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Doctor-assisted death: A dad's choice sheds light on national issue

Grace Wang

Ethan Remmel with his boys, from left, Miles, then 3, and Seth, then 8, in a family photo. Remmel, a cancer patient, opted to use Washington's Death with Dignity Act.

Ethan Remmel was only 41 when he died on June 13, 2011, barely a year after being diagnosed with terminal colon cancer that quickly spread to his bone.

The Bellingham, Wash., psychology professor and father of two young sons took a lethal dose of crushed prescription sedatives, becoming one of 255 terminally ill people to exercise that option so far under the state’s 2009 Death with Dignity Act.

“One of the things that Ethan kept saying is he didn’t want to deteriorate to the point where he couldn’t interact with his kids,” recalls his partner, Grace Wang, 44.

Now, nearly two years later, the hospital program that aided Remmel is offering an inside look at what it means when a medical center devoted to curing cancer also decides to help people die.

Dr. Elizabeth Trice Loggers, medical director of the Seattle Cancer Care Alliance's Supportive and Palliative Care Service, said the report published in this week’s New England Journal of Medicine is helpful at a time when at least a half dozen U.S. states are considering right-to-die measures.

“There is value in having a structured program and that is why the program is structured the way it is,” she said. “If you look at the way most Americans say they want to die, it is in their home, with their family members present, not in pain, and with their mental faculties intact.”

Washington and Oregon are the only states with voter-approved laws allowing what critics call “assisted suicide” and what proponents call “aid in dying” for terminally ill people with less than six months to live.

Since 1998, 1,050 patients in Oregon have requested lethal medication under the law and 673 have died using it. In Washington, 255 have requested the drugs; 241 have died after ingesting them.

Loggers said she’s fielded recent inquiries from Montana, where state lawmakers have tabled a Death with Dignity bill at the same time a vote is expected this week on a law that would ban physician-assisted death.

The Seattle hospital found that overall, the law was rarely used -- only 2.4 percent of annual deaths at SCCA -- but when it was, it was well-received by all concerned.

“Both patients and families frequently express gratitude after the patient receives the prescription, regardless of whether it is ever filled or ingested,” the report said.

Between 2009 and 2011, 114 SCCA patients inquired about the hospital’s Death with Dignity program, Loggers’ report showed. Of those, 44 didn’t pursue the program, 30 started the process but either died or didn’t complete it, and 40 actually received lethal doses of the prescription sedative secobarbital, the report said.

Of those 40, all died, including 24 who ingested the medication.

That included Ethan Remmel, who chronicled his fight with cancer in “Living While Dying,” a blog published online by Psychology Today.  Remmel, who obtained the drugs months before he died, wrote that simply having access to them helped.

“So I have the medication now,” he wrote, months before his death. “It is safely locked up. I have not decided if or when I will use it, but it gives me great relief to know that I have some control over my dying process.”

Retaining that sense of control was important to nearly all of the SCCA participants, Loggers’ study found.

More than 97 percent of patients cited loss of autonomy as reason for participating in the Seattle hospital’s program, while nearly 89 percent pointed to the inability to engage in enjoyable activities and 75 percent were concerned about losing dignity.

SCCA's results were very similar to those previously found in Washington and Oregon, the paper showed. Overall, nearly 80 percent of patients who choose doctor-assisted deaths have been diagnosed with cancer. They're usually older than 65, white, well-educated and well-insured.

Starting a program aimed at helping people die wasn’t easy, Loggers acknowledges. Heated town hall-style meetings generated intense debate about whether staff would be forced to participate and how patients would be informed about the process.

“At SCCA, our goal is primarily to cure cancer,” she said. “What we did not want to do was scare any patient or family member.”

Grace Wang

Ethan Remmel, far left, in an undated family photo. Remmel died in 2011 after using a lethal prescription through Washington's Death with Dignity Act.

A confidential survey in March 2009 found that nearly 36 percent of SCCA doctors who answered were willing to act as prescribing or consulting physicians, 26 percent were willing to consult only -- and more than 38 percent were either unwilling or undecided about participating, the paper showed.

Developing a protocol that honored staff preferences and patient wishes was crucial, Loggers noted. In some ways, the SCCA program is stricter than the state law, requiring, for instance, that participants agree not to take lethal drugs in a public area or manner.

The program turned away one participant who couldn’t agree to that stipulation, the paper showed.

Overall, however, SCCA officials felt that developing the program was necessary in a state where 85 percent of voters turned out to weigh in on the measure -- and nearly 60 percent approved it.

“There was a substantial portion of the population who felt this was an appropriate end-of-life option,” Loggers noted.

That’s not the case in other states, of course. Last fall, a Massachusetts proposal to allow physician-assisted suicide was narrowly defeated thanks in part to substantial funding from the Catholic church and right-to-life groups, which oppose the action on moral and ethical grounds. But it was also tipped by a sharp focus on perceived flaws in the wording of the proposed law, a tactic that may pay off in other states, said Joe Baerlein, president of Rasky Baerlein Strategic Communications, whose firm was brought in to defeat the measure.

“You have to find some way to appeal to someone’s secular brain to say this isn’t a good idea and idea and here’s why,” he told NBC News.

But from Ethan Remmel’s point of view, having access to the lethal drugs allowed him to finish his life on his own terms, said Wang, his partner of five years and mother of their 5-year-old son, Miles.

“It was just really hard,” she said.

Remmel, an associate professor of psychology at Western Washington University, was able to finish the school year, teaching until 10 days before he died. He was able to spend time with his parents, with his friends and with his sons, Seth, then 8, and Miles, then 3, before becoming too incapacitated by chemotherapy and pain drugs.

Remmel didn’t regard taking the lethal drugs as suicide, said Wang, an associate professor of environmental studies at Western.

“We obviously didn’t want him to die,” she said, “but he was dying anyway.”

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