We had our dog put down yesterday.

Simon joined our family when our son was 10 years old as a two year old that we adopted from the Purdy Prison Pet Parole Program and was with us until he developed status epilepticus forcing our decision to have Simon euthanized.

Simon had been getting old, lame, nearly blind, and uncomfortable most of the time, but we felt he still had some enjoyment in life until yesterday. When we carried Simon in to our vet he said, “In your business you are not allowed to do this (euthanize patients) but in mine we are, and this seems wise.” If this had been me as a physician, and Simon a human, the process would have been much more complex, the decisions more painful, and I’m thankful that I’ve not been put in this situation yet as a physician.

The possibility that I’ll have to face this issue in Washington became real Nov 4, 2008 with the codification of the “Death with Dignity” act. For end of life situations, with careful safeguards in place and after multiple systematic steps are taken, a physician is legally allowed to prescribe lethal medication to allow a patient to commit suicide.

I was still the medical director at Sound Family Medicine at the time this law came to pass. We discussed it at length at our board meetings, and decided that this was really a personal decision for each physician to make, whether to choose to provide this care to their patient or not. We set in place a protocol to carefully assure we complied with all the explicit regulations if any of us decide to provide lethal prescriptive service for a patient.

Thankfully no patient has asked any of us for this care so far as I am aware. Personally I have very mixed feelings about this law, and participation as a physician. As a living human being, and patient, I am aware that there could be circumstances where I might choose to end my life before nature took it’s course. If I was in great pain or suffering, felt a burden to my family, knew the end was very near, and that the quality of my days was awful I could see considering suicide.

Most physicians know of patients who have chosen this route near the end. Some masked as accidents, others violent by firearm use, and others by intentional self-neglect or starvation/ dehydration. We hear things like, “They just gave up,” or “Grampa just lost his will to live and stopped eating.” Sometimes we hear the story from a surviving spouse and wonder if maybe the deceased partner decided to take too much of their pain medication on purpose and hurried nature along a bit.

As a physician I’ve made rounds in the hospital and seen a patient with severe COPD, lung cancer, terrible bone pain from metastatic disease, and had to decide how much more morphine to prescribe, knowing that if I gave enough to reduce the pain I might bring on respiratory failure and hasten death. I have easily justified the relief of suffering and not been distraught when death came in all likelihood more quickly.

This is only a short ways from this same patient asking me to intentionally be sure I gave him enough medicine to hasten his death. That’s only a short distance from a stroke patient, paralyzed, aphasic, incontinent, and yet very much aware of the situation and having the capacity to live this type of existence for a moderate period of time asking me to prescribe them a lethal dose of medication.

I appreciate the moral, religious, and highly personal issues involved in a physician making the decision as to whether to provide lethal care. I am grateful that the WA law does not mandate physician participation in this service. Yet I can also see how at least some of my patients, in some circumstances, might ask me to help them in this way.

How will I respond if they do? I‘ll definitely spend enough time with them to figure out if I believe their decision is based on reality, or not. Depression, other treatable psychiatric illness, and social, family, and economic situations can keep a patient from seeing that their situation is not as bleak as it appears to them. If I believe that their decision is reasonable, that their decision is sound, and that the medical, spiritual, social and psychiatric care that could be brought to help them will in fact be futile, then I think I could agree to help them commit suicide.

I’ve prayed about this, spent some time soul searching, and now I hope that I am never asked to act in this capacity. It certainly lends additional motivation to be sure I work diligently to give adequate pain relief and palliative care to my terminal patients. Hopefully that way I can support them to a spontaneous death before they feel a need to make assisted suicide their choice.

Maybe dogs have it better in this regard.

Edward Pullen is a family physician who blogs at DrPullen.com.

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