases can be made for both sides using the
following ethical principles
• Autonomy
– Patient’s right to choose
– Should there be limits to a patient’s autonomy?
• Beneficence/Non-Maleficence
– Do No Harm
– Minimize Suffering & Pain
– Are we doing this?
• Justice
– Fair & Equal Treatment
– Are we being fair by prolonging the inevitable for terminally ill patients?
(Hosseini, 2012)

21. • Deontological vs. Utilitarian
– Deontological
• Black & White
• Either always wrong or always right
• PAS would be considered always wrong
– Utilitarian
• Consequences weighed for the individual and society
• Focused on providing happiness
• PAS may be considered right for only some
• Doctrine of Double Effect
- Principle argued frequently in End-of-life care debates for PAS
- Explains that a harmful action is permissible if it promotes a good side
effect
- Ex. Killing a human being to bring about a good end
(Webb, 2013; McIntyre, 2004)

22. • Classical Oath
• “I will neither give a deadly drug to anybody who asked for it, nor will I
make a suggestion to this effect. Similarly I will not give to a woman
an abortive remedy. In purity and holiness I will guard my life and my
art. I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work.”
• Modern Oath
– “Most especially must I tread with care in matters of life and death. If
it is given me to save a life, all thanks. But it may also be within my
power to take a life; this awesome responsibility must be faced with
great humbleness and awareness of my own frailty. Above all, I must
not play at God.”
(Tyson, 2001)

23. • Sedation prior to death from
actual illness
• Used when other treatments
cannot relieve pain & suffering
• Nutrition supplementation is
typically withdrawn
• Often the last resort in most
states
• Shown to be 71-92% Effective
based on family perceptions of
patient’s relief
• 3 Types for End-of-life
• Medical Power of Attorney
– Patient designates person to make
end-of-life decisions
– Anyone can have this
• Out-of-hospital DNR Order
– Refusal of life-sustaining treatments
by first responders
– Copy carried at all times
• Directive for Physicians and Family
– Specifications on withholding or
withdrawing all or certain life-
sustaining procedures
– Certified by a physician
(Olsen, Swetz, & Mueller, 2010) (Texas Hospital Association, n.d.)

24. Care recipients under age 65 yrs. Were less likely to have any AD than
those aged 85 and over

25. • New health care revisions
• Clear definitions of PAS and
requirements
– Process of application
– Location of lethal drug
administration
– Diagnosis Inclusion Criteria
• Laws that make it legal.
•
• More emphasis on pain
control & consideration for the
patient’s perception of their
own dignity
• More individuals with living
wills, medical advocates, and
other documents prior to
falling ill.
• Greater awareness towards
which procedures are effective
and which simply prolong
suffering & pain.

26. We believe that legalizing PAS, after a more
adequate definition of requirements and
diagnosis criteria has been formulated, can
greatly prevent prolonged pain, suffering, and
loss of dignity experienced by some terminally ill
patients.

27. Which Statement is not true about the Death with
Dignity Act of Oregon?
A. You must be a resident of Oregon
B. You must have a terminal illness with less than
a year to live
C. You must be legally/medically competent
D. Two physicians must have confirmed your
diagnosis

28. Which is not one of the legal alternatives to Physician
Assisted Suicide?
A. Euthanasia
B. Withdrawal of Treatment
C. Terminal Sedation
D. Advanced Directives

29. True or False: Surgery, Abortion, and Physician Assisted
Suicide / Euthanasia are referred to in the Original
Hippocratic Oath. In taking this oath, healthcare
professionals swore to not perform these practices.
The Hippocratic Oath has since been revised and no
longer mentions the three of these things.

30. True or False: Oregon is the only state in the United
States where PAS is legal.

31. True or False: In PAS, a physician actively administers
the lethal medication to end the patient’s life.

32. American Medical Association. (n.d.). American College of Physicians - Care of patients near the end of life. Retrieved from http://www.ama-assn.org/ama/
pub/physician-resources/medical-ethics/ about-ethics-group/ethics-resource-center/educational-resources/ federation-repository-ethics-
documents-online/american-college-physicians/ acp-end-of-life-care.page#organ
CBS News. (2009, November 22). The cost of dying. Retrieved from http://www.cbsnews.com/ 8301-18560_162-5711689.html
Guido, G. W. (2009). Legal & ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Pearson.
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McIntyre, A. (2004). Doctrine of double effect. Retrieved from Stanford Encyclopedia of Philosphy website: http://plato.stanford.edu/entries/double-effect/
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main/art.asp?articlekey=32841
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sustaining treatments. Mayo Clinic Proceedings, 85(10), 949-954. http://dx.doi.org/10.4065/mcp.2010.0201

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ProviderPartnerResources/Evaluationresearch/deathwithdignityact/ Pages/index.aspx
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resourceID=000130
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