news.notes20090522c

[Today's Paper] from [Los Angeles Times]

In rural Washington state, law allows assisted suicide, but most doctors don't
Terminally ill patients who want to utilize a new law to end their agony often find that physicians, citing moral objections, refuse to take part.

By Kim Murphy
May 7, 2009

Reporting from Kennewick, Wash. -- Stephen Wallace had watched his wife die of cancer 22 years ago, using up the morphine as fast as they could put it into her and begging for more. NoNo, he said then. I won't let this happen to me.

So when he was diagnosed with an advanced case of pancreatic cancer March 8, and given a few days to a few weeks to live, Wallace hoped to go quickly. He told his doctor and family that he wanted to take advantage of Washington state's new law allowing physicians to prescribe a fatal dose of barbiturates to terminal patients. His five children agreed, but his doctor balked, citing moral reservations.

The family appealed to the hospital, got nowhere, and called two other hospitals in towns nearby. None of the doctors in the area was willing to give Wallace, 76, the pills for his deadly sleep.

Cancer of the pancreas has a cruel reputation, delivering what some say is the most intense pain humans can imagine. It killed Wallace on April 8.

"It was very hard to watch my father die that way," said Tricia Crnkovich, who took turns with her brothers and sisters in Wallace's small bedroom as he shrank from 250 pounds to 60, losing most of the weight in the two months before he died. "I'll tell you, if I ever get cancer," she said, "I don't want to put my kids through that."

On March 5, Washington became the second state in the nation to allow physicians to help hasten the death of terminal patients. Oregon legalized a nearly identical "death with dignity" statute in 1997, and the courts in Montana have ruled that the right to privacy extends to patients seeking a doctor's help in ending their lives.

But outside the larger population centers around Seattle, Tacoma and Olympia, many physicians are unwilling. That leaves residents east of the Cascades who choose to utilize the statute with the same problem women seeking abortions in conservative rural communities have faced: It's legal, but health providers' moral qualms mean it's essentially unavailable.

"We knew that it would be harder to find attending and consulting physicians in more rural areas," said Robb Miller, executive director of the advocacy group Compassion & Choices of Washington. "It's going to take time to get people educated about the law . . . and build up trust and confidence among the physicians -- many of whom support the law and want to use it, but who might not be ready yet to make the leap."

Wallace raised his family here amid the arid farmland that spreads out from the confluence of the Columbia, Snake and Yakima rivers. The growing popularity of Washington's wines have lent a certain cachet to an otherwise bland expanse of fast-food restaurants, budget hotels and modest neighborhoods.

The area also is home to the Hanford nuclear reservation, where plutonium for the atomic bomb that was dropped on Nagasaki, Japan, in 1945, was manufactured. Hanford has since become a nightmare of leaky, poisonous tanks and a testament to the difficulty of cleaning up nuclear waste.

For most of his life, Wallace worked at Hanford. His job was one of the more dangerous ones, transferring the facility's perilous brews from tank to tank. His work there, Crnkovich and her siblings believe, led to his cancer.

From the moment he was diagnosed, the family said, Wallace refused even to go into hospice care. "When he retired in '94, he said, 'I bought this bed, and I will die in this bed,' " said his daughter-in-law, Ginny Wallace.

But Wallace's physician could not bring himself to assist, the family said. Dr. Idar Rommen, a family practitioner in Snohomish County -- another largely rural Washington area where most hospitals have refused to participate in the new law -- understands why.

"To me, personally, giving a patient a suicide pill is like abdicating my role," Rommen said. "I'm here to heal and to make better. And the other just doesn't seem like that's what I went into medicine to do."

The extent of the hurdles patients face in the Kennewick area became clear during a recent physicians' briefing that the Benton Franklin County Medical Society held here. The presentation on the new law, which allows a physician to prescribe a fatal dose of medication after a second qualified doctor also has certified that the patient is terminal, was met with silence.

"There was no feedback," said executive director Nicole Austin. "We're trying to walk a very neutral line. It's their decision as physicians if they choose to participate. I sense that it will be a challenge in this community."

Only about a third of Washington state hospitals have opted to allow their doctors to assist terminal patients under the law. Austin said many doctors are especially uncomfortable with the requirement under the law that physicians list the cause of death as the terminal illness, not suicide.

Similar reservations have made it difficult to get assisted-suicide statutes on the books in other states. California lawmakers have failed several times to pass such legislation, although late last year they adopted a measure requiring terminal patients be counseled on various end-of-life options, including the right to be heavily sedated and withdrawn from food and water.

Through 2008, 401 people in Oregon had opted for what Compassion & Choices prefers to call "death with dignity." So far, three Washington residents have obtained lethal prescriptions under the law.

Proponents characterize the laws as a means of allowing the terminally ill to have some say over how and when they will die.

Critics, including the American Medical Assn., contend that the better response is to offer patients adequate pain medication and reassurance.

"They want to force doctors to act against their conscience and to become essentially vending machines for individuals who requisition overdoses to kill themselves," said William L. Toffler, a professor of family medicine and executive director of Physicians for Compassionate Care Education Foundation, which has opposed assisted-suicide statutes.

"The solution to suffering," he said, "never is to eliminate the sufferer."

But for Wallace, alleviating the pain did not appear to be an option.

Crnkovich said her father had been given strong medications when he went home from the hospital, but that his nurses had resisted increasing the dosage as his pain grew more intense.

Soon Wallace's mental state began to deteriorate. Because the assisted-suicide law requires a 15-day waiting period between the first oral and the first written requests for lethal medication, and an additional 48 hours before the prescription can be written, he no longer qualified.

"He couldn't talk for the last eight days," son Steve Wallace said. "He was not in contact with reality. I'd come in there, and he'd call me somebody else."

Near the end, Steve and Ginny could hardly stand to be in the house because his father was in so much pain. By the time the doctor said his medication should be increased despite the nurses' concerns, it was too late.

"He was just moaning and screaming, and it got really bad on Friday," Ginny said. "By Monday when we left, he was just screaming at the top of his lungs."

Wallace was dead two days later. An autopsy revealed that the cancer had consumed his pancreas, liver and parts of both kidneys and lungs.

Crnkovich said her father had asked family members to speak out about his failure to find a doctor to help him. They have met with state and federal legislators, telephoned hospitals and spoken with the media.

"Since I started talking, I've had people come up to me in the supermarket parking lot and say, 'Murder's murder.' And other people have come up to me and said, 'Thank you. Now I know what to do if the time comes,' " she said.

"People don't know what it's really about," her brother added. "It's not about killing people. It's about people that are going to die, but don't want to go through hell to do it."