Hospice Patients Alliance: Consumer Advocates

Questionable Death, Assisted Suicide,
Mercy Killing (& Involuntary Euthanasia)

by Ron Panzer, January 2000

Some families sometimes wonder if their loved one died because of the terminal illness or if the cause of death was related to the use of medications given during hospice care. Normally, most patients die due to their terminal illness and the medications given are simply to control pain or other distressing symptoms. It is important for families to ask questions and get answers from hospice staff so that all the family members understand the reason for the various medications used.

Communicating with other family members who have questions is important as well, because some family members may not have been present when explanations about medications were given by hospice staff. Sharing this information can reduce stress and worry in other family members. Hospice staff need to be alert to detect these sometimes unspoken questions in family members and to provide explanations about the medications and treatments given during hospice care.

Assisted Suicide, Death and Murder

In very rare circumstances which have been documented and confirmed by the courts, some physicians and/or hospice staff have given medications in dosages which were either inappropriate or given in larger dosages than that needed by the patient, resulting in adverse reactions and in some cases, even death. Accidental administration of an overdose of any medication is one thing, but intentionally overdosing a patient is in a very different category of action. Intentionally overdosing a patient so as to cause death may be termed "active euthanasia." and if involuntary, "plain talk" would call it murder.

Blatant violations of the standards of care occur when a patient is given a medication that he or she is allergic to and which he directly refuses. A patient always has the right to refuse a medication, even if the medication is appropriate. Some state regulations govening hospice specifically mandate that a hospice patient has the right to refuse a medication or treatment without risking being discharged from the hospice. A basic principle of health care is "informed consent." Consent of a patient means that the patient accepts the procedure, medication or treatment plan. If a patient does not consent, then a physician or nurse cannot continue to impose a procedure, medication or treatment against the patient's will.

Assisted Suicide is Not Accepted in Hospice Regulations

Dr. Jack Kevorkian brought the idea of assisted suicide to the forefront of public debate in the late 1990s and the public rejected his views. However, a small portion of the public still favors the use of assisted suicide. In some cases, health care workers have unilaterally decided to administer "assisted suicide" to willing or unwilling victims of their philosophy of hastening death. An unwilling suicide is not suicide but rather is labeled murder by the courts. Administering potassium chloride as an agent for causing death was one method popularized by Dr. Jack Kevorkian (who was found guilty of violating the law and is now residing in jail).

It is not necessary however, for an overly eager proponent of assisted suicide to use an agent as deadly as potassium chloride. These misguided individuals believe it is their role to hasten death as an act of mercy, similar to how dogs and cats may be "put to sleep" when they become too ill. In our society, putting a person "to sleep"/to death intentionally is labeled murder and is a criminal offense. Even in a location where "assisted suicide" is legalized, administering an agent that causes death to an unwilling terminally ill patient is still considered murder.

Just because a patient has a terminal illness does not lessen the value of that person's life. A patient may be elderly, sick and weakened. However, noone knows with certainty exactly when a terminally ill patient would die. Some patients die within days, others within weeks and some within months or even years. Cases of seemingly miraculous recoveries have been documented. Hospice regulations do not normally allow for the performance of assisted suicide in a hospice program. Performing assisted suicide is illegal in all states except for Oregon. Any individual who informs you that a hospice has a right to perform assisted suicide is misinformed.

Overmedicating the Terminally Ill:
A Method of So-Called "Mercy Killing" or Euthanasia

One method of hastening death used by physicians, nurses and even family members is to administer overly high dosages of narcotics, sedatives or antidepressants when the patient has no need for them. Giving high dosages of narcotics when the patient is not in pain or does not have a symptom requiring the use of that narcotic is inappropriate and may cause death. The most serious adverse effect of giving inappropriately high doses of narcotics, sedatives and antidepressants is "respiratory depression." Respiratory depression can be so severe that breathing stops altogether resulting in death. Families need to ask questions and know exactly why medications are given and to be especially aware of rationales for increasing a dose.

Morphine is commonly given for severe pain in terminal illnesses, especially in cancer pain. In the case of severe pain, extremely high doses of morphine or other narcotics may be necessary to control that pain and have been determined to be safe to administer under the careful supervision of the physician and hospice staff. Morphine is also given for other reasons which most family members may not understand. For example, in the case of end-stage heart failure with respiratory congestion resulting from the weakened heart action, fluid from the blood percolates out through the capillaries in the lung, causing severe respiratory congestion and distress. Medical textbooks list morphine given in combination with a diuretic like Lasix (furosemide) as a classic and one of the most effective ways of reducing respiratory distress and congestion caused by such heart failure.

In the case of overly high dosages of narcotics, sedatives and antidepressants, family members may be the only protection left for a medically comatose patient. "Medically comatose" refers to a patient that would not normally be comatose at that time due to his illness, but who has been placed into a coma (nonresponsive and unarouseable mode) by medications being given. The patient can no longer speak for himself, and the family is the only advocate left for that patient. If the patient was willing to sleep during the very last days of his life, then administering high doses of sedatives might be acceptable if the situation warranted it. However, there are physicians and nurses who believe in administering high doses even when the patient is not willing and receptive to those doses.

Research Demonstrates Some Physicians
Approve of Actively Causing Death (Active Euthanasia)

Research studies published in medical journals confirm that a small percentage of health care professionals, including physicians, admit to having hastened a patient's death. It is reasonable to conclude that a larger number have hastened death and that some physicians are not willing to admit what they routinely do in secret. The ethics of physician assisted suicide is currently being actively debated throughout our nation.

A 1998 article in the Journal of the American Medical Association conclusively reports that physician assisted suicide or hastening death is occurring and is not "unheard of" or a "rare" occasion. This report documents cases where the patient wished to die and was assisted by his or her physician to do so. A summary of this article is listed at: The practice of euthanasia and physician-assisted suicide in the United States. [For complete article see JAMA 1998 and search from the JAMA site for the following article: Aug 12;280(6):507-13 entitled "The practice of euthanasia and physician-assisted suicide in the United States: adherence to proposed safeguards and effects on physicians." written by Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR done at the Center for Outcomes and Policy Research, Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, Mass 02115, USA.]

In the above survey of 355 oncologists, "(15.8%) reported participating in euthanasia or physician assisted suicide." "Thirty-eight of 53 oncologists described clearly defined cases of euthanasia or physician assisted suicide." In the cases reported by that 15.8% of oncologists, "(60.5%) [of the patients] both initiated and repeated their request for euthanasia or physician assisted suicide, but 6 patients (15.8%) did not participate in the decision for euthanasia or physician assisted suicide. [emphasis added] Thirty-seven patients (97.4%) were experiencing unremitting pain or such poor physical functioning they could not perform self-care."

What does it mean that "6 patients did not participate in the decision for euthanasia or physician assisted suicide?" Isn't the obvious conclusion: these patients died without having requested to be killed, without asking for their death to be hastened. Who is deciding who dies and who lives in these situations? Do doctors have the right to play God with the terminally ill, even when the patients have NOT requested such "assistance?"

In the case of a patient who definitely does not wish to die and who is actively "euthanized" against his wishes, that is an even more serious question of medical ethics and law. If you are aware of a situation where the physician, nurse or other family member is giving dosages of medication which have been directly refused by your loved one, you need to directly confront that physician, nurse or family member and ask them to explain their actions. If you are not satisfied with that explanation, you need to promptly get in touch with an attorney for professional advice.

American Nurses Association
Stands Against Active Euthanasia"

The American Nurses Association, the major professional nursing association in the United States has stated:

"The American Nurses Association (ANA) believes that the nurse should not participate in active euthanasia because such an act is in direct violation of the Code for Nurses with Interpretive Statements (Code for Nurses), the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide timely, humane, comprehensive and compassionate end-of-life care." See the American Nurses Association website.



American Medical Association
Opposes Physician Assisted Suicide

The American Medical Association, one of the largest physician organizations in our nation has taken the following official position on physician assisted suicide:

"...the American Medical Association strongly oppose[s] any bill to legalize physician-assisted suicide or physician-assisted death because physician-assisted suicide is fundamentally inconsistent with the physician’s role as a healer."



Significant Number of Physicians May Approve of Euthanasia and/or Physician Assisted Suicide

It is common knowledge in hospice that there are some physicians in the community who do not prescribe adequate pain medications to properly control the pain of patients with severe pain. It is also common knowledge in the industry that there are some physicians who are extremely "aggressive" in treating pain with narcotics. Being "aggressive" in treating pain is admirable and exactly on target when it comes to hospice care and its reason for being. However, it is also common knowledge that some physicians step over the line and are willing to "push" a patient into death by hastening its arrival through the use of high doses of sedatives and narcotics. Hospices will not normally inform you or your loved one if your physician falls into either extreme category: those who under-medicate for pain or those who overmedicate and hasten death.

An article in the Archives of Internal Medicine, Vol. 160 No. 1, January 10, 2000, "Attitudes and Practices Concerning the End of Life - A Comparison Between Physicians From the United States and From the Netherlands" (by Dick L. Willems, MD, PhD; Elisabeth R. Daniels; Gerrit van der Wal, PhD; Paul J. van der Maas, PhD; Ezekiel J. Emanuel, PhD) reports the varying percentages of physicians in Oregon who were willing to increase the dosage of morphine given under various patient circumstances. This article is summarized briefly at: Entrey-PUBMED where you can search for the article by title, you can also order a full copy of the article. The article is also available from the AMA site at: Archives of Internal Medicine - AMA

  1. When pain was involved, 97% stated they approved of increasing the dosage of morphine; 53% approved of physician assisted suicide ("PAS") 24% approved of euthanasia

  2. When severe weakness and debility of the patient were involved, 36% approved of increasing the dosage of morphine; 37% approved of "PAS"; and 14% approved of euthanasia.

  3. When patients felt that they were a burden on their families, 24% of the physicians approved of increasing the morphine dosage; 24% approved "PAS"; 7% approved of euthanasia.

  4. When patients felt that their lives were meaningless, 20% of the physicians approved of increasing the morphine dosage, 22% approved of "PAS", and 7% approved of euthanasia.
    See the table of data at: http://archinte.ama-assn.org/issues/v160n1/fig_tab/ioi81180_t3.html

Increasing the dosage of morphine when pain is involved makes sense and leads to improved quality of life for the terminally ill. However, other than hastening a patient's death, what is the reasoning for increasing the dosage of morphine when patients feel their life is meaningless or feel that they are a burden on others in the family? It is obvious that physicians approve of hastening death in many end of life circumstances. 20% or one out of five physicians approved of "PAS" when patients felt their lives were meaningless. 24% approved of PAS when the patient felt they were a burden.

Even more surprising is that 24% of the physicians approved of euthanasia when the patient had severe pain, 14% (or one out of every 7 physicians) approved of PAS when the patient had debility, 7% when the patient felt they were a burden or felt that their lives were meaningless. 7% is one out of 14 physicians who admitted to being willing to act to end a patient's life in those circumstances.

48% of the physicians reported that patients had requested "PAS" or euthanasia. None of the physicians admitted to having performed euthanasia, but 7% admitted to performing "PAS", and 2% admitted to ending a patient's life without a request from the patient.

While these results are from confidential surveys of physicians in Oregon, attitudes of physicians around the country may be quite similar.



Durable Power of Attorney for Medical Care Does Not Give Right to Overmedicate and Kill a Patient

Some family members who have been approved and appointed by the terminally ill patient as their Representative for medical decisions feel that they have the right to "do anything." However, the regulations regarding the administration of medications do not allow medications to be given in a manner contrary to the physician's orders. Nor does a medical power of attorney allow the Representative to intentionally go against the conscious wishes of the terminally ill patient. Even if morphine or other narcotics are ordered to be given for pain, that does not mean that the family member can give whatever dose they want to give. If death results when a family member gives an overdosage of narcotic, the family member may be held responsible for that death, rather than the physician.

Even if the killing is done out of a belief in euthanasia or mercy killing, it is still killing or causing death. The district attorney or U.S. attorney for that region would be able to bring a charge against the individual involved and the criminal court system would then be able to rule on what punishment would be appropriate for a person who is found to have intentionally caused another person to die, even in the case of a terminally ill patient.

If a patient or loved one had refused certain medications and those medications were given against his or her will, and the patient later died when those medications were given, you need to consult an attorney who has expertise in criminal law. By discussing the situation with an attorney with expertise in criminal law, the attorney will be able to advise you how to proceed to address your concerns. In some cases, family members have actually gone to the County District Attorney or U.S. attorney and had charges brought against unethical health care staff who have intentionally killed a patient.

Criminal Prosecutions on Record for Hastening Death

For a discussion of the criminal prosecutions of some cases involving the deaths of patients in health care situations, please refer to the following article posted at the American Society of Law, Medicine and Ethics website: "Criminal Act or Palliative Care? Prosecutions Involving the Care of the Dying" by Ann Alpers, JD. Ann Alpers is a professor at the University of California at San Francisco's School of Medicine and has taught Medical Bioethics, among other topics.

What To Do About Involuntary Euthanasia

If you know of any incidences of involuntary euthanasia where a patient was medically killed (various methods), please contact us to let us know. Visit our euthanasia and hospice information center where we provide directions on how to stop these medical killings. Involuntary euthanasias, if continued, offer the greatest threat to hospice as we know it. In countries where euthanasia is encouraged, hospice services decline and patients are killed rather than cared for (documented in The Netherlands, Europe).

One important point to remember though, you will need to send a detailed complaint to the State Board of Medicine as soon as possible, because in some cases, the DEA will wait to see the findings of the State Board of Medicine. You can also file a complaint to the State Board of Nursing if a nurse was involved in administering a fatal dose of narcotic. It is wise to consult a medical malpractice attorney before filing your complaint to the Board of Medicine and it is also important to get a medical review by an independent physician.

If you wish to stop the involuntary euthanasias (medical killings of patients), you will need to get a copy of the medical record for an independent medical review of your loved one's case. Your attorney can assist you in that, because most hospices will fight tooth and nail to never give you the medical records if something truly terrible happened. If you don't have or know of a medical malpractice attorney in your area, you can search for a plaintiffs' attorney.

It is very important that you try to find an attorney who files claims as a plaintiffs' attorney to represent you. If you get an attorney who handles medical malpractice, but regularly represents the corporations, you may not get the legal representative you deserve! Hospices have been known to falsify documentation, delete information, send incomplete records, stall and many other tactics that infuriate the families of the victims. A plaintiff's attorney will be able to successfully overcome the obstacles that hospice corporations routinely throw in the way of families seeking the truth (and a full, accurate copy of the medical record).

Taking the step by step approach to achieving justice will help make it more likely that the truly egregious violations of standards of care are noted (some you may miss, not being a physician) and corrected through the government justice departments and local district attorney's office. Having a medical malpractice attorney help you will assure that the complaint to the Board of Medicine and Board of Nursing is written in such a way that the allegations are not capable of being misunderstood or brushed aside.

If people remain silent about these medical killings, nothing will happen. Rape, murder and child molestation can only flourish if families or victims remain silent. Only when crimes are reported can they be stopped. In the same way, hospice abuses must be reported for the medical killings (involuntary euthanasias) to stop. We urge you to report what you know to our government representatives. See our hospice and euthanasia information and action center for addresses to write to, sample letter and examples of involuntary euthanasias in our nation. You can make a difference! Let others know about our efforts to stop medical killings!





The Hospice Patients Alliance provides information in the spirit of consumer advocacy, believing that informed consumers of healthcare are best able to protect their rights and obtain quality hospice care. If you have questions about the legality of certain health care interventions and are seeking legal or medical advice, we strongly encourage you to consult with a competent and experienced attorney or physician. In order to obtain completely objective and un-"politicized" advice, you may need to consult with an attorney or physician who is not located in the same area as the hospice or physician involved.




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