Background     Requests for hastened death among terminally ill patients occur commonly (see Fast Fact #156).  With good symptom management, psychological and spiritual support, most patient requests do not persist.  This Fast Fact focuses on ways of responding to patients with persistent wishes for a hastened death despite every effort to find appropriate alternatives.  This Fast Fact does not address such requests by surrogate decision makers of patients who have lost decision-making capacity.

1. Reflect on your personal feelings about the request and discuss with other professionals.  These cases are emotionally and ethically difficult.  Brainstorm options with other members of the care team including physician colleagues, nurses, psychologists, chaplains and others.  Allow trusted colleagues to support your emotional reactions. 
2. Seek out consultation/2nd Opinion.  Make sure you understand the medical, legal and ethical issues involved in responding to a particular request for hastened death.  Palliative care and/or ethics consultations are invaluable.  Independent second opinions may be helpful in clarifying the prognosis and ensuring that all potentially effective therapeutic alternatives have been considered.
3. Learn the possibilities.  Possibilities are listed below from least to most ethically controversial. Considering these possibilities assumes that aggressive measures to control physical, psychological and spiritual suffering have been exhausted and/or rejected by the patient:
   • Withdrawal of life-sustaining treatments.  While most clinicians consider stopping invasive treatments under these circumstances (e.g. ventilators, ICDs, feeding tubes), simpler therapies such as insulin, antibiotics, oxygen, or steroids might also be voluntarily discontinued if they are prolonging life against the patient’s wishes. (Unlike the other possibilities, there is widespread legal and ethical consensus about the permissibility of this response based on the right to bodily integrity.)
   • Voluntary withdrawal of oral intake.   Patients may choose to stop eating and drinking to shorten the dying process.  Completely stopping oral food and liquids will typically result in death within two weeks.
   • Sedation for severe intractable physical symptoms (see Fast Facts #106,107).  The intent of sedation is to relieve intolerable suffering by a reduction in patient consciousness.   If artificial hydration and feeding are simultaneously stopped, death will come within 1-2 weeks. 
   • Assisted Suicide.   Assisted suicide is defined as someone who provides the means for another person to end their life (e.g. prescribing an overdose amount of medication), but the patient is the one to decide if and when the medicine is actually used, and the patient is responsible for taking the medicine.  Physician-assisted suicide is illegal in the United States except for selected states (e.g. Oregon, Washington, Vermont, and Montana).     

1. Decision making process.  Have a detailed conversation regarding the risk and benefits of the different possibilities that fit the patient’s clinical circumstances, and which the patient, family and you find ethically acceptable. Be as specific as possible, and document your thinking process clearly.  Thus, if stopping eating and drinking is being considered, be sure everyone understands the importance of complete cessation of drinking or else the process can take months rather than weeks. 
2. Balance integrity and non-abandonment.  It is not always possible to find common ground between the patient and physician.  When asked if one can support a particular act, a physician needs to be as specific as possible about what he/she can and cannot do, and why.  While the physician should not violate personal principles to respond to a request he/she finds unacceptable, he/she should search in earnest with the patient and family for alternative options that might be mutually acceptable.  Typically, this approach will allow the physician to maintain integrity while not abandoning the patient, even if agreement on the particular act in question is not possible (1-4).

References

1. Quill TE, Cassel CK. Non-abandonment:  A central obligation for physicians. Ann Intern Med. 1995; 122:368-374.
2. Quill TE, Lo, Brock DW. Palliative options of last resort:  A comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA. 1997; 278:1099-2104.
3. Quill TE, Byock I. Responding to intractable terminal suffering:  the role of terminal sedation and voluntary refusal of food and fluids.  ACP-ASIM End-of-Life Care Consensus Panel. Ann Intern Med. 2000; 132:408-414.
4. Quill TE, Coombs-Lee B, Nunn S. Palliative options of last resort: Finding the least harmful alternative. Ann Intern Med. 2000; 132:488-93.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in July 2006.  Version re-copy-edited in April 2009; then again November 2016 (legality of physician assisted suicide in US updated).