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EM” A’ITITUDES TOWARD PAS
€DUCATION AND PRACTIC€ I
Oregon Emergency Medical Technicians’ Attitudes toward Physician-assisted Suicide TERRIA. SCHMIDT,MD, ANDREW D. ZECHNICH,MD, MPH, MELISSA DOHERTY,EMT-P Abstract. Objectives: ‘Ib determine Oregon intermediate and advanced emergency medical technicians’ (EMTs’)attitudes toward physician-assisted suicide (PAS) and factors associated with those attitudes. Methods: A n anonymous survey was sent to a random sample of 498 EMTs registered in Oregon. Results: Surveys were delivered to 498 EM% and 343 completed surveys were returned, for a response rate of 69%. The mean age of the respondents was 37.5years (28.73)and 79% were male. 232 (68%) agreed that PAS should be legal, 263 (77%) agreed that terminally ill people have a right to decide to commit suicide, while 57 (17%) thought not attempting resuscitation would be immoral. 251 (73%)reported seeing attempted suicide in terminally ill patients a t least once, with 117 (34%) experiencing such calls >5 times. Only 22 (6%) stated that they would be unable to work in a system that directed them to withhold resuscitation after a PAS attempt, and 277 (81%) agreed that treatment protocols should direct EMTs to withhold resuscitation. 105 (31%) thought EMTs should participate in the decision to withhold resuscitation. 206 (60%) thought the law
I
N NOVEMBER 1994, Oregon passed a voter initiative legalizing physician-assisted suicide (PAS). The law was subject to multiple legal challenges and a second vote in which Oregonians voted 60% to 40% in support of legalization. PAS became legal in Oregon on October 27, 1997, after the US. Supreme Court let a lower court ruling stand. In ruling on related cases from Washington and New York, the Supreme Court has stated that
should allow lethal injection for terminally ill patients. 201 (59%) agreed there were circumstances under which they might personally consider PAS. If PAS were legal, EMTa stated they would withhold treatment from a terminally ill patient following attempted suicide in the following circumstances: based on standing orders, 78%; with on-line medical direction, 67%; after speaking with the primary physician, 53%; if the patient had decision-making capacity, 45%; with written documentation from the patient’s physician, 68%; and never, 6%. Conclusions: A majority of Oregon EMTs responding to this survey expressed support for PAS, think treatment protocols should direct paramedics to withhold resuscitation in such cases, and would feel comfortable withholding resuscitation given appropriate protocols. Nearly 3 out of 4 Oregon EMTa report seeing a t least 1 terminally ill patient who had attempted suicide. Key words: medical ethics; physician-assisted suicide; emergency medical systems; EMS; Oregon; emergency medical technicians; attitudes. ACADEMIC EMERGENCY MEDICINE 1998;5~912-918
the right to PAS is not constitutionally guaranteed but did not ban it, either, leaving i t to the states to decide.’V2 The attitudes and experiences of a number of health care professionals toward PAS have been s t ~ d i e d .Support ~-~ rates for PAS outside of Oregon ~.~ vary from 22% to 56% of those s ~ r v e y e d .Oregon health professionals have shown some of the highest rates of support, ranging from 60% in a survey of those potentially qualifying as “attending phyFrom the Department of Emergency Medicine, Oregon Health sicians” under the Death With Dignity Act to 69% Sciences University (TAS, ADZ, MD), Portland, OR. among Oregon psychiatrists and emergency phyReceived December 1, 1997; revision received February 13, sicians ( E P S ) . ~ - ~ 1998;accepted February 25, 1998.Presented at the 7th InterTo date, attitudes of emergency medical technational Conference on Emergency Medicine, Vancouver, Britnicians (EMTs), who may be called to intervene if ish Columbia, Canada, March 1998. Supported by the Department of Emergency Medicine, Oregon deaths take longer than expected or complications Health Sciences University. arise, have not been addressed. The Oregon meaAddress for correspondence and reprints: Terri A. Schmidt, sure legalizing PAS explicitly provides that “health MD, Oregon Health Sciences University, Department of Emergency Medicine, 3181 SW S a m Jackson P a r k Road, Portland, care providers” may choose not to “. . . participate e-mail:
[email protected] OR 97201. Fax: 503-494-4997; in the provision to a qualified patient of medication
ACADEMIC EMERGENCY MEDICINE
September 1998. Volume 5, Number 9
to end his or her life . . .” (the so-called “conscience clause”).10Such conscientious objection would be difficult to implement in a n emergency medical services (EMS) system in which EMTs work under medical protocols because there is little time for consideration of complex ethical issues and there is no way to control which responder will be sent to the scene of a potential emergency. Whereas other health care workers (e.g., nurses and pharmacists) may at least be able to functionally refuse to involve themselves in the PAS process, EMTs face a unique dilemma: once called to the scene of a PAS attempt, they are bound not only to be involved in the process, but also to follow whatever guidelines or directions are given to them by their medical control. Such directions may or may not be consistent with their own personal, moral belief systems with regard to PAS. Further, because the Oregon law specifically requires that the medication be patient self-administered, and precludes lethal injection, there is a chance that death may not occur as soon as family or patients expect or that a complication will arise. In addition, the Oregon law provides physicians no direction about which medications to prescribe and there is little or no literature available to help physicians select which medications to use. I t has been argued that physicians’ lack of experience in prescribing lethal dosages of medication, the difficulty a patient may have with self-administration, and the variability of drug effects on different patients could all potentially lead to unsuccessful suicides.11-13There is no provision for supervision of the suicide attempt by any health care provider. This, coupled with the fact that family notification is not explicitly required by the law, enhances the likelihood that EMTs could be summoned to intervene in a PAS attempt. The Oregon law is also silent on the issue of documentation requirements, such as do-not-attempt-resuscitation (DNAR) orders, which might direct the response by out-ofhospital personnel. In light of the potential impact that legalization of PAS could have on Oregon’s out-of-hospital providers, as well as the implications for out-of-hospita1 providers nationwide should PAS become legal in other states, we surveyed Oregon EMTs. The purpose of this study was to determine EMTs’ attitudes toward PAS and concerns, should PAS be legalized.
METHODS Study Design. A survey w as mailed to a random sample of Oregon EMT-paramedics (EMT-Ps) and EMT-intermediates (EMT-Is) in June 1997, a time when the law was on hold due to legal challenges. A reminder postcard was sent to nonresponders
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approximately 2 weeks after the initial survey, and the survey was remailed two weeks later. The return envelopes were coded to track nonresponders, but the surveys were immediately separated from the envelopes and the coded envelopes were discarded by the research assistant to maintain the confidentiality of the respondents. The survey itself contained no identifying information. Based on the survey design, the study is exempt from review by the human subjects committee. Survey Instrument. The questionnaire contained 10 demographic questions, 14 Likert-type attitude questions, and 3 forced-choice questions. The survey was modeled after a previous survey about PAS in the state of Washington and a survey instrument for a study of primary care physicians in Oregon and the authors’ previous study of E P s . ~ .The ~ . ~ term “lethal prescription,” consistent with the wording in t h e Oregon initiative, was used in reference to PAS. After review of the questionnaire by a statistician, the survey was pilottested on a convenience sample of 18 paramedics. The pilot surveys were reviewed for content. Based on the paramedic responses and their comments, several questions were modified. Sample. A list of all EMTs (including EMT-Is and EMT-Ps) certified in the state of Oregon (n = 3,187) was obtained from the Oregon Health Division. EMT-basics (EMT-Bs) were excluded from the study because in Oregon a large number of people are certified as EMT-Bs but do not work in a n EMS setting where they might come into contact with a patient after a PAS attempt. After excluding EMT-Bs and those EMTs who did not list a n address in the state of Oregon, each was assigned a computer-generated random number, and the 500 lowest random numbers were selected as the sample, resulting in a simple randomization process without stratification. After the first mailing, 6 surveys were returned by the postal service for lack of a forwarding address, and the survey was then mailed to a n additional 6 EMTs. Two further subjects were deleted: one was a member of the research team (MD) and the other was no longer certified as a n EMT. Data Analysis. Data were manually entered into an electronic database (Microsoft Access) and analyzed using SPSS for Windows version 7.5. All surveys were reentered by the research assistant to verify data integrity, and no data entry errors were detected. Additionally, 5%of the surveys were reentered by another abstractor (ADZ) and no errors were identified. Initial analysis included standard descriptive techniques (mean and frequency of responses). Likert scale responses were col-
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TABLE1. Religious Affiliations of the Respondents Religious Affiliation ~~
Number ~
~
Protestant and other non-Catholic Christian Catholic None Other* Jewish ~
~
Proportion
~~
~
(47%) (15%) (30%) (5%)
161 52 104 17 6 ~~
gression modeling was used to assess the relationship between characteristics of respondents (certification level, education, gender, age, religion, and practice location) and attitudes toward legalization of PAS.
RESULTS
(2%)
~
EMT AlTITUDES TOWARD PAS
~~
*Includes Latter Day Saints, Unitarian, Native American beliefs, Buddhist, and nondenominational.
EMT Characteristics. As of October 1, 1997, completed surveys were returned by 343 of 498 respondents (with 5 additional respondents relapsed to agree (agree and strongly agree), neutral, turning the survey but declining to answer), for a and disagree (disagree and strongly disagree). x2 response rate of 69%. The majority of the responor Fisher’s exact test was applied as appropriate dents were male (79%), with a mean age of 37.5 to 2 X 2 tables comparing agree and disagree, and years (58.73;range 21-64 years). The respondents paired responses on the questionnaire were ana- included 208 (61%) paramedics and 135 (39%) lyzed using the McNemar test. Where appropriate, EMT-Is. The majority (78%)had some college or a n analyses were repeated using the Wilcoxon rank associate degree, while 16% had a bachelor’s desum test without significant effect on the results. gree, 2% a master’s degree, and el% a doctorate Correlations between ordinal scale data were per- degree. On average, the EMTs are currently working 44 formed using Spearman’s rank correlation. Significance was set a t p = 0.05, but for the multiple hours per week (523.40;range 0-120). Seventyunivariate comparisons against the primary out- three (23%) live in a large city (>250,000) or subcome measure (attitudes toward legalization of urb, 59 (17%) in a medium-sized town (50,000PAS), the Bonferroni correction was applied (11 250,000),and 191 (56%) in a small town (’.,“’
20%
40%
I tl Unanswered
60%
Disagree
T.
. 80%
Neutral 0 A ~ r e e
Figure 1. Attitudes toward physician-assisted suicide by Oregon emergency medical technicians.
100%
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September 1998, Volume 5, Number 9
rcsuscitatc a tmnindl) 111 patient who has mkcn a lethal ovndow
Ph).ncians h w e an ethical obligation to pro\& \muen documentationwhich pro\idcs dueflion 0th- UTC providcn dthm prcrcrik a lethal medication for a patient
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18%
3 1%
10
Treatment protocols should direfl EMTs to mlhhold resuscitationon a tcrminalh 111 penon who has DV 4R o r d m and has ingcsted medication
1
0%
40%
20%
60%
-
80%
100%
I El Unanswered W Disagree 0Neutral 0 Agree 1 Figure 2. Concerns about implementation of physician-assisted suicide laws in emergency medical services (EMS) systems. EMT = emergency medical technician; DNAR = do-not-attempt-resuscitation.
respondents currently are working in a 911 system, 235 (68%); 68 (20%) are volunteer EMTs, 11 (3.2%) work in a non-911 system, and 29 (8.5%)are not currently working as EMTs. Table 1 lists the religious preferences of the respondents. Seventy-one (21%) reported that they were very religious, 216 (63%) were somewhat religious, and 51 (15%) were not at all religious (2% no answer).
swer), as shown in Figure 2. Nonetheless, only 22 (6%) stated they could not work in a system that directed them to allow a terminally ill person to die without attempting resuscitation after the person had ingested lethal medication (80% disagree, 12% neutral, 2% no answer). In fact, most respondents, 277 (81%), agreed t h a t treatment protocols should direct EMTs to withhold resuscitation on a terminally ill patient who has DNAR orders and has ingested medication (9% disagree, 9% neutral, Attitude toward PAS. The majority of the re- 2% no answer). Thirty-one percent of the responspondents (68%) agreed that i t should be legal for dents thought that EMTs should participate in the a physician to assist a terminally ill patient to com- resuscitation decision (49% disagree, 18% neutral, mit suicide by providing a lethal prescription in 3% no answer). When asked about lethal injection, 206 (60%) some circumstances (23% disagree, 8%neutral, 1% no answer), and most respondents (77%) believe agreed that the law should allow physicians to use that terminally ill persons have a right to decide a lethal injection (27% disagree, 12% neutral, 1% about suicide (17% disagree, 6% neutral, 1% no an- no answer). However, when asked about Oregon’s swer), as shown in Figure 1. However, 57 (17%) current law allowing PAS, only 111(32%) thought respondents agreed t h a t a n EMT not attempting that it has enough safeguards to protect vulnerable resuscitation of a terminally ill person after a le- people (31% disagree, 34% neutral, 3% no answer). thal overdose would be immoral (64% disagree, 17% neutral, 3% no answer). Further, 60 respon- I f l u e n c e s on Attitudes toward PAS. Eightydents (18%)agreed they would never allow a per- one respondents reported that their positions on son to die without attempting resuscitation o n a PAS were influenced by religion, while 177 (52%) person who took a lethal medication prescribed by stated that personal experiences of illness in thema physician (66% disagree, 15% neutral, 2% no an- selves or others made them more supportive of
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TABLE2. Proportions of Respondents Who Would Feel Comfortable Withholding Resuscitation of a Terminally I11 Person after Ingesting Medication before and after Implementation of a Law Legalizing the Practice of Physician-assisted Suicide Circumstance
Without a Law
With a Law
p-value*
Based on standing orders With on-line medical control With direction from the physician who prescribed the drug After talking to the alert patient With written documentation from the physician Never withhold resuscitation
189 (55%) 206 (60%)
268 (78%) 229 (67%)
