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Terminal sedation is not an argument against assisted dying law reform.

Opponents of assisted dying often claim that the appropriate response to refractory symptoms at end of life is terminal sedation — also known as palliative sedation or continuous deep sedation.e.g. 1 Terminal sedation is the administration of sedatives so as to render the patient unconscious until death. Thus, the patient’s active experience of suffering is removed, even if the underlying causes of the suffering are not.

Terminal sedation can help in some cases of end-of-life suffering, but it remains a problematic practice — and not a substitute for lawful assisted dying — for eight broad reasons.

1. Directly and foreseeably causing death

Unless the patient is already likely to die of her illness within a few days, it is the withholding of artificial nutrition and hydration during terminal sedation that causes the patient’s death. Lack of fluids causes circulatory collapse and organ failure within 14 days; less if the patient is frail.

In addition, at least one study has found that the terminal sedation medication itself can cause depression of respiration and/or circulation, directly resulting in death in 3.9% of cases.2 Another study purporting to show no survival difference in patients given terminal sedation3 has been exposed as deeply scientifically flawed.4

While opponents of assisted dying usually claim that the intention of terminal sedation is the relief of symptoms and not the hastening of death (their fundamental objection to assisted dying), in practice, terminal sedation can directly and foreseeably cause death.

2. Inapplicable prior to 2–14 days before death

A standard of practice in terminal sedation in many jurisdictions is that it should be used to address refractory symptoms only if the patient’s death is anticipated within hours or days, and in any case less than 14 days.5

However, intolerable and intractable symptoms often occur much earlier, for example amongst those with metastatic cancer where death is still weeks off, or those with a progressive degenerative neurological condition such as motor neuron disease, who may have several months to live.

Thus, terminal sedation is not a practical solution to intractable symptoms in many cases.

3. It doesn’t always help

Palliative Care Australia’s acknowledgement that even best practice can’t always alleviate intolerable suffering at end of life6 is confirmed by a study into terminal sedation practice which found that, in contrast to popular belief that it alleviates (the patients’ conscious awareness of) all suffering, it was ineffective in 17% of cases.7

4. It may violate the patient’s value system

Most calls for terminal sedation as “the answer” to assisted dying law reform focus on the views of the doctor, for whom this is another familiar “intervention”. However, terminal sedation may be unacceptable to the patient.

A patient may deeply believe that being forced to dehydrate to death — unconscious in a bed for a couple of weeks — to be an anathema to her most deeply-held values and sense of self as an active participant in her own life trajectory. This patient may profoundly prefer another route whose equally caused and foreseeable consequence is death: voluntary assisted dying, an option that gives her the chance to say goodbye to loved ones at a time of her own choosing.

5. It extinguishes the patient’s decisional capacity

Rendering the patient unconscious extinguishes her decision-making capacity. The patient can no longer participate in her own treatment decisions unless terminal sedation is ceased, she regains consciousness and becomes aware of her intolerable suffering once more.

6. Doctors’ intention not always clear-cut

When a doctor administers terminal sedation to a patient, the doctor’s intention is not always clear-cut. The doctor may intend to alleviate the patient’s suffering and/or intend to hasten death.

The administration of a single large bolus of sedatives is generally indicative of an intention to hasten death, in which case the doctor in likely to be investigated and prosecuted. However, the administration of increasing doses of sedatives is less clear: significantly increasing titrations of sedatives may be necessary to alleviate intractable symptoms, or they may be an intention to hasten death.

7. Risk of coercion

There is a conceptual risk that greedy relatives, service providers who need the patient’s bed, and others, might inappropriately persuade the patient to opt for a death hastened by terminal sedation, a similar theoretical risk to that in assisted dying.

However, unlike assisted dying which under statutory law is an express, fully informed, independently examined and documented desire and intention to hasten death, there are no statutory requirements in Australia regarding testing of desire, informedness, intention or possible coercion in terminal sedation. This is incoherent.

8. Worse experiences for the bereaved

Studies have found a significant minority of relatives of patients receiving terminal sedation are quite distressed by the experience. Problems causing distress include concern about the patient’s welfare and terminal sedation’s failure to address symptoms, burden of responsibility for making the decision, feeling unprepared for changes in the patient’s condition, short time to the patient’s death and whether terminal sedation had contributed to it, feeling that healthcare workers were insufficiently compassionate, and wondering if another approach would have been better.e.g. 8,9 Periods of longer terminal sedation may be more distressing than shorter periods.10

In contrast, an Oregon study found that the bereaved from assisted deaths appreciate the opportunity to say goodbye, to know that the choice was the deceased’s wish, that the deceased avoided prolonged suffering, that the choice was legal, and they were able to plan and prepare for the death.11

Another Oregon study found that the mental health outcomes of bereaved from assisted deaths were no different from the bereaved from natural deaths.12 Bereaved from assisted deaths were more likely to believe that the dying person’s wishes had been honoured and were less likely to have regrets about the death.

A Swiss study found the rate of complicated grief after assisted death was comparable to the general Swiss population,13[^] while a Dutch study found bereavement coping in cancer was better after assisted death than after non-assisted death.14

Incoherent professional association standards

Neither the Australian Medical Association nor Palliative Care Australia have guidelines for doctors for the practice of terminal sedation.[*] Indeed, even Palliative Care Australia’s carefully reviewed and updated national standards released in late 2018 don’t mention sedation at all.15

In contrast, in countries where assisted dying is now lawful, clear and specific frameworks have been developed to guide the practice of terminal sedation: in the Netherlands,16 Canada,17 and Belgium.18 This deliberative development and implementation points to continued improvement in (not deterioration of) professional medical practice across the board when assisted dying is legal.

Given the profound issues in terminal sedation as in voluntary assisted dying, the failure of the peak Australian medical associations to publish guidelines on terminal sedation, while opposing assisted dying for perceived issues in its implementation, is incoherent and indefensible.

Summary

Palliative and medical care can never address all profound suffering at the end of life, regardless of funding or organisation: some kinds of suffering have no relevant or effective medical interventions, and even terminal sedation may be inapplicable or ineffective. To claim that palliative care is always the answer is a “monstrous arrogance19 and “represents the last vestiges of [medical] paternalism”.20

 

"It is clear that improving palliative care will not remove the need for legalizing assisted dying, and that legalizing assisted dying need not harm palliative care.”21

 

While terminal (palliative) sedation may help a minority of patients, it's a problematic practice that is often not a practical solution to refractory symptoms at end of life.

Terminal sedation is not a substitute for lawful assisted dying choice.


[^]     Slightly elevated levels of PTSD were found amongst the bereaved (compared to the general population), but it was not established whether this would have been different from the trauma of experiencing continued suffering and deterioration or different from PTSD rates of those who had recently lost a loved one by any other means, including terminal sedation.

[*]     Revealed through direct correspondence between myself and the two associations.

 

References

  1. Somerville, M 2009, 'We can always relieve pain', Ottawa Citizen, (24 Jul).
  2. Morita, T, Chinone, Y, Ikenaga, M, Miyoshi, M, Nakaho, T, Nishitateno, K, Sakonji, M, Shima, Y, Suenaga, K, Takigawa, C, Kohara, H, Tani, K, Kawamura, Y, Matsubara, T, Watanabe, A, Yagi, Y, Sasaki, T, Higuchi, A, Kimura, H, Abo, H, Ozawa, T, Kizawa, Y, Uchitomi, Y, Japan Pain, PMR & Psycho-Oncology Study, G 2005, 'Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan', J Pain Symptom Manage, 30(4), pp. 320-8.
  3. Maltoni, M, Pittureri, C, Scarpi, E, Piccinini, L, Martini, F, Turci, P, Montanari, L, Nanni, O & Amadori, D 2009, 'Palliative sedation therapy does not hasten death: results from a prospective multicenter study', Ann Oncol, 20(7), pp. 1163-9.
  4. Francis, N 2016, How bad research fuels dodgy claims, DyingForChoice.com, viewed 11 Mar 2016, http://www.dyingforchoice.com/f-files/how-bad-research-fuels-dodgy-claims.
  5. Twycross, R 2019, 'Reflections on palliative sedation', Palliative care, 12, pp. 1-16.
  6. Palliative Care Australia 2006, Policy statement on voluntary euthanasia, Canberra, pp. 2.
  7. Davis, MP 2009, 'Does palliative sedation always relieve symptoms?', Journal of Palliative Medicine, 12(10), pp. 875-877.
  8. Morita, T, Ikenaga, M, Adachi, I, Narabayashi, I, Kizawa, Y, Honke, Y, Kohara, H, Mukaiyama, T, Akechi, T & Uchitomi, Y 2004, 'Family experience with palliative sedation therapy for terminally ill cancer patients', Journal of Pain and Symptom Management, 28(6), pp. 557-565.
  9. Bruinsma, SM, Brown, J, van der Heide, A, Deliens, L, Anquinet, L, Payne, SA, Seymour, JE, Rietjens, JAC & on behalf of, U 2014, 'Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries', Supportive Care in Cancer, 22(12), pp. 3243-3252.
  10. van Dooren, S, van Veluw, HT, van Zuylen, L, Rietjens, JA, Passchier, J & van der Rijt, CC 2009, 'Exploration of concerns of relatives during continuous palliative sedation of their family members with cancer', J Pain Symptom Manage, 38(3), pp. 452-459.
  11. Srinivasan, EG 2009, Bereavement experiences following a death under Oregon's Death With Dignity Act, Human Development and Family Studies, Oregon State University, pp. 127.
  12. Ganzini, L, Goy, ER, Dobscha, SK & Prigerson, H 2009, 'Mental health outcomes of family members of Oregonians who request physician aid in dying', J Pain Symptom Manage, 38(6), pp. 807-15.
  13. Wagner, B, Müller, J & Maercker, A 2012, 'Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide', European Psychiatry, 27(7), pp. 542-546.
  14. Swarte, NB, van der Lee, ML, van der Bom, JG, van den Bout, J & Heintz, AP 2003, 'Effects of euthanasia on the bereaved family and friends: a cross sectional study', British Medical Journal, 327(7408), pp. 189-192.
  15. Palliative Care Australia 2018, National Palliative Care Standards, Griffith ACT, pp. 44.
  16. Verkerk, M, van Wijlick, E, Legemaate, J & de Graeff, A 2007, 'A national guideline for palliative sedation in the Netherlands', J Pain Symptom Manage, 34(6), pp. 666-70.
  17. Dean, MM, Cellarius, V, Henry, B, Oneschuk, D & Librach, LS 2012, 'Framework for continuous palliative sedation therapy in Canada', J Palliat Med, 15(8), pp. 870-9.
  18. Broeckaert, B, Mullie, A, Gielen, J, Desmet, M, Declerck, D, Vanden Berghe, P & FPZV Ethics Steering Group 2012, Palliative sedation guidelines, Federatie Palliatieve Zorg Vlaanderen, viewed 18 Sep 2015, http://www.pallialine.be/template.asp?f=rl_palliatieve_sedatie.htm.
  19. Hain, RDW 2014, 'Euthanasia: 10 myths', Archives of Disease in Childhood, 99(9), pp. 798-799.
  20. Horne, DC 2014, 'Re: Why the Assisted Dying Bill should become law in England and Wales', BMJ, 349, p. g4349/rr/759847.
  21. Downar, J, Boisvert, M & Smith, D 2014, 'Re: Why the Assisted Dying Bill should become law in England and Wales [response]', BMJ, 349, p. g4349/rr/760260.
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Victoria has shown what happens at the ballot box to candidates who oppose VAD

Many news outlets are reporting that Victoria's voluntary assisted dying (VAD) Act comes into effect mid-year, and how other Parliaments around the country are likely to implement similar reforms. Moves are afoot in Western Australia, Queensland, NSW and Tasmania, with other jurisdictions to follow. Marshall Perron, former Chief Minister of the Northern Territory and architect of the first VAD law in Australia, has penned a media release to highlight how VAD influenced the Victorian election. The result wasn't pretty for opponents of VAD law reform.

Media release - Marshall Perron

Parliamentarians traditionally shy away from supporting voluntary assisted dying (VAD), believing it is politically toxic to do so. Victoria, under the Andrews government, has changed all that by showing the opposite to be true.

After legislating VAD – Victoria is the first Australian state to do so – Andrews won a thumping victory at the 2018 Victoria State election.

Former NT Chief Minister Marshall Perron said there is a common perception that the political class has not been listening to its constituents. VAD is a classic example.

There were multiple reasons for Victoria’s election result, and VAD was clearly one of them. With unprecedented 80-85% public support, it should be no surprise that Victorian candidates who supported VAD polled more strongly.

In the previous parliament, almost all Liberal members voted against the VAD legislation. The party suffered an average 6.04% swing against it in the State election.

In addition, two of the staunchest Liberal opponents of the VAD bill lost their seats. In the lower house, Robert Clark was tossed out as the Member for Box Hill, a seat he’d comfortably held for a quarter century. In the upper house, Inga Peulich was rejected by voters in South Eastern Metropolitan, a Region she’d represented for three terms.

Dying With Dignity Victoria and Andrew Denton ran targeted campaigns focusing on four electorates – Burwood, Albert Park, Bentleigh and Prahran.  They used Robo calls, advertising, social media and face to face meetings to inform voters about where their candidates stood on VAD.

The Liberal candidates (one a sitting member) in these four electorates all opposed VAD. They suffered an average 10.1% drop in primary votes compared with the average drop in the Liberal vote overall of 6.04%.

The Liberal sitting member lost his seat. In the other three seats the sitting Labor and Greens members, who all supported VAD, were returned with significantly increased votes. The results for these four electorates were, compared to the 2014 election:

  • In Burwood, Liberal member Grahame Watt lost his seat with a 6.47% swing against. Labor candidate and VAD supporter Will Fowles was elected.
  • In Albert Park, Labor member and VAD supporter Martin Foley was returned with a massive 10.17% increase (two party preferred). The Liberal primary vote dropped 10.24%.
  • In Bentleigh, Labor member and VAD supporter Nick Staikos was returned with a massive 11.27% increase. The Liberal primary vote dropped 12.59%.
  • In Prahran, Greens member and VAD supporter Sam Hibbens was returned with a 7.0% increase. The Liberal vote dropped 10.29%.
     

Mr Perron, who introduced the world’s first successful VAD legislation in the Northern Territory in 1995 said candidates can increasingly expect to lose support when they ignore the wishes of the voters they seek to represent.

In a contest tighter than the Victorian election turned out to be, a handful of seats retained or lost on VAD could determine the outcome.

Marshall Perron


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Which doctors 'play God' most with patient end of life decisions might surprise you

In two supplementary submissions to the Parliament of Western Australia, I report empirical evidence about the standards of end-of-life medical decision making in jurisdictions with and without voluntary assisted dying (VAD) laws. The evidence clearly contradicts the assumption of assisted dying opponents that legalised VAD will lead to worse end-of-life decision making by physicians. In fact, the evidence clearly shows which physicians are 'playing God' with their patients, and it's not the Dutch.

When I appeared as an expert witness before the Parliament of Western Australia's Joint Select Committee on end of life choices, the Hon. Nick Goiran, a staunch Christian opponent of VAD, asked me for evidence of bringing end of life decision making out of the 'dark shadows' and into the light in jurisdictions in which VAD is lawful.

Existing evidence

Of course, there's the clear evidence from both the Netherlands and Belgium that the rate of non-voluntary euthanasia (NVE) has dropped significantly and stayed lower after their Euthanasia Acts each came into effect in 2002. There's also the clear evidence that the rate of nurse administration of possible life-ending drugs has dropped significantly in Belgium with a VAD law, over a similar time period in which it had increased significantly in New Zealand, where there is no VAD law. These forms of evidence were already documented in the comprehensive submission (PDF 5.4Mb) I'd made to the Committee.

Training and decision making has improved (Supplementary 1)

Mr Goiran opined that any improvements in palliative care were not relevant to his question. In my first supplementary submission to the Committe (PDF 0.6Mb) to further inform it of the empirical evidence, I disagree. As I point out, VAD decisions are not made in a vacuum: they are made after other interventions have been considered and declined, or tried and failed to provide sufficient relief. Palliative care options are central to these considerations. Therefore, whether palliative care improves or deteriorates after VAD laws are introduced is crucial.

Adding to the body of knowledge about the quality of palliative care, in this first supplementary submission I report that Dutch and Belgian physicians attended palliative care professional training at vastly higher rates than most other countries in the several years after VAD was legislated.

I also report the research evidence showing increases in desirable end of life decision rates, and decreases in undesirable decision rates in both the Netherlands and Belgium.

Where decision making is best and worst (Supplementary 2)

In my second supplementary submission (PDF 0.2Mb), I report data from two careful scientific studies into end of life decision making by doctors across multiple countries, including the Netherlands, Belgium, Switzerland, Italy and Australia.

The results are striking: for clearly inappropriate decisions such as withholding chemotherapy or administering terminal sedation without consulting their mentally competent patient, the Netherlands was clearly the best performer with the lowest rates of these kinds of decisions amongst physicians. And who was the overall worst? Italy.

Yes, that jurisdiction that harbours the head office of the world's most actively VAD-opposing organisation, the Catholic church, and where 82% of physicians are Catholic, were by far the most likely overall to make medical end of life decisions about their mentally-competent patients without consulting either the patient or her family. Italian physicians were, respectively, more than five times, three times, and twice as likely as those from the Netherlands, Beligum or Switzerland, to make unilateral end of life decisions without consulting either the patient or her family.

So much for high moral standards under a more religiously-driven and VAD-opposing regime.

I also illustrate from another study how VAD decision making in the Flemish north of Belgium, where the rate of VAD deaths is higher, is significantly higher in quality than in the Walloon south.

Conclusion

The peer-reviewed research data currently available consistently and directly demonstrate improvements in end of life care education and decision making in jurisdictions with VAD compared with those that don't. In contradiction to VAD opponents' assumptions, it's Italian physicians — who largely oppose VAD — who tend to 'play God' most with their patients.

The evidence comprehensively supports the view that legalisation of VAD brings a wide range of end of life decision making out of the shadows and into the light, where critical and open appraisal results in significant improvements.


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Lead author Professor Ezekiel Emanuel discusses the findings of the JAMA study.

Several of the world's foremost researchers in medical end-of-life matters have released a detailed and comprehensive review of the practice of assisted dying in lawful jurisdictions around the world. Published in the Journal of the American Medical Association, it does not support slippery slope hypotheses.

Professors from universities in the USA, the Netherlands and Belgium studied data from government and statutory authority reports, primary scientific studies and other sources to examine how assisted dying has been practiced in different jurisdictions around the world where it is lawful in one form or another: self-administered medication (physician-assisted dying) or physician-administered medication (active voluntary euthanasia).1

Their primary conclusion is that:

"Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices."

Key findings

Key findings include:

  • Public opinion favouring assisted dying in developed countries has been increasing, or remained stable at high levels of approval.
  • The trends seem to correlate with decreasing religiosity in Western countries.
  • The only place where assisted dying approval appears to be decreasing is in eastern Europe, where religiosity has been increasing.
  • Approval amongst physicians seems to be consistently lower than amongst the public.
  • Assisted dying occurs everywhere, including juridictions where it is unlawful (as I have previously reported).
  • Most individuals who choose assisted dying have advanced cancer (as I have previously reported).
  • Supposedly 'vulnerable' groups are not represented in assisted dying figures at rates any higher than their presence in the overall population.
  • Numbers of assisted deaths in lawful jurisdictions continue to increase, but represent a tiny minority of deaths.
    • In jurisdictions where only self-administration is permitted, assisted deaths represent around 0.3% of all deaths.
    • In jurisdictions where physicians may administer, assisted deaths represent around 3–5% of all deaths.
  • Assisted deaths for minors and those with dementia are a very small minority of cases (as I have previously reported).
  • The dominant reasons for requesting assisted death include loss of autonomy and dignity and the inability to enjoy life and regular activities; not physical pain.
  • Doctors still report that honouring a request for assisted death is emotionally burdensome; not a routine or welcomed option.
     

"In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population."

Complication rates

One aspect of the study is worthy of special mention: the small rate of assisted dying procedure complications. The available data suggests that complications may occur more often for self-administered medication than for physician administration:

  • For self-administration—
    • Difficulty in swallowing in 9.6% of cases
    • Vomiting or seizures in 8.8% of cases
    • Awakening from coma in 12.3% of cases
  • For physician administration—
    • Technical problems such as difficulty in finding a suitable vein in 4.5% of cases
    • Vomiting or seizures in 3.7% of cases
    • Awakening from coma in 0.9% of cases
       

This data is however of Dutch practice in the 1990s, before assisted dying was codified in statute—at a time when practice was poorly defined and a range of drugs, including opioids, were widely used. Now, practice is well-defined with almost universal use of barbiturates. The researchers expressly note that these complication rates may well have reduced.

Further, the authors refer to more recent data from Oregon and Washington which indicate very much lower complication rates (in those jurisdictions for self-administration only):

  • In Oregon, the complication rates are around 2.4% for regurgitation and 0.7% for awakening from coma.
  • In Washington, the complication rates are around 1.4% for regurgitation, plus a single case of seizure.
     

The importance of context

It is worth comparing the complication rates of assisted dying procedures with rates for other medical interventions to provide an appropriate context so that they may be realistically interpreted.

For example, a study of common over-the-counter analgesics for short-term pain management2 found that significant adverse effects occurred amongst 13.7% of ibuprofen users, 14.5% of paracetamol useres and 18.7% of aspirin users.

In another example, an anlaysis of primary research about surgical outcomes found that 14.4% had adverse events, almost half of which (47.5%) were moderate to fatal in severity.3

Conclusion

The study is a solid synthesis of research data and indicates that assisted dying is accessed sparingly and in accordance with the intentions of each legislature.

The adverse event rate for assisted dying appears to be substantially lower than the rate of adverse events in the use of common over-the-counter analgesics and in surgery.

 

References

  1. Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW & Cohen, J 2016, 'Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe', JAMA, 316(1), pp. 79-90.
  2. Moore, N, Ganse, EV, Parc, J-ML, Wall, R, Schneid, H, Farhan, M, Verrière, F & Pelen, F 1999, 'The PAIN Study: Paracetamol, Aspirin and Ibuprofen new tolerability study', Clinical Drug Investigation, 18(2), pp. 89-98.
  3. Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
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The Canadian Parliament has passed a law that allows the terminally ill to choose assisted dying in restricted circumstances.

The Parliament of Canada has legalised assisted dying. (Photo: Jeffery Nichols)

The Parliament of Canada has legalised assisted dying. (Photo: Jeffery Nichols)

 

The historic law was passed this Friday and allows a dying patient to opt for assisted dying within specific limitations:

  • The patient must —
    • be 18 or older;
    • be mentally competent;
    • be eligible for government-funded healthcare (at the same time as ensuring the patient has access to appropriate care, this prevents non-residents from accessing the law);
    • Have a serious, incurable illness or condition in an advanced state of irreversible decline; and
    • Be experiencing intolerable suffering.
  • The patient's request must be signed by two independent witnesses.
  • There is a mandatory cooling off period of fifteen days.

 
Canadian Prime Minister Justin Trudeau supported the legislation.

Jody Wilson-Raybould, Miniter for Justice, issued a statement with the Attorney General and Minister of Health, saying that the legislation as passed "strikes the right balance between personal autonomy for those seeking access to medically assisted dying and protecting the vulnerable."

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In this thirteen minute video, Oregonians share their experiences of the State's Death With Dignity Act, in effect since 1997. How the Act has worked successfully is described from the medical, palliative care, patient advocate, hospice, legislator and other perspectives, including the daughter of an individual who used the Act.

Part 1 covers attitudes and apprenehsions prior to the Act coming into effect.

Part 2 (2'05") reveals how patient-family-doctor conversations have improved immensely since the Act came into effect.

Part 3 (4'25") discusses the modest numbers of patients using the Act, and that many more Oregonians achieve peace of mind knowing they have a choice even if they don't use it.

Part 4 (7'30") describes how people are free to participate or not, that it is not the 'vulnerable and disenfranchised' who use the Act, and that only minor changes have been made to the Act in order to clarify certain matters, such as residency status.

Part 5 (10"50') concludes with opponents acknowledging there's no evidence for their claim that the Act has caused a 'slippery slope' effect, and State leaders clarifying that the Act has worked as intended, with positive outcomes for the people of Oregon.

Visit the YouTube page.

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