Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online at http://clinicalcenter.nih.gov I WANT TO WELCOME YOU TO OUR FIRST ETHICS GRAND ROUNDS OF THE ACADEMIC YEAR. I'M DAVE WENDLER FROM THE NIH BIOETHICS CLINICAL CENTER, AT LEAST FOR THIS SESSION AND THE DECEMBER SESSION, WE WILL CONTINUE TO DO THOSE VIRTUALLY AND HOPEFULLY MAYBE IN THE SPRING WE CAN GET BACK TO IN-PERSON IN THE LIPSETT AUDITORIUM. SO A REMINDER THESE ARE SPONSORED BY THE DEPARTMENT OF BIOETHICS AT THE NIH CLINICAL CENTER AND WE DO THEM 4 TIMES A YEAR AND FOR NEW COMERS THE WAY THIS WORK SYSTEM WE PRESENT AN ETHICAL ISSUE THAT CAME TOEUR DEPARTMENT AND WE HAVE 1 OF THE INVOLVED CLINICIANS PRESENT THE BACKGROUND AND THE ETHICAL ISSUES AND THEN WE INVITED AN OUTSIDE EXPERT TO GIVE US THEIR VIEW ON HOW WE SHOULD THINK ABOUT AND HOW WE SHOULD ADDRESS THOSE ISSUES. SO FOR PEOPLE WHO PLAN AHEAD,--WE HAVE 3 MORE IN THIS ACADEMIC YEAR, THOSE ARE THE FIRST WEDNESDAYS IN DECEMBER, FEBRUARY AND APRIL. SO FIRST WEDNESDAYS, IN DECEMBER, FEBRUARY, AND APRIL. SO THE TOPIC FOR TODAY, IS THE ETHICS OF TEACHING MEDICAL AID-IN-DYING TO TRAINEES, MEDICAL AID-IN-DYING IS ALSO SOMETIMES KNOWN AS PHYSICIAN-ASSISTED SUICIDE, SO WHATEVER TERM YOU USE FOR IT, OBVIOUSLY MEDICAL AID-IN-DYING OR PHYSICIAN-ASSISTED SUICIDE IS VERY CONTROVERSIAL. A LOT OF DISCUSSION ABOUT THE ETHICS OF IT AND THE APPROPRIATENESS OF IT AND THOSE ISSUES WILL BE RELEVANT TO TODAY'S SESSION BUT I WANT TO EMPHASIZE THIS IS NOT SPECIFICALLY A SESSION ABOUT THE ETHICS FOR MEDICAL AID-IN-DYING, IT'S A SESSION ABOUT THE ETHICS OF TEACHING TRAINEES ABOUT MEDICAL AID-IN-DYING. AND THE REASON WHY THAT IS I THINK AN IMPORTANT AND INDEPENDENT ISSUE IS IN THE UNITED STATES AS WE HEAR MORE IN A MINUTE, MEDICAL AID-IN-DYING IS LEGAL IN SOME JURISDICTIONS, IT'S ILLEGAL IN MANY OTHERS SO FOR INSTANCE IT'S LEGAL IN WASHINGTON D. C. NOW AND IT'S ILLEGAL IN A LOT OF STATES. IT'S ALSO A FEDERAL STATUTE WHICH PROHIBITS THE USE OF FEDERAL FUNDS AND FEDERAL FACILITIES LIKE THE IN, IH CLINICAL CENTER FOR MEDICAL AID-IN-DYING. NOW IF PEOPLE JUST TRAIN INDIVIDUALS FOR THEIR OWN JURISDICTIONS THIS MIGHT BE STRAIGHT FORWARD, YOU COULD JUST FOLLOW THE GUIDELINES INVOLVED WITH YOUR JURISDICTION BUT OBVIOUSLY THAT'S NOT THE WAY TRAINING WORKSS, WE TRAIN FELLOWS, WE TRAIN THEM TO GO TO OTHER PLACES IN THE COUNTRY AND SO THE QUESTION IS WHETHER TO HOW AND WHAT EXTENT WE SHOULD BE TRAINING TRAINEES WITH RESPECT TO MEDICAL AID-IN-DYING. AND I THINK 2 OTHER ISSUES WE WILL GET TO IS HOW SHOULD WE DO THAT TRAINING AND THEN IF WE DO IT SHOULD IT BE VOLUNTARY OR MANDATORIA TORSKPE BAKUGAN THAT'S A QUESTION WE COULD ASK BOTH FOR THE TRAINEES, SHOULD BE VOLUNTARY MANDATORY FOR THEM AND ALSO FOR TRAINERS BE REQUIRED TO DO IT OR SHOULD THAT BE VOLUNTARY ON THEIR PART AS L. SO JUST TO REMIND EVERYBODY AS WITH ALL ETHICS GRAND ROUNDS, THERE'S GOING TO BE A NUMBER OF PEOPLE SPEAKING TODAY, BUT UNLESS THEY TELL YOU EXPLICITLY OTHERWISE, THEY ARE SPEAKING ONLY FOR THEMSELVES. THEY'RE NOT SPEAKING FOR THE GROUPS OR THE INSTITUTIONS TO WHICH THEY BELONG SO AS LONG AS OUR PEOPLE KNOW CME CREDIT IS AVAILABLE FOR THESE SESSIONS THROUGH JOHNS HOPKINS AND TO CLAIM THAT CREDIT, YOU HAVE TO TEXT THE ACTIVITY CODE WHICH I WILL GIVE YOU IN ABOUT 15-SECONDS, AND YOU HAVE TO TEXT THAT TO THE PHONE NUMBER WHICH WILL APPEAR ON THESE SLIDES, THAT'S THE HOPKINS NUMBER FOR CME CREDIT AND THAT ACTIVITY CODE IS 36690. AGAIN THE ACTIVITY CODE FOR CME CREDIT IS 36690. AND YOU WILL TEXT THAT TO THE HOPKINS NUMBER WHICH WILL COME UP ON THE SLIDES IN A MINUTE. THERE'S ALSO AN EVALUATION FORM IN THE FORM OF A PDF ON THE CLINICAL GRAND ROUNDS WEBSITE, ANYBODY WHO HAS COMMENTS, SUGGESTIONS ON GRAND ROUNDS IN GENERAL OR--PLEASE LET ME KNOW AND YOU CAN E-MAIL ME DIRECTLY DAVE WENDLER AND MY E-MAIL IS ON THE NIH GROABAL AND I WOULD LOVE TO HEAR SUGGESTIONS FOR FUTURE SESSIONS. IN ORDER TO ASK QUESTIONS THEY SHOULD GET E-MAILED TO DO ME, AND THE WAY TO DO THAT IS TO LOCATE THE FEEDBACK BUTTON ON THE VIDEOCAST WEBSITE, SHOULD BE AT THE BOTTOM OF THE PAGE, YOU CLICK ON THAT AND THEN YOU ENTER YOUR COMMENT AND THOSE WILL GET SENT TO ME, SO AGAIN IT'S THE LIVE FEEDBACK BUTTON ON THE NIH VIDEOCAST WEBSITE. SO WE HAVE 3 PEOPLE INVOLVED TODAY, SO WHAT I WILL DO JUST TO SAVE A BIT OF TIME IS I WILL BRIEFLY INTRODUCE ALL 3 NOW AND THEN THEY WILL GO IN THE ORDER THAT I INTERROUGH ATOM DUCED THEM. SO PRESENTING THIS CASE TO GET US STARTED IS ANN BERGER, SHE IS WELL KNOWN AT THE NIH AND THE CLINICAL CENTER AND SHE IS KNOWN AS THE CHIEF OF PAIN AND PALLIATIVE CARE CENTER AND SHE WILL GET US GOING AND PRESENT THE ISSUE, AND THEN THE DISCUSS ANT WHO WILL LEAD US THROUGH THE ETHICAL ISSUES IN QUESTION IS DR. KATLIN ROTH TRAINED AS A PHYSICIAN AND A LAWYER, AND HER CURRENT POSITION IS DIRECTOR AND ALSO DIRECTOR OF DIVISION OF GERIATRICS AND PALRATIVE MEDICINE AT GEORGE WASHINGTON UNIVERSITY AND THEN AFTER DR. ROTH GIVES HER COMMENTS, THEN MIMISMAZE MAHON HO IS A DOCTOR AT THE PAIN AND PALLIATIVE CARE CENTER, WILL GO FROM THERE SO ANN? >> SO SUICIDE OR MEDICAL AID-IN-DYING ALLOWS SOMEONE WITH A TERMINAL ILLNESS TO TAKE THEIR OWN LIFE WITH ASSISTANCE. USUALLY BY A PHYSICIAN. STATES WITH THESE LAWS MAKE IT LEGAL AND THAT'S NOT JUST A FEW STATES, FOR ADULTS WITH TERMINAL ILLNESS TO RECEIVE A PRESCRIPTION MEDICINE TO ASSIST IN THEIR DEATH. SOME CONDITIONS MUST BE MET. PATIENT MUST BE MENTALLY COMPETENT, MUST HAVE BEEN GIVEN 6 MONTHS OR LESS TO LIVE BECAUSE OF A TERMINAL ILLNESS, 2 PHYSICIANS MUST CONFIRM THE PATIENT'S RESIDENCY, DIAGNOSIS, PROGNOSIS, MENTAL COMPETENCE AND THE VOLUNTARINESS OF THE REQUEST AND THEN THERE ARE 2 REQUIRED WAITING PERIODS 1 BETWEEN THE ORAL REQUEST AND THE SECOND BETWEEN RECEIVING AND FULFILLING THE PRESCRIPTION. ASSISTED SUICIDE IS TOTALLY CONTROVERSIAL BECAUSE IT RAISES QUESTIONS SURROUNDING BOTH THE ETHICS AND RELIGIOUS BELIEFS FOR MANY PEOPLE, PEOPLE WHO BELIEVE THAT SUICIDE IS A SIN WITH THEIR RELIGION FOR EXAMPLE, MAY BE AGAINST ASSISTED SUICIDE BECAUSE OF RELIGIOUS BELIEFS. SUPPORTEDRELIGIONS IT'S OKAY TO DECIDE FOR THEMSELVES AND NOT THE INSTITUTIONS OR THE STATE. IN THE UNITED STATES, THE SURVEYS PREMARKET AUTHORIZATION COURT RULE THAD STATES MAY MAKE THEIR OWN CHOICES REGARDING LEGALIZED AND ASSISTED SUICIDE, THE FIRST STATE TO ALLOW THIS ASSISTED SUICIDE WAS ARGON IN 1994 AND IT'S NOW LEGAL IN OREGON, WASHINGTON STATE, CALIFORNIA, JERSEY, D. C., VERMONT, COLORADO, HAWAII AND NEW MEXICO. MEDICAL AID-IN-DYING REMAINS ILLEGAL IN MOST STATES INCLUDING MARYLAND. EVEN THOUGH IT IS ONLY LEGAL IN A FEW STATES, MEDIA HAS PORTRAYED EXAMPLES OF ASSISTED SUICIDE. SO ON TV SHOWS SUCH AS GOLDEN GIRLS, CHICAGO MED AND THEY DID A SHOW ABOUT VERY ORTHODOX JEWISH PEOPLE WE SEE EXAMPLES OF ASSISTED SUICIDE. IN THESE SHOWS IT IS ALWAYS SEEN AS A RIGHT OF THE PERSON TO CHOOSE WHEN TO DIE AND IT IS PRESCRIBED AS DYING WITH DIGNITY. REASON LENIENT, 2 OF MY MOM'S--RECENTLY 2 OF MY MOM'S FRIEND BOTH IN STATES WITH NO MEDICAL AID-IN-DYING, BOTH ON HOSPICE, WANT TO SUPPORT OR COMPASSIONATE DYING CHOSE TO STOP EATING AND TOOK PAIN MEDS FOR PAIN, CLEARLY SOME OF THE PAIN WAS SURGICAL PAIN AND THEY DIED. HOSPICE AND PALLIATIVE CARE IS BOARD SPECIALTY THAT DEALS WITH SPIRITUAL, PSYCHOSOCIAL DIMENSIONS OF THEM AND THEIR FAMILIES. THE PATIENTS ARE THOSE WITH CHRONIC AND/OR LIFE-LIMITING DISEASE. THE TOPIC OF AID IN DYING IS VERY CONTROVERSIAL. AS CHIEF OF PAIN AND PALLIATIVE CARE, THE QUESTION NEEDS TO BE ASKED, WHAT IS THEIR OBLIGATION AND HOW AND WHAT DO WE TEACH OUR FELLOWS ABOUT THE PHYSICIAN AID IN DYING. AND I CAN SAY THAT AT LEAST 1 OF OUR FELLOWS LAB--BEING PART OF THE PHYSICIAN AID IN DYING PROCESS. AND WE, AT THAT POINT, THAT WAS A FEW YEARS AGO DID NOT HAVE ANY LECTURES ON IT AND HAD NO TEACHING ON IT. KATLIN, I THINK YOU DID NEXT. >> ANN, THANK YOU FOR THE WONDERFUL INTRODUCTION AND WE HAVE A FELLOWSHIP PROGRAM AT GW IN PALLIATIVE MEDICINE AS WELL AND I WORK WITH OUR ALS CLINICS, SO I UNDERSTAND--OOH, I'M HAVING--LET'S SEE. SHARE SCREEN ... HAVING TECHNICAL DIFFICULTIES, THIS WORKED A MINUTE AGO. AND I AM NOT SEEING MY SLIDES, SHARE, OKAY, HERE WE ARE. SORRY, THANK YOU. SO I THINK THAT--I WILL TALK A LITTLE BIT ABOUT THE OVERVIEW OF THE MEDICAL AID-IN-DYING AND THEN WITH TRYING TO KEEP A FOCUS ON WHAT OUR OBLIGATION IS FOR TRAINEES. >> DR. ROTH, REALLY QUICKLY, CAN YOU PUT IT IN FULL SCREEN MODE FOR US PLEASE? >> YES, CERTAINLY, SO SORRY. HOW'S THAT? >> EXCELLENT. THANK YOU VERY MUCH. >> SO THIS IS A PICTURE FROM THE WASHINGTON POST, THE ARTICLE CITED AT THE END OF, IN MY PRESENTATION, IN THE REFERENCES, BUT THIS IS A PICTURE OF A WOMAN NAMED MARY DAWSON KLEIN WHO WAS THE FIRST PERSON TO USE MEDICAL AID-IN-DYING IN THE DISTRICT OF COLUMBIA, SHE WAS MY PATIENT, I WAS PRIVILEGED TO TAKE CARE OF HER, BE INVOLVED IN HER END OF LIFE CARE. SHE KNEW SHE WAS SUFFERING FROM OVARIAN CANCER. SHE KNEW WHAT SHE WAS FACING AND WAS A SUPPORTER OF MEDICAL AID-IN-DYING AND 1 OF THE MOST OUTSPOKEN ADVOCATES IN THE PROCESS OF THE D. C. DEATH WITH DIGNITY LAW BEING PASSED AND IT'S A VERY INTERESTING ARTICLE AND IT WAS AN AMAZING EXPERIENCE FOR ME TO WORK WITH SOMEONE WHO WAS SO KNOWLEDGEABLE ABOUT THIS. SO WE DON'T GET ALL MIXED UP IN TERMINOLOGY, PHYSICIAN AID IN DYING, MEDICAL AID-IN-DYING, WHICH IS NOW PREFERRED BECAUSE THERE ARE STATES IN WHICH P As AND APs MAY BE INVOLVED IN THE PROCESS OR PHYSICIAN-ASSISTED SUICIDE WHICH IS AN OLDER TERM. BASICALLY IS A FORM OF VOLUNTARY IEWGHT AN ASKRA, IN YEEGHT EUTHANASIA MEANS MEANS GOOD DEATH, AND INVOLUNTARY EUTHANASIA IS NOT LEGAL ANYWHERE IN THE UNITED STATES OR CANADA. SO BY SAYING INGEST MEDICATION RIGHT NOW, THERE IS SOME CONTROVERSY ABOUT PEG TUBES OR OTHER ROUTES OF ADMINISTRATION BUT IN THE U.S., A PERSON REALLY NEEDS TO BE ABLE TO TAKE THAT MEDICATION ORALLY WHICH DEFINITELY RAISES AN ISSUE FOR PEOPLE WHO HAVE SWALLOWING PROBLEMS LIKE ALS, BUT I WILL COME BACK TO THAT LATER. SO THESE ARE MY OBJECTIVES AND I HOPE THAT I CAN ALSO MENTION A LITTLE BIT ABOUT VOLUNTARILY STOPPING, EATING AND DRINKING WHICH ANN BROUGHT UP AT THE END AND I HAVE NO FINANCIAL INTERESTS OR DISCLOSURES IN THIS. SO THE PROHIBITION AGAINST MEDICAL AID-IN-DYING IS IN THE HIPPOCRATIC OATH. IT SAYS THAT EVEN IN THE CASE OF EXTREME PAIN, THE PHYSICIAN WILL NOT TERMINATE LIFE EARLIER, EVEN TO ALLEVIATE SUFFERING. THE REASON IT CAME UP IN THE HIPPOCRATIC CORPUS FOR THOIZ WHO ARE INTERESTED IN THE HIPPOCRATIC HISTORY IS THAT THERE WERE OTHER SCHOOLS OF THOUGHT AT THE TIME OF SOCAATHESTHAT WAS SUPPORTING PHYSICIAN-ASSISTED SUICIDE, BUT IT WAS CONTROVERSIAL YEARS AGO AND IT REMAINS CONTROVERSIAL, BUT IT IS THE CHRISTIAN TRADITION THAT OPPOSES SUICIDE SO MEDICAL AID-IN-DYING IS VIEWED AS A FORM OF SUICIDE. OVER THE COURSE OF HISTORY WE'VE HAD MANY, MANY EXAMPLES OF INDIVIDUALS CHOOSING TO END THEIR LIFE WHEN THEY WERE SUFFERING SEVERE ILLNESS, FREUD'S PHYSICIAN IS NOTABLE FOR PROMISING SIGMUND FREUD WHO WILL HELP HIM AT THE END WHEN HE WAS SUFFERING FROM VERY PAINFUL ORAL CANCER. THERE'S A LOT OF ARGUMENT ABOUT WHETHER THE TERM SUICIDE SHOULD BE USED AT ALL, WHEN LIFE HAS BECOME UNENDURABLE AND IS CLEARLY NEARING ITS END AND AS PHYSICIANS WE'RE PRETTY GOOD AT PROGNOSIS AT LEAST AT THE VERY END OF LIFE. SO 11 JURISDICTIONS IN THE U.S. NOW SUPPORTED MEDICAL AID-IN-DYING AS AN END OF LIFE OPTION SO ALTHOUGH IT'S THE MINORITY ACTUALLY ONE-THIRD OF THE U.S. POPULATION GIVEN THE HUGE POPULATION IN CALIFORNIA NOW ACTUALLY HAVE ACCESS TO MEDICAL AID-IN-DYING AND IT'S CLOSE TO PASSAGE IN A NUMBER OF OTHER STATES, IT MISSED--IT'S COME UP IN THE MARYLAND LEGISLATURE SEVERAL TIMES AND IS ONLY MISSED BY 1 OR 2 VOTES. SO AS A GENERAL PUBLIC IT'S IMPORTANT TO NOTE THAT SUPPORTS MEDICAL AID-IN-DYING IS AN OPTION BY ABOUT 75%. AS USUAL, THE POPULATION IS A LITTLE BIT MORE OPEN THAN THE MEDICAL PROFESSION AND AS DR. BERGER SAID, THE REQUIREMENTS ARE THAT THE PATIENT IS ALREADY VERY CLOSE TO END OF LIFE, THEY MUST HAVE A PROGNOSIS OF LESS THAN 6 MONTHS, THEY MUST BE ABLE TO MAKE THEIR REQUEST AND BE TO BE ABLE TO REPEAT THAT REQUEST WITH A 2 WEEK WAITING PERIOD IN MOST STATES, ALTHOUGH THAT'S BEING CHALLENGED AS WELL, AND THEN THERE'S A 24-48 HOUR WAITING PERIOD IN MOST JURISDICTIONS BEFORE THE PRESCRIPTION CAN BE AFTER THE PATIENT MAKES THEIR SECOND REQUEST. THE DEATH ITSELF, INGESTION OF THE MEDICINE AND THE DEATH ITSELF CANNOT BE DONE IN A HOSPITAL OR IN A PUBLIC PLACE AND THE D. C. RULE WHICH IS THE 1 I'M MOST FAMILIAR WITH DEFINES PUCK LICK ACCOMMODATIONS--PUBLIC ACCOMMODATIONS INCLUDING HOTELS AND HOSPITALS. THERE IS A RESIDENCY REQUIREMENT, IT VARIES FROM STATE TO STATE. AND EVERY PRESCRIPTION THAT'S WRITTEN UNDER MEDICAL AID-IN-DYING, IN ALL THE JURISDICTIONS WHERE IT'S LEGAL REQUIRE THAT THE PHYSICIAN REGISTER THE PATIENT AND THE PRESCRIPTION AND THE FORM CYST REGISTER THE PRESCRIPTION WITH A VERY CONFIDENTIAL DATABASE AND DEPARTMENT OF HEALTH. SO THIS CANNOT BE DONE UNDER THE TABLE, THIS HAS TO BE DONE ABSOLUTELY OPENLY AND THEN OUR DEPARTMENTS OF HEALTH COMPILES STATISTICS EVERY YEAR ABOUT HOW IT'S DONE BUT THERE ARE SAFE GUARDS TO CONFIDENTIALITY, FOR THE PHYSICIAN, FOR THE PATIENT, FOR THE PHARMACIST, BUT THIS IS NOT SOMETHING THAT CAN BE DONE OFF ON THE SIDE OR SECRETLY. THERE'S A LOT OF CRITICISMS OF THE CURRENT LAWS AND A LOT OF QUESTIONS THAT HAVE COME UP SO I WILL JUST RAISE SOME OF THEM. THERE ARE SOME ILLNESSES IN WHICH IT'S HARD TO PROGNOSTICATE BUT WHICH CAUSE SUFFERING SUCH AS PARKINSON'S, ALS, MS, THERE'S REFRACTORY DEPRESSION THAT'S ACCEPTED AS A TERMINAL ILLNESS IN SOME COUNTRIES AND IN CANADA BUT NOT THE U.S. THERE ARE PEOPLE WHO ARE CONCERNED THAT THE REQUIREMENT THAT MEDICATION BE TAKEN BY MOUTH ACTUALLY DISCRIMINATES AGAINST DISABLED PEOPLE AND THERE IS CURRENTLY A LAWSUIT ABOUT THAT IN CALIFORNIA. THERE'S SOME CONTROVERSY ABOUT WHETHER PHYSICIAN ASSISTANCE OR NURSE PRACTITIONERS SHOULD BE ALLOWED TO PRESCRIBE, AND THIS IS A BIG ISSUE IN AREAS WHERE, THERE ARE LARGE RURAL AREAS AND HARD TO ACCESS A PHYSICIAN. THERE ARE QUESTIONS ABOUT WHETHER THE 2 WEEK WAITING PERIOD IS TOO ONEROUS AS WELL, AND THEN FINALLY THE COMPETENCY ISSUE COMES INTO PLAY WHEN THE PATIENT MAKES COMPETENT REQUEST, A REQUEST WHILE THEY'RE--IT'S INTERESTING IN THAT VIEW. THE FEDERAL GOVERNMENT TRIED TO BLOCK THE ORIGINAL 1994 OREGON LAWS AND THE SUPREME COURT OR THE FEDERAL COURTS AND THE SUPREME COURT SUPPORTED THE RIGHT OF STATES AND POPULAR VOTERS IN STATES TOO ENACT MEDICAL AID-IN-DYING SO ALTHOUGH THE FIRST LAW IN OREGON WAS PASSED IN 94, IT WASN'T IMPLEMENTED UNTIL 1997. BUT A STATE'S RIGHT TO BAN OR MAKE--OR TO FORBID MEDICAL AID-IN-DYING HAS ALSO BEEN UPHELD. AND SINCE 2016 IT'S BEEN LEGAL IN ALL OF CANADA. IF WE LOOK AT THE STATE OF WASHINGTON WHICH STARTED TO DO MEDICAL AID-IN-DYING IN 1997--I'M SORRY THE STATE OF OREGON IN 97 AND THE STATE OF WASHINGTON IN 2005, WE CAN--WE GET A PRETTY GOOD IDEA ABOUT HOW MEDICAL AID-IN-DYING HAS AFFECTED, THE PRACTICE OF PALLIATIVE CARE AND IT HASN'T REALLY AFFECTED THE PRACTICE OF PALLIATIVE CARE VERY MUCH. THERE'S NO DATA TO SUGGEST THAT PUBLIC FAITH IN PHYSICIANS HAS BEEN UNDERMINED. HOSPICE HAS NOT BEEN UNDERMINED. THEY'RE NOT GREAT RUPTURES THAT HAVE BEEN DOCUMENTED BETWEEN DOCTORS WHO SUPPORT IT AND DOCTORS WHO DON'T. AND IN THOSE STATES IT'S WIDELY ACCEPTED THAT SOME PHYSICIANS ARE COMFORTABLE, SOME ARE NOT, AND THE PRACTICE OF PRESCRIBING HAS PROBABLY WIDENED FROM INITIALLY PALLIATIVE AND PRIMARY CARE DOCTORS TO NOW NEUROLOGYSTS AND ONCOLOGISTS AND OTHER PHYSICIANS. BUT IT HAS BECOME THE NORMAL STATUS OF AFFAIRS IN THOSE STATES. YOU COULD ASK WHETHER MEDICAL AID-IN-DYING IS CONSISTENT WITH THE GOALS OF PALLIATIVE MEDICINE BUT HERE AGAIN, THERE'S GREAT DISAGREEMENT. WE ALL AGREE THAT PALLIATIVE MEDICINE IS A SPECIALTY THAT RESPONDS TO PATIENT SUFFERING, AND WE RESPOND TO PATIENT SUFFERING THAT IS EXISTENTIAL AS WELL AS PHYSICAL. THERE IS A CONCERN THAT PALLIATIVE PHYSICIANS WHO PARTICIPATE AND HOSPICES THAT PARTICIPATE IN MEDICAL AID-IN-DYING, MIGHT GIVE THE PUBLIC THE WRONG IDEA THAT HOSPIN WAS DESIGNED TO HASTEN DEATH BUT THAT HAS NOT BEEN THE PUBLIC PERCEPTION IN THE STATES OF OREGON AND WASHINGTON. SO NOW WE COME TO THE KEY QUESTION HERE SHOULD ALL TRAINEES IN PALLIATIVE CARE, PALLIATIVE MEDICINE GET TRAINING IN PRESCRIBING FOR MEDICAL AID-IN-DYING. IT HAS NOT BEEN PART OF THE ROUTINE TRAINING SO FAR. JUST TO GO ON A LITTLE BIT MORE ABOUT OUR AGREEMENT TO DISAGREE AMONG OURSELVES BUZZ WE'RE NOT GOING TO SELTZ THIS 2000 YEAR OLD QUESTION HERE TODAY, THE MAJOR SOCIETIES THAT ARE INVOLVED IN MEDICAL AID-IN-DYING ARE THE AMERICAN GERIATRIC SOCIETY, AND THE AMERICAN ACADEMY OF HOSPICE AND PALLIATIVE MEDICINE. NEITHER OF THESE SOCIETIES BY YEARS OF CONVERSATION HAVE COME TO ANY CONCLUSION ABOUT WHETHER TO RECOMMEND OR NOT RECOMMEND AGAINST MEDICAL AID-IN-DYING AND BOTH SOCIETIES HAVE AGREED TO DISAGREE AND THE VOTE IS ABOUT 50/50 EVERY TIME IT COMES UP IN THESE SOCIETIES SO THEY ARE NEUTRAL. IT IS IMPORTANT TO NOTE THAT THE AMA STILL HAS A PROHIBITION ALTHOUGH ITS ETHICS COMMITTEE HAS RECONSIDERED IT SEVERAL TIMES. AT 1 POINT THE CALIFORNIA BRANCH OF THE AMA WITHDRAW FROM THE NATIONAL ORGANIZATION ALTHOUGH I THINK THEY'VE REACHED AN ACCOMMODATION ABOUT THIS ISSUE. BUT THE AMA IS WELL KNOWN FOR NOT BEING ALWAYS A LEADER, UP UNTIL I THINK 1987, THE AMA OPPOSES FOR ORAL VENTILATORS AND THEY ALSO WERE OPPOSED TO ABORTION FOR A LONG TIME, SO THAT'S 1 SERIOUS PROFESSIONAL ASSOCIATION THAT HAS TAKEN A STAND. I'M A DOCTOR AND A PATIENT BRINGS UP MEDICAL AID-IN-DYING O SHOULD I OR MY COLLEAGUES IN END OF LIFE CARE RESPOND TO A PATIENT INQUIRY? MOST OF THE RECENT STATUTES ABOUT MEDICAL AID-IN-DYING HAVE A VERY STRONG ETHICAL OR RELIGIOUS EXEMPTION FOR RELIGIOUS ORGANIZATIONS AND FAITH-BASED MEDICAL INSTITUTIONS. THE CALIFORNIA LAW HAS A VERY STRONG RELIGIOUS EXCEPTION AND THE D. C. LAW HAS COPIED THE CALIFORNIA LAW. THIS ALLOWS ORGANIZATIONS WHICH FEEL THAT MEDICAL AID-IN-DYING IS NOT CONSISTENT WITH THEIR VALUES TO ACTUALLY RESTRICT THEIR EMPLOYEES FROM PARTICIPATING TO THE EXTENT THEY COULD FORBID THEIR EMPLOYEES FROM HAVING A CONVERSATION AND THEY ARE ALLOWED TO MAKE NONPARTICIPATION IN MEDICAL AID-IN-DYING EVEN OUTSIDE OF WORK HOURS A CONDITION OF EMPLOYMENT. SO IT IS POSSIBLE THAT A PATIENT COULD ASK THEIR ONCOLOGIST OR THEIR PALLIATIVE PHYSICIAN AND A PARTICULAR INSTITUTION ABOUT MEDICAL AID-IN-DYING TO BE TOLD BY THEIR PHYSICIAN THAT THEY'RE NOT ALLOWED TO DISCUSS THE MATTER, PERIOD. IT'S VERY UPSETTING FOR PATIENTS WHEN THE CONVERSATION IS SHUT OFF. THE CONVERSATION IS JUST AN INQUIRY AND MY EXPERIENCE HAS BEEN THAT PATIENTS ARE VERY UPSET WHEN THEIR PHYSICIANS SAY WE DON'T DO THAT OR THAT'S IMMORAL, THAT CAN CAUSE A LOT OF PAIN. SO I THINK IT'S REALLY IMPORTANT TO ALERT OUR TRAINEES THAT THEY MAY WALK INTO A SITUATION WHERE THEY ARE NOT ALLOWED TO TALK ABOUT IT OR PARTICIPATE. IF A PATIENT BRINGS UP THE ISSUE OF WHAT ABOUT ENDING IT EARLY AND HOW DO PATIENTS SAY IT IF THEY SAY, I CAN'T TAKE THIS ANYMORE, I'M GOING TO STOCK PILE MEDICATIONS AND JUST END EVERYTHING, I'M GOING TO THROW MYSELF OFF THE BRIDGE, CAN'T YOU MAKE IT GO AWAY FASTER, CAN'T YOU GET THIS OVERWITH. THESE ARE THE KINDS OF THINGS PEOPLE SAY. WHAT DO YOU SAY? NOT EVERYBODY SAYS, OH I UNDERSTAND, AND NOW D. C. PERMITS MEDICAL AID-IN-DYING, ALTHOUGH MY FIRST PATIENTS ALL SAID THAT SO WHAT CAN WE TEACH OUR TRAINEES AND COLLEAGUES TO SAY? I THINK IT'S REALLY IMPORTANT TO BE OPEN TO HEARING YOUR PATIENTS CONCERN AND HAVING A CONVERSATION, WHETHER YOU SAY YES OR NO, NO MATTER WHAT YOU THINK ABOUT THIS. SO THERE'S CERTAIN THINGS THAT WE CAN ALL SAY, I'M SORRY THAT YOUR ILLNESS IS PROGRESSED. TELL ME MORE ABOUT WHY YOU'RE INTERESTED IN MEDICAL AID-IN-DYING. WHAT WORRIES YOU, WHAT ARE YOU MOST CONCERNED ABOUT? IF AS A CLINICIAN YOU SUPPORT MEDICAL AID-IN-DYING OR YOU'RE WILLING TO PARTICIPATE, THEN THAT CAN BE SAID. IT DOESN'T MEAN THAT YOU'RE GOING TO DO IT, I WOULD SAY ABOUT HALF OF THE PATIENTS WHO RAISE IT WITH ME, AND GO THROUGH THE PROCESS, NEVER FIND IT NECESSARY, TO TAKE ADVANTAGE AND WE CAN TALK ABOUT THAT BUT THEY ARE COMFORTED BY KNOWING THAT THE OPTION IS THERE, SO WE CAN TEACH OUR TRAINEES TO SAY, TELL ME ABOUT YOUR CONCERNS, IF YOU WANT THIS OPTION, I'M WILLING TO SUPPORT YOU AND HELP YOU FIND KNOWLEDGEABLE DOCTOR OR HELP YOU WITH THE PAPERWORK AND GUIDE YOU THROUGH IT BUT WE ALWAYS SHOULD SAY FIRST, I HAVE TO MAKE SURE YOU UNDERSTAND WHAT'S INVOLVED. PEOPLE ALWAYS HAVE A RIGHT TO NOT USE IT, IN FACT ON THE D. C. WEBSITE, THAT I HAVE USE TO USE TO REGISTER MY PATIENTS, I HAVE TO CERTIFY THAT I HAVE TOLD MY PATIENTS NOT ONCE BUT TWICE AND BOTH TIMES OF REQUEST THAT THEY DON'T HAVE TO USE THE MEDICATION, THAT THERE'S NO OBLIGATION TO USE IT AND THEY HAVE THE RIGHT TO NOT USE IT. I ALSO HAVE AN OBLIGATION TO MAKE SURE THAT MY PATIENTS KNOW THAT THERE ARE REASONABLE ALTERNATIVES. A LOT OF PEOPLE DON'T KNOW ABOUT IT, BELIEVE IT OR IN THE THEY DON'T UNDERSTAND THAT HOSPICE AND PALLIATIVE MEDICINE CAN MEET MANY OF THEIR CONCERNS OR ALL OF THEIR CONCERNS. I CONSIDER THAT AN OBLIGATION AS A PALLIATIVE PROVIDER TO MAKE SURE THAT PATIENTS ARE SUPPORTED IF THEY MAKE THIS DECISION. OH MY GOD. I HAVE LOST MY ZOOM. CAN YOU ALL STILL HEAR ME? >> WE CAN HEAR YOU, WE CAN HEAR YOU. >> CAN YOU SEE MY SLIDES? >> NO, ARE THEY MINIMIZED ON THE DESKTOP, I SEE THEM ON THE BOTTOM. >> I JUST LOST THE WHOLE THING. >> SCROLL YOUR CURSOR TO THE BOTTOM RIGHT, KEEP GOING TO THE RIGHT TOWARDS THE RIGHT, TOWARD THE RIGHT YEAH BECAUSE I SEE IT MINIMIZED ON THE LOWER RIGHT. >> STOP SHARING ALL THE WAY TOGETHER. >> YEAH, STOP SHARING SO CAN YOU TAKE DOWN WHAT YOU HAVE AND HIT SHARE AGAIN, PLEASE? >> I CAN SHOW YOUR SLIDES FOR YOU. >> COULD YOU DO THAT? >> YES. >> LET ME HIT SHARE 1 MORE TIME. >> NO. >> OH. ARE WE BACK? >> NOT YET, I CAN PUT THEM UP, GIVE ME 1-SECOND, PLEASE. >> DO YOU WANT TO-- >> RECORDING STOPPED. THIS IS TOTALLY WRONG. >> STOP SHARING. THAT'S ANOTHER SET OF SLIDES, THANK YOU. OKAY, CAN YOU SEE THAT? >> NO, WE ASKED YOU TO TAKE IT DOWN SO THAT I CAN SHOW IT. >> ALL RIGHT, ARE YOU SHOWING IT NOW? >> I CAN ON YOUR BEHALF IF THAT'S YOUR PREFERENCE? BECAUSE YOU'RE SEEING YOU CAN'T SEE YOUR SLIDES. >> WHAT TO SAY INSTEAD OF JUST NO? WE'RE ALMOST DONE. >> I'M GOING TO SHOW THEM FOR YOU, JUST HOLD ON 1-SECOND. OKAY AND JUST GUIDE ME TO EXACTLY WHERE WE ARE. >> YOU HAVE TO GO UP A LITTLE, GO UP 1 MORE. THAT'S-- >> THERE YOU GO. >> ONE MORE, I THINK. OKAY, TEACH TRAINEES. OKAY. CAN YOU ADVANCE THAT--CAN YOU GO BACK? >> NEXT 1 DOWN, RITA, RIGHT THERE, THAT'S WHERE YOU ENDED KATLIN. >> THAT'S WHERE I ENDED, CAN WE GO TO THE NEXT SLIDE, PLEASE. OKAY, IF A TRAINEE IS NOT COMFORTABLE WITH MEDICAL AID-IN-DYING EVEN IF YOU--OR YOU FEEL LIKE YOU'RE NOT ALLOWED TO DISCUSS IT WHERE ARE YOU, HERE ARE SOME THEY THINKS YOU CAN SAY THAT ARE HELPFUL. I'M SORRY THAT YOUR ILLNESS HAS PROGRESSED. TELL ME MORE ABOUT WHY YOU'RE INTERESTED? AND THEN IF YOU DON'T FEEL YOU CAN PARTICIPATE OR HELP, YOU CAN SAY, IF YOU WANT THIS OPTION, I'M WILLING TO HELP YOU FIND A DOCTOR BUT MY PERSONAL OR RELIGIOUS BELIEFS OR MY EMPLOYER WON'T LET ME PARTICIPATE AND DO THIS FOR YOU. IF YOU DECIDE TO STICK WITH ME AND YOU DON'T CHOOSE ANOTHER DOCTOR, I PROMISE TO REMAIN YOUR DOCTOR FOR THE REST OF YOUR LIFE AND I WILL DO EVERYTHING I CAN TO PREVENT OR RELIEF YOUR SUFFERING INCLUDING USING HOSPICE AND PALLIATIVE CARE BUT I CANNOT PARTICIPATE IN MEDICAL AID-IN-DYING. DON'T JUST SAY NO, DON'T CLOSE THE DOOR. NEXT SLIDE, PLEASE. I HAVE FOUND THAT JUST KNOWING THAT THE AVAILABILITY OF MEDICAL AID-IN-DYING IS VERY COMFORTING FOR MANY PATIENTS. I DON'T BRING IT UP FIRST. I DO UNDERSTAND WHEN PEOPLE ARE USING CODE WAYS OF ASKING BUT AS FARs I KNOW NONE OF THE STATES REQUIRE IT. BUT MY OWN PERSONAL REQUIREMENT IS THAT I CAN'T BE THERE FOR PEOPLE 24/7 AND HOSPICE MEETS SO MANY NEEDS FOR PATIENTS AND FAMILIES THAT I TELL PATIENTS WHEN THEY ASK FOR MEDICAL AID-IN-DYING THAT I WON'T PRESCRIBE UNTIL THEY'VE--UNTIL AFTER THEY'VE ENROLLED IN HOSPICE. THAT MEANS IF SOMEBODY IS ENGAGED IN A TREATMENT LIKE A PROTOCOL OR PALLIATIVE CHEMO, THAT IS NOT COVERED BY HOSPICE, I WILL REGISTER THE PATIENT. I WILL TALK THEM THROUGH THE PROCESS, BUT I WON'T PRESCRIBE UNTIL AFTER THEY'VE EXHAUSTED THOSE REMEDIES, AND THOSE OTHER OPTIONS AND HAVE ENROLLED IN HOSPICE. BUT THAT'S NOT NECESSARY UNDER THE LAW. AND I THINK THAT--IT'S NOT ABOUT JUST PRESCRIBING, I BECOME THEIR PALLIATIVE DOCTOR. WHEN THEY'RE IN HOSPICE, I WORK WITH THEIR HOSPICE PHYSICIANS. IT'S NOT A 1 TIME, 1-OFF PRESCRIBING. NEXT SLIDE, PLEASE. DR. BERGER BROUGHT UP THE ISSUE OF VOLUNTARY STOPPING EATING AND DRINKING AND LIKE MEDICAL AID-IN-DYING, I THINK I HAVE A LOT OF PALLIATIVE FELLOWS WHO DON'T KNOW ABOUT THIS. WE HAVE A LOT OF PALLIATIVE DOCTORS THAT WE DON'T KNOW THAT VSED IS NOW AN OPTION AND BEING USED VERY WIDELY, AND BEING PROMOTED ON WEBSITES IN DEATH CAFES, AND COMPASSIONATE CHOICE WHICH IS IS A LEADING ADVOCACY ORGANIZATION HAS A LOT OF THAT VSED ON THEIR REBECCA SITE AND A LOT OF PEOPLE KNOW ABOUT IT SO LIKE DR. BERGER'S MOTHER'S FRIEND, THIS IS AN OPTION THAT PEOPLE ARE TAKING. IT'S NOT EASY. AND WHEN PEOPLE ARE CONSCIOUS IT'S HARD TO STOP EATING AND DRINKING, THIS REQUIRES A LOT OF WILL AND SUPPORT FROM FAMILY AND IT REQUIRES A LOT OF PALLIATIVE SUPPORT BECAUSE IT CAN BE PAINFUL AND IT CAN BE SYMPTOMATIC AND IF HOSPICE OR PALLIATIVE PHYSICIAN IS NOT AWARE OF THE PIT FALLS OF THIS, IT CAN CAUSE A LOT OF DISTRESS. SO VSED IS ANOTHER OPTION IN NONMEDICAL AID-IN-DYING STATES BUT IT DOES REQUIRE A KNOWLEDGEABLE PALLIATIVE PRACTITIONER FOR THIS. LAST SLIDE, PLEASE. SO WE HAVE--I THINK THIS IS THE LAST SLIDE--YOU KNOW SHOULD PROGRAMS PARTICIPATE? SHOULD FELLOWSHIP PROGRAMS ONLY TALK ABOUT IT, IF THEY'RE IN A JURISDICTION WHERE MEDICAL AID IS DYING, IT'S LEGAL OR MAYBE AN ADJACENT JURISDICTION? ACTUALLY NOW THE WHOLE WEST COAST, NEW MEXICO, COLORADO, WASHINGTON STATE, OREGON AND CALIFORNIA ALL ALLOW MEDICAL AID-IN-DYING. SO IN THOSE STATES IT'S NOT AN ISSUE, BUT WHAT IF IT'S A PALLIATIVE PROGRAM IN NEW YORK STATE AND YOUR PALLIATIVE FELLOW IS GOING TO PRESCRIBE IN NEW JERSEY OR IN VERMONT, IT'S A PRACTICE THERE, SHOULDN'T THEY KNOW ABOUT IT? AND YOU KNOW DOES TALKING ABOUT MEDICAL AID-IN-DYING CREATE MORAL DISTRESS AMONG OUR PROVIDERS, AMONG OUR FACULTY AND AMONG PALLIATIVE TRAINEES? I DON'T THINK WE REALLY ADDRESSED THAT. THERE IS 1 MORE SLIDE, I THINK. AND LOOKING--LOOKING AT MEDICAL AID-IN-DYING, SHOULD IT BE OPTIONAL FOR FELLOWS, THEY BE ABLE TO OPT-IN AND OPT-OUT THE WAY ABORTION, SHOULD TRAINERS BE ABLE TO OPT OUT? NEXT SLIDE, PLEASE. I WANT TO MENTION THESE REFERENCES, I DON'T KNOW IF THEY CAN STAY POSTED ON THE WEBSITE OR NOT, BUT, THERE ARE SOME REALLY INTERESTING ARTICLES HERE FOR THOSE OF YOU WHO LIKE FILMS, THE DIANE REEM FILM IN WHICH I AM INTERVIEWED, IS VERY INTERESTING AND SOME OF THESE ARTICLES ARE QUITE INTERESTING AND THERE IS A NEW BOOK NOW ON VSED THAT I DID NOT LIST THAT'S EDITED BY A NUMBER OF WELL KNOWN AUTHORS. THANK YOU VERY MUCH FOR YOUR ATTENTION. >> THANK YOU VERY MUCH DR. ROTH, >> THE SKILLS TO MANAGE THESE SITUATIONS ARE GAINED THROUGH CLINICAL EXPERIENCE, HOWEVER, OFTEN THE COST OF ANXIETY OR DOUBT. AS FACULTY AND AS HEALTHCARE PROVIDER WHO IS HAVE EXPERIENCED THE ANXIETY OF FEELING UNPREPARED, WE HOPEFULLY HAVE THE WISDOM AND INDEED THE OBLIGATION TO ANTICIPATE DIFFICULT SITUATIONS FOR OUR FELLOWS AND FOR OTHER TRAINEES. THE BENEFITS OF EXPERIENCE INCLUDE HAVING DEVELOPED THE SKILLS TO MANAGE SITUATIONS THAT MAY LIE OUTSIDE OF STANDARD TRAINING BUT SKILLS NEVERTHELESS THAT ARE INEGULATION--REGULATORYERAL TO PATIENT CARE. WE CAN GIVE OUR FELLOWS AND OTHER TRAINYS THE TOOLS THEY NEED TO ADDRESS PATIENTS AND THEIR FAMILIES. AT THE SAME TIME, HOWEVER, WE HAVE AN OBLIGATION TO HELP OUR FELLOWS MAINTAIN THEIR PERSONAL AND PROFESSIONAL INTEGRITY. EVERY PHYSICIAN IN PALLIATIVE MEDICINE MUST BE ABLE AND WILLING TO ENGAGE IN DISCUSSIONS ABOUT HASTENED DEATH. PRIMARY CARE PHYSICIANS, ONCOLOGISTS AND OTHER HEALTHCARE PROFESSIONALS ARE ALSO LIKELY TO HEAR THE REQUEST FOR HASTENED DEATH. THEY TOO SHOULD BE ABLE TO HAVE THE CONVERSATION. SPICER AND COLLEAGUES IN A STUDY PUBLISHED IN 2017 EXPLORED RESIDENTS, EDUCATION AND BELIEFS ABOUT ASSISTED DEATH. SEVENTY-FIVE% OF RESIDENT RESPONDENTS RECEIVED NOR EDUCATION ABOUT PHYSICIAN ASSISTED DEATH, THEIR LANGUAGE, THOUGH 85% WANTED MORE EDUCATION ABOUT IT. ALTHOUGH 35% OF RESIDENTS BELIEVED THAT THEIR EDUCATION PROVIDED THEM WITH ENOUGH INFORMATION ABOUT P A D, AND 59% WILL PROVIDE A CONSENTING ADULT WITH PHYSICIAN ASSISTED DEATH. ON THE OTHER HAND, HALF OF PHYSICIAN RESPONDENTS BELIEVE THAT PHYSICIAN ASSISTED DEATH WOULD ULTIMATE GOAL MAILTLY BE PROVIDED BY PALLIATIVE CARE PHYSICIAN. YOU RECALL DR. ROTH'S ADMONITION WHAT TO SAY INSTEAD OF JUST YES OR NO. THERE IS A GOOD REASON FOR THAT. EXPRESSING THE DESIRE TO DIE, THAT IS EXPRESSING A STATE OF MIND THAT FINDS DEATH LESS BURDENSOME AND CONTINUE LIVING DOES NOT NECESSARILY EQUATE TO A REQUEST FOR HASTENED DEATH. WE MUST UNDERSTAND THE REQUEST. IT IS NOT AT ALL UNCOMMON FOR PATIENTS WITH ADVANCED DISEASE TO SAY, I'M DONE,IVE JUST WANT TO DIE. I'M OVERALL OF THIS, I'M JUST TOO TIRED TO GO ON. REQUESTS FOR HASTENED DEATH OFTEN HAVE TO DO WITH FEARS ABOUT WHAT MIGHT LIE AHEAD, AS WOMAN SAID TO ME, I'M OKAY NOW BUT I DON'T WANT TO SUFFER AT THE END, I DON'T WANT TO DO THAT TO MY FAMILY. WHEN THE TIME COMES WILL YOU HELP ME JUST END IT PEACEFULLY? PATIENTS MAY BELIEVE THAT DEATH IS THE ONLY RELIEF FROM THE BURDENS THEY'RE CARRYING. IT'S OUR DUTY TOW FIND THAT BURDEN AND TO EXPLORE WAYS TO ALLEVIATE THAT BURDEN. ENCOURAGING LISTENERS--EXCUSE ME ENCOURAGING LEARNERS NOT ONLY TO HEAR BUT TO EXPLORE MEANING IS CRITICAL. ALTHOUGH THE DESIRE TO DIE MAY BE EXPRESSED LITERALLY, SUCH REQUESTS ARE ALMOST ALWAYS HIGHLY SYMBOLIC, THESE REQUESTS HAVE A DEEPER UNDERLYING MEANING. CICLEE SAUNDERS, A PHYSICIAN, PHARMACIST AND SOCIAL WORKER CHRONICALLY OVEREDUCATED FROM THE WOMB AND THE FOUNDER OF THE MODERN HOSPICE UNIT SAYS THE PHRASE LET ME DIE OFTEN REFERS NOT TO A DELIBERATE HASTENING OF DEATH BUT RATHER TO A FEAR OF TREATMENT AIMED OF PROLONGING THE BURDENS OF EXISTENCE. PARADOXICALLY A PATIENT'S DISTRESS MAY BE EXPRESSED AS WANTING TO DO EVERYTHING THAT COULD POSSIBLY BE DONE TO EXTEND THEIR LIFE. THIS IS THE QUOTE, DO EVERYTHING REQUEST, IT MAY BE EASIER FOR CLINICIANS TO ASSIEGE TO THE PATIENT'S LITERAL EXPRESSIONS AND MISS THEIR IMBOLT-ONTIC DIMENSION. IT IS MORE DIFFICULT TO HAVE THE CONVERSATION ABOUT BURDENS AND OTHER COSTS OF TREATMENT OR TO DISCUSS A CHANGE IN GOALS AND CARE. THE SKILLS TO HAVE THESE DISKUTIONZS MAY BE THE MOST IMPORTANT TEACHING THAT WE DO. THIS IS WHERE THE CONVERSATIONS BEGIN. THOSE ARE TAUGHT TO LISTEN, TO EXPLORE AND TO DO THE WORK TO UNDERSTAND. YOU SOUND OVERWHELMED, YOU SOUND TIRED, YOU HAVE BEEN WORKING SO HARD TO LIVE WITH THIS DISEASE. PATIENTS OFTEN FEEL AN OBLIGATION TO PROVIDE WHAT THE PHYSICIAN SUGGIESTS, THIS IS A TECHNOLOGICAL IMPERATIVE, BECAUSE THE TECHNOLOGY EXISTS THE PROVIDER MIGHTING COMPELLED TO OFFER IT. I BELIEVE THERE'S AN EXTENSION TO THIS, BECAUSE THE PHYSICIAN OFFERS THIS TECHNOLOGY, PATIENTS AND OFTEN FAMILIES OFTEN FEEL COMPELLED TO ACCEPT IT, THE TREATMENT WOULD NOT BE OFFERED WERE IT NOT AN UNQUALIFIED GOOD. SO WHO REQUESTS? DR. ROTH ALREADY ADDRESSED SOME OF THE CHARACTERISTICS OF THOSE WHO REQUEST HASTENED DEATH, THE BEST DATA IN THE U.S. ARE FROM OREGON, THE WASHINGTON STATE AND SEVERAL OTHER JURE SIS DICTIONS HAVE GOOD DATA. FROM 1990 THROUGH 2020 THE POPULATION WHO REQUESTED HASTENED DEATH WERE APPROXIMATELY EQUAL BETWEEN GENDERS, GREATER THAN 96% WHITE, 1.4% ASIAN, 1.2% HISPANIC, AND 0.2% PLAQUE OR AFRICAN AMERICAN. ABOUT 71% HAVE SOME LEVEL OF COLLEGE EDUCATION. ABOUT 3-QUARTERS OF THOSE WHO REQUEST ASSISTANCE WITH HASTENED DEATH HAVE CANCER, ABOUT 10% HAVE NEUROLONGIC DISEASES AND ABOUT 5% HAVE LUNG DISEASE OR HEART DISEASE. THE REASON FOR REQUEST FOR HASTENED DEATH VERY RARELY HAVE TO DO WITH A PHYSICAL SYMPTOM. RATHER THE MOST COMMON REQUEST IS DUE TO LOSS OF AUTONOMY OR THE FEAR OF LOSING 1'S AUTONOMY. ALSO, SECOND A DECREASED ABILITY TO ENGAGE IN ENJOYABLE ACTIVITIES, LOSS OF CONTROL OR FEAR OF FUTURE LOSS OF CONTROL MUCH LESS COMMONLY PHYSICAL SYMPTOMS ARE THE REASON HOWEVER IT'S RARELY A CURRENT PHYSICAL SYMPTOM BUT IT'S NOT UNCOMMON FOR THOSE WHO EXPRESS HASTENED GEAGHT TO ADDRESS A FEAR OF FUTURE SYMPTOMS. SCREENING FOR DEPRESSION IS TYPICALLY REQUIRED BUT OFTEN OVERLOOKED. THE PREVALENCE OF DEPRESSION OF THOSE WHO ARE TERMINALLILY ILL RANGES BETWEEN 25-77%. HOWEVER, ONLY 4% OF THOSE WHO REQUEST HASTENED DEATH ARE REFERRED FOR PSYCHIATRIC EVALUATION TO DETERMINE WHETHER DEPRESSION OR OTHER FACTORS ARE AFFECTING THEIR REQUEST. IN IMPLEMENTING THEIR LAW AND PHYSICIAN ASSISTED DEATH, CALIFORNIA SPENT A GREAT DEAL OF EFFORT ADDRESSING THE ACTUAL AND POTENTIAL CONCERNS OF VULNERABLE POPULATIONS. SENSITIVITY TO CULTURAL VALUES IS ESSENTIAL. THE MORE WE KNOW ABOUT CULTURAL STANDARDS OF COMMUNICATION AND INTERACTIONS, AND THE VALUES THAT THE INDIVIDUAL HOLDS DEAR, THE MORE WE CAN FOCUS ON THE PATIENT AS AN INDIVIDUAL. WHEN DC WAS IMPLEMENTING THEIR HASTENED DEATH LEGISLATION, [INDISCERNIBLE] A REPORTER FOR THE WASHINGTON POST AND A LECTURE AT NORTHWESTERN UNIVERSITY WROTE, THE LAW HAS BEEN ENACTED AND A HANDFUL OF STATES WITH MOSTLY WHITE POPULATIONS. [INDISCERNIBLE] DESCRIBED THE FEAR HE HEARD IN THE COMMUNITY AND THAT MANY OF US HAVE HEARD. P. A. S., PHYSICIAN-ASSISTED SUICIDE IS REALLY AIMED AT OLD BLACK PEOPLE, SEVERAL PEOPLE SAID. WHEN THE D. C. LEGISLATION WAS GOING THROUGH REVEREND EUGENE RIVERS CALLED THE LEGISLATION BACK END NUGENICS, THIS IS DIFFICULT TO HEAR BUT ALL OF US HAVE HEARD OVER THE DECADES, FEARS ARE REAL, WE HAVE TO BE WILLING TO EXPLORE TO HEAR THEM, AND FINALLY, I WOULD LIKE TO SAY A WORD ABOUT MY OWN EXPERIENCES. UNEXPECTEDLY, ALMOST EVERY REQUEST I HAVE EVER RECEIVED FOR HASTENED DEATH HAS COME NOT FROM PATIENTS BUT RATHER FROM FAMILY MEMBERS. IT'S USUALLY SAID, WE KNOW SHE'S GOING TO DIE, CAN'T WE DO SOMETHING TO GET IT OVERWITH? WHY ARE WE WAITING? YOU COULD FINISH THIS NOW? OR YOU'RE JUST PROLONGING HIS SUFFERING BY NOT HELPING HIM DIE. IN THE 21st CENTURY MANY PEOPLE INCLUDING HEALTHCARE PROVIDERS DO NOT KNOW HOW TO ATTEND A LOVED 1 OR A PATIENT WHOSE DEATH IS A PROXIMAL REALITY. WE DON'T KNOW HOW TO BE AT THE BEDSIDE, AS MUCH AS THESE FAMILY MEMBERS REFER TO THEIR LOVED 1 WHO IS DYING, THEY ARE ALSO SPEAKING ABOUT THEIR OWN SUFFERING AND WANT THEIR OWN SUFFERING TO END. THOUGH ALL SHOULD BE ABLE TO ENGAGE IN THE CONVERSATION, TRAINING ALSO SHOULD HELP FELLOWS CONSIDER THEIR OWN PERSONAL PLEEFS REGARDING REQUESTS FOR HASTENED DEATH. PERSONAL AND PROFESSIONAL BELIEFS OFTEN EXIST COMPLETELY INDEPENDENT OF 1'S RELIGIOUS BELIEFS. ALTHOUGH 21st CENTURY MEDICINE HAS WORKED MIRACLES IN TERMS OF DIAGNOSIS AND TREATMENT, IT'S TECHNOLOGICAL NATURE HAS ALSO DRAWN US AWAY FROM THE BEDSIDE. THIS SEPARATION HAS LEFT US LARGELY WITHOUT THE MEDICAL SKILLS AND PERHAPS SPIRITUAL OR EMOTIONAL-- >> THANK YOU, ANN, KATLIN AND MIMI. WE HAVE A COUPLE MINUTES FOR QUESTIONS, I WANT TO START WITH 1 YOU ENDED WITH KATLIN AND SEE WHAT YOU THINK OR HOW YOU MIGHT RESPOND TO IT IN YOUR OWN PRACTICE. YOU ASKED QUESTION ABOUT CONSCIOUS CLAUSES AND HOW THEY MIGHT OR MIGHT NOT BE RELEVANT TO TRAINING WITH RESPECT TO MEDICAL AID-IN-DYING SO I WAS WONTDERRING IF YOU IMAGINE, IF THIS HAS HAPPENED BUT IF YOU IMAGINE 1 OF YOUR FACULTY MEMBERS WHOSE PART OFIOURE PALLIATIVE CARE TRAINING PROGRAM WHO TRAINS FELLOWS AND PEOPLE IN PALLIATIVE CARE, CAME TO YOU AND SAID, I THINK IT'S ETHICALLY INAPPROPRIATE NOT ONLY FOR CLINICIANS TO BE INVOLVED IN PROVIDING MEDICAL AID AND DYING OR PRESCRIBING FOR MEDICAL AID-IN-DYING I THINK IT'S ETHICALLY INAPPROPRIATE FOR CLINICIANS TO TRAIN OTHERS IN HOW TO DO AND HOW TO BE INVOLVED IN MEDICAL AID-IN-DYING. I WAS WONDERING HOW YOU THOUGHT YOU MIGHT RESPOND TO THAT? THE APPROPRIATE RESPONSE IS TO ACCEPT THAT AND ALLOW THEM TO NOT BE INVOLVED IN THAT PORTION OF THE TRAINING OR YOU THINK THIS IS SO CENTRAL TO PALLIATIVE CARE NOW THAT TRAINEES HAVE TO BE WILLING TO BE PART OF IT IF THEY'RE REALLY GOING TO BE TRAINING IN THIS? >> WOW, THAT'S NOT A QUESTION I WAS EXPECTING BUT I WILL BE HAPPY TO TRY AND TACKLE IT. I WANT TO THANK MIMI, FOR HER BEAUTIFUL REMARKS. AND SHE TOUCHED ON A LOT OF POINTS I WISH I COULD HAVE MADE SO I REALLY APPRECIATE MIMI'S REMARKS. AND WE ALL HAVE A WAYS TO GO. WHAT HAPPENED TO ME PERSONALLY IS PROBABLY THE BEST ANSWER DAVID, I WORK ON GEORGE WASHINGTON UNIVERSITY WHICH IS A SECULAR INSTITUTION AND A PRIVATE INSTITUTION. WHEN THE ISSUE CAME UP, I TALKED TO MY CLAIR ABOUT AND MY LEGAL DEPARTMENT ABOUT PARTICIPATING AND ACTUALLY MET WITH THE CHAIRS GENERALLY AND GOT A LOT OF SUPPORT, AS LONG AS I PRACTICED, IT WAS LEGAL WITHIN THE LAW AND WITHIN THE ORGANIZATION. WE HAD A SPECIAL RETREAT FOR OUR DIVISION AND WE TALKED ABOUT IT. TEN OR 11 PHYSICIANS, A COUPLING OF NURSE PRACTITIONERS AND PIs, ALMOST EVERYBODY CAME, 1 WOMAN SAID SHE PRAYED ABOUT IT THE WHOLE NIGHT BEFORE THE CONFERENCE, THERE ARE PEOPLE IN MY DIVISION WHO DO NOT SUPPORT IT I THINK THEY TOLERATED MY TALKING TO PEOPLE ABOUT IT BUT I NEVER TAKE ATTENDANCE AT OUR CONFERENCES SO IF SOMEBODYB SENTED THEMSELVES FROM CONFERENCE, I TALK ABOUT IT ONCE A YEAR WITH OUR FELLOWS. BUT I THINK IT IS A VERY PERSONAL DECISION TO DO IT, TO PARTICIPATE OR NOT PARTICIPATE AND I AM PERSONALLY COMFORTABLE WITH THAT AND WHEN I TALKED WITH PEOPLE IN OREGON AND WASHINGTON STATE IT'S JUST SORT OF SORTED OUT THAT WAY. SO IF THERE IS A TRAINEE WHO DOESN'T WANT TO DISCUSS IT OR A FACULTY SOMEBODY WHO DOESN'T WANT TO BE INVOLVED IN TEACHING ABOUT IT, I'M FINE WITH THAT BUT I THINK THE OPTION NEEDS TO BE THERE AS MIMI MENTIONED, TRAINEES AND RESIDENTS AND STUDENTS, THEY'RE VERY INTERESTED. THEY'RE A LITTLE AHEAD OF THEIR GRAY HAIRED MENTORS BECAUSE THIS HAS BECOME SOMETHING MUCH MORE ACCEPTABLEOT MORAL LANDSCAPE IN THE LAST 25 YEARS. BUT I THINK THAT WE HAVE TO BE COMFORTABLE WITH DISAGREEMENT HERE. I'M NOT COMFORTABLE WITH INSTITUTIONS, I'M NOT COMFORTABLE WITH THE STATE OF FLORIDA FOR BIDDING PHYSICIANS TO ASK ABOUT WHETHER PATIENTS HAVE GUNS IN THE HOME. I AM NOT COMFORTABLE ABOUT THE STATE OF OHIO FORBIDDING TELEHEALTH SPECIFICALLY ON THE ISSUE OF CHEMICAL ABORTIONS. I'M NOT IN FAVOR OF FREE SPEECH RESTRICTIONS ON CLINICIANS. THIS IS NOT THE ONLY AREA IN WHICH CLINICIANS ARE NOT ALLOWED TO DISCUSS A SUBJECT OPENLY. THERE ARE PLACES WHERE A PHYSICIAN IS NOT ALLOWED TO PRESCRIBE POST EXPOSURE PREGNANCY PROPHYLAXIS AFTER A RAPE. SO THERE IS A LOT OF--TO PRIORITIZE THEIR PATIENTS HEALTH AND CONCERNS, BUT I AM VERY COMFORTABLE WITH INDIVIDUALS OPTING NOT TO PARTICIPATE. IS NAA SUFFICIENT ANSWER? >> ABSOLUTELY. SO THIS MIGHT BE OUR LAST QUESTION, I APOLOGIZE, FOR THE QUESTIONS I WON'T GET TO ON THE VIDEOCAST BUT I WILL RESPOND TO THEM BY E-MAIL TO EVERYBODY AND THAT WAS AND THERE'S SOME HOPEFULLY KATLIN THAT I UPON FORWARD TO YOU, THAT ARE FOR YOU, BUT 1 QUESTION IS: IF YOU COULD SAY SOMETHING ABOUT YOUR THOUGHTS ON THE RELATIONSHIP BETWEEN BEING A PALLIATIVE CARE DOC AND BEING INVOLVED OR WILLING TO BE INVOLVED IN MEDICAL AID-IN-DYING. SO 2 QUESTIONS THAT CAME UP, 1, DO YOU THINK THAT MEDICAL AID-IN-DYING IS BECOMING SUFFICIENTLY INTEGRAL TO PALLIATIVE CARE THAT YOU NEED TO BE ABLE TO WILLING TO BE A PART OF IT TO BE A PALLIATIVE CARE DOCTOR. IF NOT, ARE THERE WAYS OR WORRIES ABOUT PALLIATIVE CARE DOCTORS WHO DON'T WANT TO BE INVOLVED BEING REGARDED AS SECOND CLASS PALLIATIVE CARE DOCTORS OR DISCRIMINATED AGAINST AS A RESULT? >> I DON'T THINK EITHER OF THESE ARE THE CASE, I WILL TELL YOU A QUICK STORY. I WAS CONTACTED A FEW MONTHS AGO BY THE HUSBAND AND THEN BY THE PATIENT OF A WOMAN WHO HAD BEEN BATTLING OVARIAN CANCER FOR A VERY LONG TIME. AND AND SHE REQUESTED MEDICAL AID-IN-DYING, SHE WAS AT THIS POINT BED-BOUND AND VERY ILL. AND I COULD TELL JUST FROM A TELEHEALTH VISIT THAT SHE DIDN'T HAVE 2 WEEKS TO MAKE A SECOND REQUEST. AND WE TALKED AND I EXPLAINED TO HER SHE WAS--SHE HAD MANY BOUTS OF BALL OBSTRUCTION AND SHE WAS THERE AGAIN AND IN GREAT PAIN AND I EXPLAINED TO HER THAT HER HOSPICE PHYSICIANS COULD PROVIDE HER WITH PALLIATIVE SEDATION IF SHE REQUIRED IT AND THEY COULD STEP UP HER PAIN MEDICATION AND THAT ACCORDING TO HER HUSBAND AFTER SHE PASSED WAS AS GOOD AS PROVIDING MEDICAL AID-IN-DYING, JUST THE COMFORTA OF KNOWING AND WITHIN A DAY, I TALKED TO HER HOSPICE DOCTOR, SHE WAS ON A DEL OTID,A MOUND AND SHE DIDN'T HAVE TO DIE IN PAIN AND SHE HADN'T VOCALIZED IT. I THINK ANY OF US WOULD DO WHAT I DID IN THAT SITUATION, ANY EXPERIENCE, MIMI ANN, ANY OF US WHO HAVE EXPERIENCE IN PALLIATIVE MEDICINE WOULD HAVE LOOKED TO HELP THIS WOMAN PALLIATE HER LAST FEW DAYS. AND THAT'S WHAT OUR TRAINEES NEED TO LEARN. IT'S NOT JUST A QUESTION ABOUT DOING IT AND GETTING IT OVERWITH, SHE NEEDED TO KNOW THAT SHE WOULD BE ABLE TO PASS GRACEFULLY TO NOT GO THROUGH THE INTIGER DATABASE NITTYS OF GREAT--INTIGER DATABASE NITTYS OF GREAT SUFFERING AND PRESENCE OF FAMILY AND EXPERIENCING THAT SUFFERING, SO I THINK THAT AT LEAST IT NEEDS TO BE ACKNOWLEDGED AND THE PATIENT'S WISHES NEED TO BE EXPLORED. I WANT TO SAY THAT I COULD NONAPOPTOTIC THE DO THE WORK I DO WITHOUT THE MENTOR SHN OF SOME AMAZING PEOPLE ON THE WEST COAST AND THERE IS ON THAT LIST OF REFERENCES, A REFERENCE TO BOTH THE COMPASSIONATE CHOICES AND ALSO TO THE AMERICAN ACADEMY OF THE MEDICAL AID-IN-DYING NOW, SO I DON'T KNOW IF YOU CAN POST THOSE REFERENCES SOMEWHERE, BUT THERE'S A GREAT COMMUNITY IN THE PALLIATIVE CARE COMMUNITY THAT HELPS 1 ANOTHER INCLUDING PATIENT PEOPLE WHO DO NOT WANT TO PARTICIPATE IN MEDICAL AID-IN-DYING BUT WANT TO KNOW HOW TO RESPOND TO A PARTICULAR SWAISHT. SO I THINK WE HAVE A WONDERFUL PROFESSIONAL AND A WONDERFUL SPECIALTY IN WHICH THE GOALS ARE TO RELIEVE SUFFERING. AND THEN WITHIN THAT WE HAVE MADE ROOM TO DIFFER. >> OKAY. ALL RIGHT. WELL, I WANT TO THANK YOU FOR A WONDERFUL PRESENTATION TO MIMI AND ANN FOR THEIR CONTRIBUTIONS AND HOPEFULLY WE WILL SEE EVERYBODY AGAIN THE FIRST WEDNESDAY IN DECEMBER. WE WILL TALK ABOUT ANOTHER NONCONTROVERSIAL TOPIC MANDATORY VACS NATION AND IN THE--VACCINATION AND IN THE MEAN TIME JOIN ME IN VIRTUALLY THANKING, ANN, MIMI AND KATLIN FOR A WONDERFUL SESSION.