A 51-year-old man comes to the office for a follow-up appointment. The patient was recently diagnosed with amyotrophic lateral sclerosis (ALS), and his condition has deteriorated rapidly. Physical examination shows progressive muscle weakness and atrophy. The patient says, "I need to know that, when things get really bad and I can't take care of myself, you will help me end my life. I haven't discussed this with my wife yet, but I think she would agree that it would be better to end my suffering when the time comes." The patient has no psychiatric history and is not currently suicidal. Which of the following is the most appropriate response to the patient's request or concern?

Question

A 51-year-old man comes to the office for a follow-up appointment.  The patient was recently diagnosed with amyotrophic lateral sclerosis (ALS), and his condition has deteriorated rapidly.  Physical examination shows progressive muscle weakness and atrophy.  The patient says, "I need to know that, when things get really bad and I can't take care of myself, you will help me end my life.  I haven't discussed this with my wife yet, but I think she would agree that it would be better to end my suffering when the time comes."  The patient has no psychiatric history and is not currently suicidal.  Which of the following is the most appropriate response to the patient's request or concern?

Quizplus · Accepted Answer

Physician-assisted suicide is the process by which a physician helps competent patients voluntarily end their lives when faced with end-of-life suffering. It involves providing medication, a prescription, or information to a patient with the understanding that the patient intends to use it to complete suicide. Although it is legal in a few states and in some countries, physician-assisted suicide is a controversial area of ethics. Physician-assisted suicide should be differentiated from euthanasia, in which a physician administers a lethal substance. In the United States, euthanasia is illegal and is considered unethical. When approached with such a request, the physician should respond with empathy and compassion and explore the reasons for the request. Reasons may include fears of loss of autonomy and dignity, fears of suffering (eg, uncontrolled pain, dyspnea) and poor quality of life, and feelings of not wanting to be a burden to others. Once the patient's fears and concerns are identified, the physician can discuss palliative care options that address these specific issues. Palliative care interventions to improve quality of life include adequate pain control, psychologic support, comfort care, and appropriate multidisciplinary referrals (eg, hospice, counseling, spiritual). (Choice A) This response ignores the patient's request and will likely make him feel that his concerns are not being heard. It fails to explore the reasons behind the patient's request and misses the opportunity to discuss potentially beneficial palliative care interventions. (Choice B) This response assumes that the patient is depressed and avoids having a difficult end-of-life conversation by recommending that the patient speak to another provider. The physician has an established relationship with this patient and should explore the issue with him first. If further counseling or intervention is required, a referral to a mental health specialist can be made. (Choice C) This response is likely to elicit guilt rather than encourage exploration and understanding of the patient's experience and fears. (Choice D) Deferring the conversation to a later date can contribute to even greater distress because the patient's concerns are likely to grow over time. Palliative care interventions to address the patient's concerns and improve quality of life should be discussed now. Educational objective: The initial response to a request for physician-assisted suicide should include exploring the patient's reasons for the request. Once the patient's concerns and fears are identified, the provider can optimize palliative care interventions to address specific issues and improve quality of life. References: The American Medical Association and physician-assisted suicide. (http://www.ncbi.nlm.nih.gov/pubmed/30046187) End-of-life management in patients with amyotrophic lateral sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/25728958)

A 51-Year-Old Man Comes to the Office for a Follow-Up