Download Supplementary Appendix Contents Seattle Cancer Care Alliance

Supplementary Appendix
This appendix has been provided by the authors to give readers additional information about their work.
Supplement to: Loggers ET, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM.
Implementing a Death with Dignity Program at a Comprehensive Cancer Center. N Engl J Med
2013;368:1417-24. DOI: 10.1056/NEFMoa1213398.
Contents
Seattle Cancer Care Alliance Death with Dignity Policy
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Seattle Cancer Care Alliance
Administrative Policies and Operating Procedures
Section:
Medical Staff
Policy Title: Death with Dignity
POLICY
The Death with Dignity Act allows competent, terminally ill adults (18 years or older) seeking to end their
life to request lethal doses of medication from medical and osteopathic physicians. These terminally ill
patients must be Washington residents who have less than six months to live. Patients requesting lethal
doses of medication must satisfy all of the requirements of the Act in order to obtain the prescription for
that medication.
The Seattle Cancer Care Alliance (SCCA), acknowledging the legal right of qualified patients to exercise
this choice, assists patients in completing the requirements of the Act so that the patient may selfadminister the medication and end his or her life as the law intends, “in a humane and dignified manner.”
SCCA participation in the Washington State Death with Dignity Act is on a team basis. Minimally, the
team shall consist of a patient advocate, an attending physician, a consulting physician, and a
pharmacist. Additional team members might include, but are not limited to, an ethics consultant, a
palliative care consultant, a social worker, a consulting psychiatrist, a nurse manager, or a spiritual care
representative.
If a health care provider receives a request from an SCCA clinic patient (or inpatient) who wishes
to access the Washington State Death with Dignity Act, that clinician should notify Patient and
Family Services. The Patient and Family Services’ Death with Dignity Patient Advocate will then
contact and deploy the team. Residents, fellows, physician assistants and nurse practitioners should
notify their attending physician, in addition to the Patient and Family Services, about any patient
requests, as they are not authorized under UW Medicine policy to participate as statutory providers
under the Act.
The SCCA does allow faculty physicians and pharmacists who otherwise qualify by statute to participate
in the Washington State Death with Dignity Act, if they so choose, and allows other SCCA
providers/employees to participate in relevant supporting roles. SCCA providers/employees may, as
applicable:
•
•
•
•
•
•
Perform the duties of an attending physician;
Perform the duties of a consulting physician;
Perform the duties of a psychiatric/psychological consultant;
Prescribe medication under this Act;
Fill a prescription under this Act;
Assist in patient or provider support related to this Act.
However, the SCCA does not mandate that any provider or other SCCA employee participate in the
Washington State Death with Dignity Act, nor does it pressure any provider/employee to do so. Only
those providers/employees who are willing and desire to participate should do so. Those
providers/employees who do choose to participate are reminded that the overall goal is to support the
patient’s end-of-life wishes, and that participation may not necessarily result in medication being
prescribed if patient needs can be met in other ways (like hospice or palliative care). Physicians who
initially elect to participate may, at any time, withdraw from the process after making reasonable attempts
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to find another qualified physician to assume their responsibilities to the patient. Patient and Family
Services or the Medical Director’s Office may also facilitate this process.
Under the Act, the attending physician is responsible for ensuring that the correct procedures are
followed and the correct documentation is completed. However, specific requirements will be assigned/
allocated to the identified team members (especially the patient advocate) to facilitate form completion
and verification of requirements under the Act.
If there is any concern regarding the competency of a patient to make an informed decision for the
purposes of this Act, a psychiatry consultation is required. The professional judgment of the consulting
psychiatrist will determine whether the request for lethal medication can proceed, and under what
conditions.
If there is disagreement between the attending physician and the consulting physician regarding the
terminal nature of the disease or the 6 month prognosis, the Medical Director’s Office will facilitate
attempts at resolving the disagreement, using the best available medical evidence to estimate life
expectancy. If reasonable medical uncertainty remains, that uncertainty will be conveyed first and
foremost to the patient. Decisions regarding whether and how to proceed should support the overall goal
of honoring the patient’s end-of-life wishes. It is acknowledged that in doing so, physicians may feel
compelled to withdraw from the process; procedures outlined above would be observed in those cases.
If there is concern regarding the voluntariness of the request by any team member, these concerns
should be shared with Patient and Family Services who will pursue the concerns with the utmost
seriousness. Appropriate responses may include consultation with legal, risk-management or lawenforcement professionals. Lethal medication will not be prescribed at any time in the presence of
concerns on the part of SCCA regarding the voluntary nature of the request.
If there is disagreement between team members regarding whether the patient’s needs can be met in
other ways, these concerns should be discussed first with Patient and Family Services. Secondly, an adhoc meeting of the patient’s team members should be convened to clarify the interventions which might
benefit the patient. Additional professional or expert consultations should be invited to this meeting as
appropriate. Interventions which are not contraindicated or futile as deemed by the specialist in that care
area, and can reasonably be offered to the patient, should be presented as options to the patient in an
organized manner to facilitate both the patient’s ability to understand the options and his or her ability to
pursue these options prior to, or in lieu of, obtaining lethal medications. SCCA and UW Medicine
providers should reassure their patients interested in the Death with Dignity Act that we will provide
ongoing continuity of care, and address their needs to the best of our ability.
The SCCA and UW Medicine do not permit the ingestion of life-ending medication under the Act in its
hospitals, clinics, or elsewhere on its premises.
REFERENCE
Procedures and forms are located under O:\Patient and Family Services\Death with Dignity
Laws/Regulations/Resources:
RCW Chapter 70.245 (Death with Dignity Act)
Washington State Department of Health Regulations WAC Chapter 246-978
Washington State Department of Health Death with Dignity Act Forms (DOH 422-063/CHS 601, DOH 422-064/CHS
602, DOH 422-065/CHS 603, DOH 422-066/CHS 604, DOH 422-067/CHS 605, DOH 422-068/CHS 606)
The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals
Approval
Director:
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F. Marc Stewart
Approval Date:
08/03/2012
(this version)
Process Owner:
Elizabeth Loggers
Moreen Shannon-Dudley
This version reviewed and approved by:
Reviewer
Medical Executive Committee
Clinical Services Team
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Next Review Due:
Revision/Review Dates:
Original Approval Date:
Date Reviewed
08/03/2012
03/04/2009
08/03/2015
08/03/2012,03/04/09
03/04/09