by Philip A. Brown DO
Chief Medical Officer
Central Vermont Medical Center
Thank you for the opportunity to speak before this committee.
My name is Philip Brown. I’ve been a resident in Tunbridge, Vermont for 23 years, a physician for 27 years, 21 years in Vermont as an Emergency Medicine specialist and 14 years as the Chief of the Emergency Medicine Department at Central Vermont Medical Center where I am currently the Chief Medical Officer. Please note that my remarks today are my own and do not represent Central Vermont Medical Center or any of it’s employees, administration, or medical staff.
As chief medical officer for our hospital, I’m one of the people responsible for assessing the quality of care rendered to our patients by physicians. In doing so I evaluate data almost every day. Data is key to supporting whether a health improvement initiative is of high quality or not. To be helpful, data must be detailed and highly scrutinized. If data is of poor quality, it never supports the notion that the initiative it presumes to support is of high quality. Keep in mind, poor data never supports a notion of high quality. I have some concerns about the quality of data present in the Oregon Public Health Division’s 2012 report of Oregon’s Death with Dignity Act.
I have the Oregon Public Health Division’s official report for physician assisted suicide (PAS) for 2012 (holds up report); I obtained this online by Googling “Oregon’s Death with Dignity Act-2012”. It is the only report that you and I or anyone from the state of Oregon can obtain to view PAS statistics. Statistics from the 2012 report also include summary statistics from 1998-2011. From a cursory review, the report’s statistics carry a lot of information. For instance, an overwhelming percentage of people who died from ingesting the physician prescribed medication for PAS were white, a small majority were men and most had a high school education. Interesting data but not tremendously important data.
Let’s look at some other data points.
Page 4 of the report notes a data point, “Referred for psychiatric evaluation”. In 2012 the report says that 2 of 77 patients (or 2.5%) who died from the PAS medication were referred for psychiatric evaluation. In 1998-2011, about 7% of the people dying from PAS were referred. That’s odd. Medical literature shows that between 30 and 40% of patients with a terminal disease (and remember, all patients who are prescribed a PAS medication are by law supposed to be terminal) have some element of depression. We know that some significant number of those people who are depressed have impaired judgement; that is, they cannot make decisions competently due to their depression. If we are to extrapolate these statistics then we would have expected 30-40% of the 77 people (23 to 30 people) in 2012 who died from the PAS prescription to have been depressed. It’s likely that a significant number of these depressed 23-30 people would have had impaired judgement and therefore, unable to understand the implications of taking a prescription to end their life verses treating their depression or even their underlying terminal disease. However, only 2 of the 77 people were referred for psychiatric evaluation. In our hospital the psychiatrists do not have any end of life discussions (ie Do not resuscitate or DNR discussions) with the depressed patient who is admitted until the patient’s depression is treated and the patient’s judgement is clear (not impaired). Depression is a treatable disease. Once again, only 2 of these people were referred for psychiatric evaluation. What was the psychiatric status of those who died from the PAS medication? We have no idea. The data doesn’t address that crucial issue. What happened to those 2 people who were referred for psychiatric evaluation? Were any treated? Did any have impaired judgement? We have no idea! Once again the data doesn’t address this. Poor data. Remember, poor data never supports the notion of good quality.
Let’s look at another data point on page 5 under “Complications”.
In medicine, we as clinicians are dedicated to helping patients “die well”. In fact we have an emerging specialty in medicine called palliative care which has as one of its goals to help people die well. In 2012, we know that 11 of 77 people dying from ingesting the PAS cocktail suffered no known complications (vomiting, seizures or “other” complications). However, we have no idea about the other 66 people regarding complications after ingesting the PAS medication. How many vomited the medication? How many had a prolonged death, days later. How many had to be hospitalized? How many died poorly? Why would I ask these questions? We know from very transparent, highly scrutinized data from the the Netherlands that 18% of people electing physician assisted suicide and taking the same medication and dose of those in Oregon fail to die. In the Netherlands all of these people who did not die were legally administered an injection of lethal medication and died from this. If we extrapolate the 18% failure- to- die rate from the Netherlands and apply it to the 77 patients in 2012 who “died” as a result of ingesting the PAS medication in Oregon, we would expect 13-14 people to have failed to die. So what happened ? According to the Oregon Public Health Division Report we have no data regarding 66 people and how they died. Did any of these people have prolonged deaths? Were any of them hospitalized? Were any of these euthanized by bystanders with a suffocating pillow? Once again we would expect from very reliable data that 13-14 of these people would not have died from the PAS medication. The Oregon data does not address any of these crucial questions. Euthanasia is illegal in the US and I hope will never be legalized. And yet it is conceivable, even likely that this practice is occurring in Oregon. The data is totally silent in this regard. What is even more bothersome is that in 2010 a revision was made to the Oregon PAS law which accepts only the report from a clinician who attended the PAS death regarding the circumstance, ie complications of the death. There is no mandate for clinicians to attend the PAS death. Once again only 11 of 77 PAS deaths were attended by a clinician. Crucial data regarding complications of PAS deaths will become less and less available. How well are people in Oregon who ingest PAS prescribed medication dying? We have no idea and that is very disturbing.
Once again, poor data never supports the notion of a quality program.
Let’s look at one more data element from the Oregon Public Health Division report on Death with Dignity. Page 4 under “Insurance”. The Oregon Public Health Division PAS report shows that from 1998-2011 the % of people dying from PAS who had private insurance was 66.2% and Medicare/medicaid, 32.1%. By 2012, the percentage of people with Medicare/medicaid had increased to 48.6%! Sometime before 2010, the report stopped splitting out Medicaid from Medicare in this report. What is important to know is that Medicaid rolls in Oregon have increased dramatically while Medicaid payments for certain end-of-life procedures/treatments ie chemotherapies have been dramatically restricted.
I want to know what percentage of people dying from PAS are on Medicaid. More importantly, I would like to know the answer to the following question,”Did an inability to obtain a specific treatment affect your decision to request the PAS prescription?” The term we apply to such a question is “financial coercion” The Oregon PAS report does not address this question. The data is superficial and not helpful in this regard. Poor data.
In conclusion, Vermont is on a quest to provide the best quality, affordable healthcare in the United States. I’m passionate about improving the quality of healthcare in this state. The data from the Oregon physician assisted suicide program is superficial where it needs to be detailed. The Oregon Public Health Division is responsible for overseeing this data; it is failing to ask the important questions as it relates to vulnerable people who are psychiatrically impaired and financially pressed. The data regarding how people are dying as a result of the PAS medication is absent and very disturbing. Remember, poor data never points to high quality. In my view, physician assisted suicide as it is practiced in Oregon cannot be claimed as “high quality”. Do Vermonters want to template this program of questionable quality in our pursuit of a high healthcare quality? I hope not. There are too many questions unanswered…