Six Months to Live – The Ethical Challenge for Doctors


“You have six months to live.” These can be frightening words to any patient who hears them.

But they are also words with legal, ethical, and emotional implications for the doctor who may be asked to put them in writing. Here are two situations where a doctor may be asked to issue a statement that a patient is expected to die within six months:

* To make the patient eligible for hospice services (in many locations)

* To allow the patient to obtain a life-ending medication under California’s new End of Life Option Act (the EOLOA) and under similar legislation in other states.

(The EOLOA took effect in June 2016. The “six-month certification” is one of several requirements for its use. An article about the EOLOA appeared in this blog in September 2015, while the legislation was pending; see The hospice requirement and the EOLOA requirement sound like they are the same thing, but before reading on, imagine that you are a doctor, asked to issue such a certification for one of your patients. How might your approach be different in the two cases? What ethical distinctions do you see?

I recently attended a talk by Dr. Lonny Shavelson, founder of Bay Area End of Life Options (Toward the end of his talk, he described the differences in his own approach when asked, as a doctor, to provide the two types of certification described earlier.

He first noted that such diagnoses are always a matter of uncertainty. A patient who appears to have less than a six-month life expectancy may end up living much longer (or may die much sooner than in six months). He then posed the question of what the implications are of making a diagnostic error in each case, and gave this analysis:

* The hospice certification: If a doctor writes a letter for hospice services, stating that patient X is expected to die with six months, what are the implications if the patient lives longer (i.e., if the doctor makes an error in judgment)? Dr. Shavelson’s perspective is that there is little down side. The main consequence of such an error is that the patient gets valuable services for which he or she perhaps should have been ineligible. Dr. Shavelson said that he tends to be generous in making such a certification, because no (or little) harm is done by a mistake.

* The EOLOA certification: On the other hand, for the EOLOA situation, if the doctor is wrong, the end result may turn out to be a significant shortening of the patient’s life. Given a six-month certification, patient may choose to request, and use, the life-ending medication available under the EOLOA, believing that the end is near anyway. The same patient, believing that he or she has a longer life span, might look differently at the issue of using life-ending medication. Because of these different implications, Dr. Shavelson said that he tends to be far more cautious in making an EOLOA certification.

So what do you think? If you were a doctor (or a patient) would you approach these two declarations differently? How and why?

Dan Fendel has been a Spiritual Care Volunteer at Kaiser Hospital in Oakland since 2014, and previously did volunteer grief support work for more than two decades with the Shanti Project and Namaste in the Berkeley/Oakland area. He is co-founder of the Chevrah Kadisha at Temple Sinai in Oakland, CA, as well as co-author, with Rabbi Stuart Kelman, of both the Expanded Third Edition of Chesed Shel Emet: The Truest Act of Kindness: Exploring the Meaning of Taharah, and Nichum Aveilim: A Guide for the Comforter. He was lead organizer of the East Bay Chevrah Kadisha Consortium, which promotes cooperation and sharing of resources among the dozen or so Chevrah Kadisha groups in the greater Oakland/Berkeley area.

 

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