In his 35 years as an oncologist, Dr. Charles Miller has seen a lot of patients with breast, prostate, colon, lung or ovarian cancer.

For those at the end of their lives, most are either in lots of pain or experiencing a poor quality of life.

“They say to you, ‘Doc, I want to get this over with. I just want to finish this,'” said Miller. “And it is a decision between the patient and the physician.”

Typically, a patient will be in a hospice and a nurse will call the doctor to get permission to increase a morphine dose so that the patient will not wake up.

“But that does not give the patient control or choice,” said Miller. “I know that there were patients who wanted to have more control — who wanted to say, ‘Doctor, I want to do this.'”

The problem has been uncertainty among many doctors about how to provide that control, and whether there is a legal risk.

To help doctors, Miller has helped form a new group called the Physician Advisory Council for Aid in Dying, or PACAID. The four-member council will help doctors “empower” their terminally ill patients, including prescribing lethal barbiturates.

PACAID is likely to have an impact locally on the socio-political debate over aid in dying.

So-called Death With Dignity legislation has met with strong opposition from churches, some social-service agencies and end-of-life care providers at the Hawaii Legislature, and lawmakers have repeatedly heeded their concerns.

But PACAID’s establishment also comes in the wake of a January survey by QMark Research of Hawaii that found 76 percent of doctors agree that “people in the final stages of a terminal disease should have the right and the choice to bring about their peaceful death.”

Equally important, say supporters of the aid-in-dying movement, is a growing belief that the courts and state and federal governments do not have to be involved.

Groups like Compassion & Choices, which has a local chapter, argue that there are already laws on the books that favor autonomy when it comes to end-of-life decisions.

“The bottom line, in overwhelming numbers, people are saying this is not the government’s business, that this is between a patient and their doctors,” said Dr. Robert Nathanson, another member of PACAID. “So, if that’s the case, doctors need to have some kind of guideline. And we felt that PACAID was needed.”

Rigorous Process

PACAID is described as first-of-its-kind in the nation, and physicians in Montana are in the process of starting a similar council.

Beside Miller and Nathanson, PACAID’s other founding member was Dr. Max Botticelli, who passed away last month.

Two other Hawaii MDs — Clifton S. Otto and John Samuel Spangler — are also council members. PACAID will also lead and support a larger a network of supportive physicians.

While PACAID doctors could prescribe life-ending medication, that is a decision that must go through a rigorous process. PACAID members have adopted best-practice guidelines from states like Oregon and Washington where aid-in-dying laws exist. An Aid-in-Dying Practice in Hawaii—Physician Guide and pro-bono legal counsel will also be provided.

“We see the council as an advisory and consultative source, and one of the guidelines is that we would never write any prescription without collaboration and getting all that medical information,” said Miller. “We would be willing to write a prescription, but ideally it would be best if the primary doctor writes it.”

Miller added, “We do understand there are physicians who are not comfortable with this for what ever reason. So we see us as helping the patient, to give support to them for their choice for end-of-life care.”

Compassion & Choices Hawaii — a 501(c)(3) — will provide staffing to support administrative needs of PACAID physicians, who are volunteers and do not receive compensation.

How PACAID and its mission will be received is unclear.

While PACAID and Compassion & Choices believe Hawaii law allows doctors to advise patients on ending their lives, Hawaii Attorney General David Louie issued an opinion in December stating that one of those laws — a 1909 statute regarding Hansen’s disease patients — does not make doctor-assisted suicide legal.

The opinion came at the request of state Sen. Josh Green, an MD, who has held hearings on Death With Diginity.

One critic of Death With Dignity, Allen Cardines Jr., executive director of the Hawaii Family Forum, was alarmed to hear of PACAID’s formation.

“This is the first I’ve heard of it, but, top of mind, I would be very concerned about a bunch of doctors going around providing aid in dying,” he said. “I think doctors should provide aid in living, not aid in dying.”

Not Expecting Flood of Applicants

QMark Research of Hawaii conducted phone and fax interviews from Jan. 5-23 by sampling from MD listings in each county.

The specialities were cardiovascular disease, family and general practice, geriatrics, immunology, infectious disease, internal medicine,
nephrology, oncology, hematology and pulmonology.

The sample size was small — just 43 doctors completed the interviews, yielding a margin of error of plus 15 percentage points. But three out of four agreed that people in the final stages of a terminal disease “should have the right to bring about their peaceful death and the decision to receive medication to help is a personal decision between patient and doctor.”

And nearly nine in 10 doctors agreed end-of-life decisions “should be an individual decision and the medical community, rather than government, should establish practice guidelines to prevent abuse.”

Just 57 percent of doctors, however, favored allowing their terminally ill patients the choice to request and receive medication from their doctor “to bring about a peaceful death.”

PACAID’s Miller and Nathanson say they are not worried about legal repercussions.

They also do not expect to be flooded with requests for lethal doses. They base that on the experience of Oregon, which, in the 14 years since it passed a Death With Dignity law, saw only 525 patients actually use the medication.

“All the concerns are way overblown,” said Miller.

“There may be a few requests, but I am willing to bet that a majority of them won’t quite understand what the regulations are,” said Nathanson, who adds that he has turned down requests from friends. “The only reason they wanted the pills is because they are elderly, but they are perfectly healthy. I told them, ‘You don’t qualify and I hope you never do.'”

Nathanson, who rejects the argument that prescribing lethal medication is enabling suicide — “Terminal people don’t have a choice, they are going to die from disease” — said the drugs may actually produce an unexpected outcome.

“One of the paradoxes is that when a patient gets the medicine, they frequently will live longer than expected,” he said. “The hospice nurse will tell the family that their mother who wasn’t eating hardly at all or watching TV or reading or interacting is now eating like a horse and now doing those things. It’s because the person no longer has that toxic anxiety. They know that they are empowered if things become intolerable. And the definition of that is whatever the patient says is intolerable.”

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