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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 5: Physician-Assisted Suicide Debate
    A Six Step Protocol

    Step 1: Clarify the Request Step 2: Determine the Root Causes

    Step 1: Clarify the Request

    Only when the patient’s point of view has been characterized, will it be possible to talk about what suffering means to the patient and what assurances can or cannot be given

    Initiate/Encourage the Discussion

    When a request for hastened death is first received:

    • Listen carefully to the nature of the request
    • Ask open-ended questions in a calm and non-judgmental manner to elicit:
      • Specific information about the type of request that is being made
      • The underlying causes for the request
    • Remember that while some physicians fear that talking about suicide or hastened death will increase the likelihood that the patient will act, this fear has not been substantiated. An open discussion is more likely to reduce the intensity of the request


    Ask Detailed Questions

    • Once the underlying reasons are known, more directed questions can be asked
    • During the course of the questioning, it is particularly important to learn whether the patient is imagining a future that is either unlikely, or easily preventable
    • Several examples, and the common areas to which answers may point, follow:
      • "MD: "What makes you ask that?"
        • desire for a pain-free death
        • control over the dying process
      • MD: "What do you expect will happen without PAS?"
        • understanding and expectations of the illness
        • expectation of what dying will be like
      • MD: "What type of assistance do you want?"
        • pills, injection
      • MD: "Who do you want to be involved? Why?"
        • self, family member, physician
      • MD: "When do you think you want to die?" (provides some indication of acuity)
        • now
        • at some later point
      • MD: "What do you hope to accomplish?" (provides some understanding of the patient’s reasoning and what he or she is hoping for)
        • freedom from pain, disability, bankruptcy, dependency, indignity
        • removing burden on others


    Use Empathic Listening Skills

    • As you listen to the answers, use the therapeutic effect of empathetic listening
    • Avoid endorsing the request for PAS in a way that confirms the patient’s perception that his or her life is worthless
    • Remember that empathizing is not the same thing as agreeing
    • Premature affirmation of any perspective can propel both parties to stark choices


    Be Aware of Personal Biases

    • To respond effectively to the needs of the patient, the physician must be aware of:
      • His or her own biases
      • The potential for countertransference
    • If the idea of suicide is offensive to the physician, the patient may feel his or her approbation and worry about abandonment
    • Be open to the possibility that your personal reactions to the patient’s suffering may give insight into his or her experience
        For Example
        If the physician feels weighed down by meeting with the patient, perhaps the patient is depressed
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