We need a real proposal for better end-of-life care

After a decade without success, the Connecticut legislature is again considering a bill to allow physicians to assist patients in the taking of their own lives. I am not a legislator, but a practicing academic physician and as such I ask three questions when considering the merits of legislation: (1) What problem is it trying to solve? (2) Is it enforceable if safeguards are not followed? (3) Are there better alternatives?

What is the problem the bill is trying to solve?

Many physicians have seen patients whose physical pain and emotional misery could have been better managed at the end of life. Some advocates for the proposed legislation see it as a solution to end-of-life suffering and see its passage as a way to give the patient and their families more autonomy in how these final days are spent.

Although I strongly advocate for the patient to be at the center of endof-life decisions, I have many concerns about the bill. First, although the proposed legislation requires death to occur within six months “within reasonable medical judgment,” physicians are not so good at predicting the precise timing of death.

Secondly, the “attending physician” has only been defined as “a statelicensed physician with primary responsibility for the patient’s medical care and treatment of the patient’s terminal illness” and the “consulting physician,” as one who is assigned to render a second opinion to confirm the attending physician’s initial diagnosis and prognosis. If you are a patient, how do you know that your attending physician made the correct diagnosis and then referred you to the most appropriate person to render a second opinion on your care?

And then, how do you know you are receiving state-of-the art care? Instead of taking medication to end your life, perhaps what you need is an independent opinion from a more specialized physician.

Lastly, and for the first time this year, the bill requires that “the attending physician shall refer the patient for counseling to determine whether the patient is competent to request aid in dying.” There is no mention of the qualifications of the individual who will make this determination.

Is it enforceable if safeguards are not followed?

The proposal provides for the usual proposed safeguards seen in other countries and states. This includes requiring the physician to report to the Department of Health patients whom they assisted including their name, diagnosis and prognosis, and that all requirements under the law have been met. It also states, presumably to give assurance that no malice will occur, that “any attending physician who fails to act in good faith when determining whether a patient meets the requirements in order to request aid in dying … shall be guilty of a class B felony.”

This all sounds good in theory, but I can assure you that there is no way lawmakers or law enforcement can find their way into the examination room, hospital or home where these decisions are made, or deaths reported. Just look at history to see how often the law was not followed. In Holland, by one account, 60 percent of cases were not completely reported to authorities. In Oregon, reportedly less than 5 percent of assisted suicide cases were referred for psychiatric consultation. Additionally, if we allow physician assisted suicide, must we then legalize euthanasia to “protect” those too debilitated to take the medicines themselves?

Are there better alternatives?

I think we all agree that the end of life must be handled with the utmost care and expertise from our medical team. I also believe we must do better than we are doing with end-of-life care, including management of pain and anxiety. As a physician with over 35 years of experience taking care of patients and teaching the art of medicine, it is my firm belief that physicians must not be put in the position, and patients given an expectation that we will give medications for the ending of life.

Although the intent of legislators may be good, the resultant bill is terribly misguided. Instead, our lawmakers should advocate for and fund programs that ensure we are well-trained in end-of-life care and that our patients have access to the best diagnostic modalities and treatment for their illnesses as well as have palliative care at the end of life (as is being discussed in Senate Bill 1075.).

This is the kind of care that I and my colleagues advocate for every day at our own hospitals and clinics. Let our legislators accompany and support us so we can deliver the care our patients deserve.

Dr. Andr é N. Sofair is a professor of medicine, epidemiology, and public health at the Yale School of Medicine in New Haven. This opinion is his alone.