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The impact on general practice of prescribing assisted dying drugs

Claud Regnard is an Honorary Consultant in Palliative Medicine at St. Oswald’s Hospice, Newcastle-upon-Tyne.

Carol Davis is a Consultant in Palliative Medicine and Clinical Lead for End-of-Life Care, University Hospital Southampton.

Katherine Sleeman is the Laing Galazka Professor of Palliative Care, NIHR Clinician Scientist and Honorary consultant in palliative medicine, Kings College London.

Philip Williams is a General Practitioner, Nettleham Medical Practice, Lincolnshire.

Ana Worthington is at Keble College, University of Oxford.

Assisted dying is the topic of much debate by societies and governments today. The issue of the drugs used to assist patients in dying, and their safety and efficacy, is rarely discussed. This has important implications for UK general practice if assisted dying is legalised and incorporated into existing healthcare.

Until 2016, doctors in Oregon prescribed one of two oral barbiturates to produce unconsciousness and death. Since the European Commission restricted the sale of these barbiturates to the US due to their use in judicial executions, the availability of these drugs has become increasingly scarce.1 This has compelled doctors to prescribe experimental drug combinations to bring about patient death.

The issue of the drugs used to assist patients in dying, and their safety and efficacy, is rarely discussed.

For example, in 2020, 87% assisted deaths in Oregon have used a drug combination called ‘DDMA’, a mixture of a benzodiazepine, a cardiac glycoside, an opioid and an antidepressant, with some also receiving a barbiturate.2 In Canada, oral protocols vary from a barbiturate plus antiemetic, to combinations of a benzodiazepine, barbiturate, opioid and a hypnotic.3 Oregon has used four different protocols in the last 7 years.

The safety and efficacy of previous and current oral assisted dying drug combinations is not known. There have been few well-conducted studies, some several decades old.4 Using multiple drugs multiplies the risk of adverse events, especially when they are used in high doses in patients with no previous exposure. Reported adverse effects include vomiting, myoclonus and a prolonged dying process of up to 47 hours.2 In 2020 the official Oregon report stated that, compared with single barbiturates, “All drug combinations have shown longer median times until death..2 The physical and psychological impact of a prolonged assisted death on the patient has not been investigated, and we do not know the impact of such deaths on the grieving process of friends and relatives.

Reported adverse effects include vomiting, myoclonus and a prolonged dying process of up to 47 hours…. we do not know the impact of such deaths on the grieving process of friends and relatives.

Oregon states the complication rate for assisted deaths in 2020 was 6.9% (5 out of the 72 cases where this information was known), but this does not include prolonged deaths, and information on complications was unknown in 71% (173 out of 245).2 Reports by the Canadian Association of MAID Assessors and Providers acknowledge that individuals may experience a range of complications with oral assisted dying drugs.4

Drugs are normally required to undergo a formal approval process that demands direct measurements of patient outcomes. Using death as the only endpoint takes no account of how quick this was or what complications occurred on the way. Medicine is littered with treatments that were widely used and promoted but later found to be harmful. Thalidomide was approved by 17 countries including the UK, until its harmful effects were recognised. Assisted dying drugs have less published data on patient and carer outcomes than thalidomide.

Using death as the only endpoint takes no account of how quick this was or what complications occurred on the way.

If assisted dying is legalised in the Meacher bill currently before parliament, general practitioners will have to consider prescribing untested drugs or drug combinations. This could breach GMC prescribing guidance that a doctor “must be satisfied that the drugs serve your patient’s needs.” In addition, last year’s BMA survey on assisted dying showed a majority of UK licensed doctors (47% vs 34%) were unwilling to prescribe oral drugs for assisted dying.6 Unless assisted dying is practised separately from healthcare, this will pose challenges for working relationships in general practice. This assumes that conscientious objection is protected, and the UK does not follow Canada in requiring all doctors and organisations to take part in assisted deaths.

It is not clear which drug or drug combination is most effective for bringing about a quick and peaceful assisted death. Oregon and Canada’s untested use of multiple drug mixtures should act as a warning to jurisdictions and clinicians considering the legalisation of assisted dying.

References

  1. Commission Implementing Regulation (EU) No 1352. Official Journal of the European Union. December 12, 2011. https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:338:0031:0034:EN:PDF
  2. Oregon Health Authority. Death with Dignity Act Annual Reports (2020). https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx
  3. Zworth M, Saleh C, Ball I, Kalles G, Chkaroubo A et al. Provision of medical assistance in dying: a scoping review. BMJ Open, 2020; 10: e036054. https://bmjopen.bmj.com/content/10/7/e036054
  4. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen B Willems DT, van der Maas PJ, van der Wal G. Clinical problems with the performance of euthanasia and physician assisted suicide in the Netherlands. New Eng J Med; 2000; 342: 557-563. https://pubmed.ncbi.nlm.nih.gov/10684914/
  5. Bakewell F, Naik VN. Complications with medical assistance in dying (MAID) in the community in Canada: review and recommendations. Canadian Association of MAiD Assessors and Providers. March 28, 2019. https://camapcanada.ca/wp-content/uploads/2019/05/Failed-MAID-in-Community-FINAL-CAMAP-Revised.pdf).
  6. BMA Physician-assisted dying survey, October 2020. https://www.bma.org.uk/advice-and-support/ethics/end-of-life/physician-assisted-dying-survey

 

Featured image by Kate Hliznitsova at Unsplash     

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