A Palliative Care Doctor Weighs California's New Aid-In-Dying Law

Jan 4, 2016
Originally published on January 11, 2016 1:18 pm

When she first heard that California's new aid in-dying law was signed, Dr. Carin van Zyl was relieved to hear that assisted death would be an option for her if she ever needed it herself. But as a palliative care doctor at the University Of Southern California Keck School Of Medicine, she's worried the law might lead people to consider lethal medications over other options that may better accommodate their wishes.

"Patients feel as though their choices are between untreated suffering or physician-assisted suicide," she told NPR's Renee Montagne. "Palliative medicine, when it's applied skillfully and at the right time, often relieves most of the suffering that prompts people to ask for [death] in the first place," she says.

But palliative care, which is focused on managing symptoms and relieving pain, isn't available to everyone, van Zyl says. There are smaller hospitals that don't have palliative medicine teams, and it may be hard to get treatment even in urban areas. Van Zyl thinks more work should be done to make palliative medicine more accessible. "I worry that we make [lethal medication] available before we put the necessary effort forward," she says.

Not everyone can be helped with palliative care, van Zyl says, and some people truly would have benefited from the aid-in-dying law had it been passed earlier. "I think about those patients all the time. I do recall a patient who understood that his death would be sudden and unpredictable and likely quite painful."

He had a cancer that had spread and become intractable. A tumor developed in his neck that was swelling into both an artery and his windpipe; eventually it would connect the two. "This gentleman with very little warning might have his airways flooded with blood, and he would drown," van Zyl says. "He asked if it would be possible to shorten his life before that."

The care team was able to administer pain medication that would ease his death when it happened, which worked, van Zyl says, but he wasn't able to die in the way he wanted — at home, surrounded by his family. Aid in dying would have offered more control over his situation, van Zyl says.

Still, the reasons why people choose aid in dying can be complicated. "You'll notice in the Oregon data, many people chose this option not because of physical suffering. It was the loss of dignity, control and independence," she says. "I would imagine writing a prescription for somebody for whom palliative sedation is not an option or would not relieve intolerable physical distress. I struggle with emotional and existential requests." Times like that, van Zyl says she would rather administer palliative care.

Choosing the best course of action is a conversation that van Zyl says she'll continue to have with her patients. "Palliative medicine discussions are about learning the story of the person, helping this patient navigate choices. If [death] is an option that gets them closest to the things they hold dearest, then we will explore those things honestly."

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And when California this year becomes the fifth and by far the largest state to adopt an aid in dying law, it will draw many doctors into those decisions. Physicians will prescribe the lethal drugs, and there have to be two doctors involved in every case. Patients must administer the drugs themselves. Doctors most likely to be involved are those specializing in palliative care, those who try to relieve the suffering of patients as they are dying. Some are conflicted about the new rules, and that includes Carin van Zyl. She's a palliative care physician at the USC Keck School of Medicine.

Thank you for coming in and talking to us about this.

CARIN VAN ZYL: Oh, it's my pleasure.

MONTAGNE: What has been your reaction - your initial reaction to the possibility that you will be asked to be involved in hastening one of your patient's death?

ZYL: Well, it's so funny. If you ask me as a patient, I was relieved to hear that something like this might be an option for myself in the future. Like, at the very basic level I think I feel a panic around my death and what that might look like. And I'm certain I'm not alone in that feeling, and I recognize that in my patients and empathize with it when I see it all the time. So from a personal standpoint, knowing that the law is there calms that panic just a little bit. If you ask me as a professional, I was really worried. Part of the reason was that I feel too often patients feel as though their real choices are between untreated suffering or physician-assisted suicide. And there's a really effective third choice that isn't available to everybody.

You know, palliative medicine, when it's applied skillfully and at the right time, often relieves most of the suffering that prompts people to ask for this in the first place. I've never had somebody persist in their request once their physical suffering has been dealt with. Their outlook really changes. And so I worry that we made this available before we really put the necessary effort behind making sure that palliative medicine was available to anybody with a serious illness and that anybody treating seriously ill people have a baseline fluency with good symptom management and good communication skills around these issues.

MONTAGNE: End-of-life discussions, do you have them with your patients?

ZYL: All the time, every day.

MONTAGNE: Obviously very delicate.

ZYL: Yes.

MONTAGNE: How might this new aid in dying law change that conversation?

ZYL: At its heart, palliative medicine discussions about end-of-life options are about learning the story of the person and figuring out what it is that they cherish the most, what they're hoping to achieve with treatment. And then my job is to help this patient and their family navigate the choices and pick the one that gets them closest to what they most cherish. That conversation isn't going to be changed by this option being made available. And if we arrive at the conclusion that this might be an option that gets them closest to the things that they hold dearest, then we will explore those things honestly.

MONTAGNE: This has not been an option up until now in the state of California.

ZYL: Right.

MONTAGNE: Now that you're looking ahead to this new law, if in fact any given patient came to you and said I want to hasten my death...

ZYL: Right.

MONTAGNE: ...What do you think at this point you would say to that patient?

ZYL: I could imagine lying awake at night for months no matter what I do.

MONTAGNE: For months?

ZYL: Oh, yeah. I would always worry that I hadn't done enough to get to the root of that request. Once the prescription is actually ingested, there's no going back. And I would carry my part of the responsibility for that. And I would feel the same if I said no to a patient.

MONTAGNE: It sounds like a great burden of guilt is being placed upon you.

ZYL: I would rephrase it more as responsibility than guilt. I worry when it's easy. That to me means that an appropriate thoroughness in the examination for whether this was a good idea or not might not have taken place. I think it ought to be difficult to make these decisions. I think that's the internal check.

MONTAGNE: Well, thank you very much for sharing this with us.

ZYL: Thank you so much for letting me be here.

MONTAGNE: Carin van Zyl is a palliative care doctor at USC. Transcript provided by NPR, Copyright NPR.