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PHYSICIANS FOR COMPASSIONATE CARE NEWS

Affirming An Ethic That All Human Life is Inherently Valuable

Vol.2, No.2, Summer 1999


Pain Relief Act Protects Doctors--Nurses
Provides Education Funds for End-of-Life Care
Medical Groups Rally in Support

Over a quarter of the US House of Representatives have signed on to co-sponsor “The Pain Relief Promotion Act of 1999.” The bill will make certain that aggressive pain management is considered a legitimate use of controlled substances; for the first time, it includes in the federal Controlled Substances Act(CSA), an explicit statement of support for aggressive pain relief. PCC was invited to consult on the drafting of this important piece of legislation.

The CSA amendment states: “(i) (1) For purposes of this Act and any regulations to implement this Act, alleviation of pain or discomfort in the usual course of professional practice is a legitimate medical purpose of the dispensing, distributing, or administering of a controlled substance that is consistent with public health and safety, even if the use of such a substance may increase the risk of death. Nothing in this section authorizes intentionally dispensing, distributing, or administering a controlled substance for the purpose of causing death or assisting another person in causing death (HR 2260; Title I sec. 101.lines10-16).”

The bill promotes better understanding of palliative care and supports training programs for health professionals to incorporate the best available methods for pain and symptom management into their practices. The Public Health Service Act (42 USC 299 et seq.) is amended by adding to it’s purpose: “(1) Develop and advance scientific understanding of palliative care. (2) Collect and disseminate protocols and evidence-based practices regarding palliative care with priority given to pain management for terminally ill patients and make such information available to public and private health care programs and providers, health professions schools and hospices, and to the general public. (HR 2260 Title II sec. 906 lines5-13).” Furthermore, the amendment gives the Agency for Health Care Policy and Research and the Health Resources and Services Administration an increase of $5 million a year for five years to fund educational grants.

Medical groups from around the country that have joined PCC in endorsing the bill include the American Medical Association, the American Society of Anesthesiologists, the National Hospice Association, the American Academy for Pain Management, Americans for Integrity in Palliative Care, and the National Legal Center for the Medical Dependent and Disabled. The Oregon Hospice Association appears to have separated itself off from it’s national organization and to be out on a limb in it's opposition of the bill. The proposed legislation "goes a long way toward helping doctors and nurses meet the needs of suffering patients,” Doctor Hamilton, President of PCC, told the US House Judiciary Subcommittee on the Constitution. “Individual medical organizations cannot do it alone. A nationwide and federally sponsored educational effort is required,” he said.

In a letter of support to Senator Don Nickles, Dr. Ratcliffe Anderson, Executive Vice President of the American Medical Association said, "Thus, we are very pleased to note that your bill would recognize the ‘double effect’ as a potential consequence of the legitimate and necessary use of controlled substances in pain management, and explicitly include this as a provision of the Controlled Substances Act. This is a vital element in creating a legal environment in which physicians may administer appropriate pain care for patients and we appreciate its inclusion."

“Let this bill not become an end unto itself,” Dr. Walter Hunter, Associated National Medical Director of Vista Care Hospice, said in his testimony before the Subcommittee on the Constitution, “but the beginning of a national commitment to caring for our citizens in the final stages of their lives.” Dr. Hunter finished by saying, “Not one of you must perish at your own hands or at the hands of your physician simply because we failed to understand your physical and mental anguish.”

The Oregonian said in it’s editorial on the Act, “...the proposed legislation comes not a moment too soon. A new report by the Center for Ethics in Health Care at OHSU shows that end-of-life care in Oregon -- which fancies itself a leader in this area -- is far from all it should be.”

Richard Doerflinger, of the National Conference of Catholic Bishops, supported the bill and the seriously ill by telling Subcommittee members, “Terminally ill patients deserve better pain control precisely because they have the same innate worth and dignity as all other human beings and are in special need of our love and support. In our view this bill promotes genuine supportive care for some of our most vulnerable citizens.”

The Pain Relief Promotion Act of 1999 does not overturn Oregon’s assisted suicide law. Instead, it clarifies the legitimate use of controlled substances for pain control in all states, and negates the impact of one state law attempting to bring itself out from under this pre-existing federal standard. Forty-nine states currently follow this standard. “Oregon is not singled out by the Act for disparate treatment. To the contrary, the Act would assure that all states are treated equally by assuring that controlled substances should not be used for killing purposes under federal law regardless of state law on the matter,” according to testimony by Thomas Marzen of the Legal Center for the Medical Dependent.

Oregon doctors who have already assisted suicides will not be prosecuted upon passage of the Act, however. Any expanded surveillance would be discouraged by this bill and thus avoid any adverse effect on legitimate use of controlled substances in palliative care in the United States. The Pain Relief Promotion Act of 1999 protects physicians, nurses and patients.


A GOOD REFERRAL
by N. Gregory Hamilton, MD

Physicians don't need to talk patients out of considering assisted suicide. When the patient's underlying concerns are addressed, inquiries about possibly wanting an early death simply become irrelevant. For example, Jim Patterson, a Portland pulmonologist, told a local newspaper (Oregonian, December 28, 1998) "...that in more than 20 years as a pulmonologist and critical care doctor, the two patients who even hinted at wanting to die early changed their outlook when he promised attentive care." Dr. Patterson's experience is consistent with Hendin's observation in Seduced by Death (1998) that addressing patients' underlying medical concerns, and particularly their fears, dissipates most suicidal ideation among the seriously ill.

Both specialists and primary care physicians have handled such situations with compassion and depth of human understanding over the centuries. Yet, many prefer to refer such patients. Referring patients without their feeling a bit abandoned can sometimes prove a delicate exercise in both tact and timing. The following is a disguised example of a good referral:

This 43-year-old man had been bedridden by an exacerbation of multiple sclerosis. His health care plan denied adequate funding for attendant care and a needed special mattress. He developed extensive, infected decubitus ulcers, which a surgeon needed to debride.

During the procedure, the patient mused aloud about assisted suicide. Despite the fact that he once before had become bedridden and recovered, he had become discouraged about the likelihood of another partial remission.

After the wounds were dressed and the instruments set aside, the surgeon sat down next to his patient for just a few moments. "I'm concerned," he began. Perhaps this simple beginning healed the patient’s spirits as much as anything else -- a plain statement of human concern for the life of this discouraged man.

They briefly discussed his mood, his social isolation, and his feelings of helplessness. Not once did the doctor contradict him. Instead, he empathized with his patient’s feelings. He decided to refer him to a psychiatrist whom he knew would treat suicidal discouragement in the seriously ill the same way she treated it in anyone else.

Before he rose from his stool, he added, "And if you ever feel like you can't take it anymore, you call me up and we will get you in here or get someone out there to see you. We'll do something. Because I value your life and I don't want you to kill yourself."

The patient’s eyes shone brightly through unshed tears. He smiled, as he said simply, "I just may take you up on that sometime, doctor."

Because of the message of hopelessness and despair that the legalization of assisted suicide has brought to the patients of Oregon, it is more important than ever for physicians to let their patients know that they care about them and that they value their lives regardless of the difficulty. A caring referral, when needed, can save the life of and restore the spirits of even the most seriously ill individual. When someone develops a life threatening illness, it is the small things that they find meaningful and which keep them going. A tone of voice, a look, a gesture -- these can make all the difference.


California--Michigan to Join Oregon and Washington PCC

William Toffler, MD, PCC National Director, was delighted to announce that California Physicians for Compassionate Care officially opened its doors late this spring. Lead by Vince Fortanasce, MD, President, California PCC has joined the Oregon and Washington affiliates in an effort to educate medical professionals, legislators, patients and the public about the importance of basing the practice of medicine upon the principle that all human life is inherently and equally valuable.

California PCC got off to a quick start when it was called upon to educate the California legislature about the importance of providing compassionate palliative care to the seriously ill without sanctioning or assisting suicide.

Next on the horizon, is a developing Michigan affiliate.


PCC Opposes California Assisted Suicide Bill

Dr. Miles Edward, a PCC board member from Portland, Oregon, joined Dr. Vince Fortanasce of the newly formed affiliate, California Physicians for Compassionate Care, in opposing the latest attempt to pass California assisted suicide legislation, modeled after Oregon’s law. During his trip to Sacramento, Dr. Edwards told those gathered at news a conference, “The economic reality is that to pay for assisted suicide is much cheaper (a total of $35) than paying for continued comfort care for the patient, however long that patient lives,” he said. “This applies to whoever pays, whether it be an insurance company, an HMO, the State of Oregon, or the patient and /or patient’s family. Especially vulnerable in this context are the poor and disabled members of our society...with these realities in mind, I strongly oppose the legalization of physician-assisted suicide in California, hopefully not to repeat the tragic mistake made by voters in my own state of Oregon.”

Dr. Fortanasce, in his testimony, also emphasized the dangers of economic pressures on the poor to commit suicide. PCC and California PCC were joined by the California Medical Association, California Nurses Association, the International Anti-Euthanasia Task Force, Western Service Workers Association ( low income and disabled workers), Catholic Hospitals, and Coalition of Concerned Medical Professionals in opposing the draft legislation. Groups representing minorities and the poor decried the bill as discriminatory and threatening to the poor.

Subcommittee hearings were marked by tortuous manipulations, reportedly including replacement of three committee members with those favoring assisted suicide and claiming a vote would not be held, clearing the halls, then holding a vote. Nevertheless, opponents of the legislation succeeded in stalling the bill, which is now tabled. Proponents of assisted suicide, however, succeeded in transforming it to a long-term bill, which gives them the ability to bring it out again. Meanwhile, California PCC remains alert.


Recent Publications

Edwards, M.J. and Connor, W.E. (1999). “Legalized Physician-Assisted Suicide in Oregon.” New England Journal of Medicine 341:212.

Hamilton, N.G. (1999). “Down the Slippery Slope.” Brainstorm (May).


Third Annual Compassionate Care Conference
Saturday, October 2, 1999
Oregon Convention Center

The goal of this conference, co-sponsored by PCC and Providence Health Systems, is to improve the knowledge and skill of physicians in managing pain and giving comfort care to seriously ill patients.

The main objectives of this program are:
to understand the principles of narcotic analgesia
to understand the principles of adjuvant analgesia
to understand challenges facing patients and providers when dealing with life-threatening illness
to understand the medical care provider’s needs when caring for dying patients
to understand the role of hospice in the care of dying patients

A few of the scheduled lectures are:

“The ‘Real’ Ethics of End of Life Care”
Ira Byock, MD

“Advanced Pain Management I: Optimizing Opioid Analgesics”
Mark Kallgren, MD

“Advanced Pain Management II: When Opioid Analgesics Fail”
Marshall Bedder, MD

“Beyond Symptom Management: Human Development at the End of Life”
Ira Byock, MD

and much more...

For more information contact:
Ruth Parker
216-6587


PCC Officers
N. Gregory Hamilton, MD
President
William M. Petty, MD
Vice President
Mark Kummer, MD
Treasurer
Miles J. Edwards, MD
Secretary
William L. Toffler, MD
National Director

Board Members
Pamela J. Edwards, MD
Thomas Pitre, MD
Kenneth R. Stevens, MD
Paul D. Stull, MD

Regional Directors
Gerald B. Ahmann, MD
Medford
Thomas Comerford, MD
Bend
Carl R. Jenson, MD
Coos Bay
Marvin M. John, MD
Hermiston
Robert DuPriest, MD
Eugene
Richard M. Thorne, MD
Salem
George Middlekauf, MD
Roseburg

PCC ADDRESS:

P.O. Box 6042
Portland, Oregon 97228
503-533-8154 Phone
503-533-0429 Fax
www.pccef.org
PCC News Editor: Catherine Hamilton


© Copyright 1999
Physicians for Compassionate Care Educational Foundation