In this national survey of hospice and palliative medicine physicians, we found evidence that well-accepted, ethical, and legal end-of-life care practices continue to be commonly misperceived as being euthanasia or murder and the accusers are often other health care professionals. A small proportion of physicians were investigated for hastening death when that had not been their intention. Physicians practicing palliative medicine misidentify the medical practices that place them in jeopardy. Accused physicians experience significant emotional distress, professional havoc, and personal turmoil.
The ethical principles that underpin palliative care are respect for autonomy and beneficence. Autonomous patients may forgo or withdraw life-sustaining treatments. For patients who lack decision-making capacity, surrogates may direct medical treatments toward comfort and relief of suffering as long as it is in line with the patient's known goals and desires for medical care. It is both legal and ethical for physicians to administer drugs such as opiates and benzodiazepines to treat suffering, even if death may be hastened, provided that the physician's intent is to relieve symptoms, not shorten life. Indeed, misperceptions around the use of these medications for pain and other symptoms persist despite multiple studies showing they are safe, beneficial, and, when used correctly, they have benefit profiles that far outweigh adverse effects.10–12
What is paramount is the physician's intention. As long as medical treatment is proportional, directed toward the amelioration of the symptoms, and the physician's intention is not to hasten death, both the judicial system and most major religious traditions acknowledge the correctness and compassion of these practices. This principle, called the rule of double effect (RDE), is based on the principle of beneficence and was supported in Vacco v. Quill
the 1997 U.S. Supreme Court decision that found no constitutional barrier to states criminalizing assisted suicide. Although the Supreme Court in the combined cases of both Glucksberg
(the case of Washington v. Glucksberg
argued that Washington State's ban on assisted suicide violated the Fourteenth Amendment) and Vacco
rejected a right to assisted suicide, the cases have been read to suggest a right to palliative care, including palliative sedation and pain relief that may hasten death.16
Although legal precedents on this matter are clear, they cannot prevent conflicts and misunderstandings over terminal care practices or settle the discord in our society as to what constitutes humane end-of-life care.
Against the backdrop of controversies such as the Schiavo case and the furor around a legislative effort to reimburse practitioners for advance care planning visits, our findings suggest that educational efforts have been insufficient to stem conflicts in the arena. This is disheartening given the advances over the last decade in promoting care that eases suffering for patients with serious illness.17,18
It is possible that even with education some health care providers, patients, or family members would continue to believe these palliative treatments are wrong, because they do not agree with the underlying moral principles.
Physician education efforts should continue around the rationale for the most common palliative treatments—stopping life-sustaining treatments and prescribing opiates—not just those perceived as higher risk, such as palliative sedation. Although hospice and palliative medicine physicians may be comfortable with these practices, it is important that they maintain open lines of communication to other health care practitioners as well as meticulous documentation as to the purpose of the medications they use and treatments they provide. Efforts to clarify and explain the intent of palliative medicine treatments seem particularly important given that the majority of the formal accusations reported were brought by other members of the health care team. As one physician noted, explicit documentation about the rationale for opiate use and even the recording of dosage calculations turned out to be essential in justifying his clinical care.
None of the physicians in this sample who had been formally accused were found guilty. They nevertheless experienced substantial emotional distress and concern over dreaded outcomes during the course of the investigation, and even when cleared, many had their professional careers disrupted or damaged. What may be useful, in addition to education about the importance of documentation, is the publication of additional consensus statements and position papers differentiating euthanasia or murder from commonly employed ethical and legal palliative medicine practices. The field may also consider a unified and coordinated effort to provide accused clinicians with legal expertise and support from leaders and professional organizations in order to expedite the process of exoneration and potentially mitigate the psychological and financial expense of these investigations. Creating methods to seek more mediation and less adversarial professional and legal proceedings for the resolution of these conflicts should be a goal for health care professionals, health care administrators, medical boards, and regulatory bodies overseeing health care law. Further education of health care professionals and the public is of paramount importance.7
Limitations in this study that leave uncertainty about the generalizability of the findings include our response rate of 53% and the inclusion of only physicians who practice hospice or palliative care. Our response rate does not appreciably differ from other physician surveys about care for patients near the end of life.19,20
Any physician who works with patients near the end of life may be the potential target of murder allegations if their motivations are not understood by families and other members of the health care team; we chose to survey palliative care physicians because we believed they would have the greatest exposure to these cases and thus have the greatest breadth of experiences. However, any physician, nurse, or other practitioner who works with dying patients may be a potential target of murder allegations if their motives are doubted or misunderstood by members of the health care team and families.8
Finally, although the introduction to our survey stated that we were asking about accusations when the intent was not murder or euthanasia, we did not include a question formally asking what the intent of the action was for which the physician had been accused.
In this national study of physicians who practice hospice and palliative medicine, we found that there remains a public misperception of their practice as being euthanasia, and, at times, this leads to accusations, formal investigations, and even criminal trials for murder. Although this study surveyed only hospice and palliative medicine physicians, all clinicians who care for patients near the end of life face the possibility of allegations and investigation. Recognition of the prevalence of accusations and identification of the specific practices that put physicians at risk are the first steps in improving the care of patients with life-threatening illness.