Q&A with Cassie Sauer: Hospitals and Washington State’s “Death with Dignity Act”

Published on
April 14, 2009

Initiative 1000, the so-called "Death with Dignity Act," took effect in Washington state on March 5, after being approved by voters in November. And it has put hospitals in a strange position. Hospitals are considered the place where doctors and staff do everything in their power to keep a person alive. Now hospitals are being asked to allow their patients to kill themselves. Cassie Sauer, vice president for communications for the Washington State Hospital Association, is speaking on a panel this Saturday at the Association of Health Care Journalists conference in Seattle alongside veteran Oregonian reporter Don Colburn, who wrote a series about a woman who decided to commit suicide.

Here is a recap of my conversation with Sauer, which has been edited for clarity and space.

Q: Before Initiative 1000, if a patient committed suicide inside a hospital, the hospital would get in trouble, right? It could be fined or even lose its federal funding, if the situation was bad enough.

A: That's right. But now it's legal if the patient goes through the right steps. There has to be an oral request, a written request, witnesses, potentially a mental health evaluation and a second opinion from another doctor.

Q: Doctors are now allowed to prescribe lethal doses of medicine to patients who they believe have a life expectancy of six months or less. Hospitals can't control what a doctor does and does not prescribe, right?

A: They can restrict the doctors who are their employees, and they can restrict doctors who are in the buildings that they own. They can modify their leases to say the activity is not prohibited on the hospital grounds. If you are a hospital employee, you could even go off the hospital grounds to make the prescription.

Q: I suppose a doctor would have to be pretty committed to prescribing a lethal medication to go that route, right?

A: You can do it but you would be nutty to do it because you would not be covered by liability insurance. Someone could bring a case that you handled it improperly, that you didn't do proper mental health evaluation when it was needed. The patient is dead and can't speak for themselves, but the family can still take action.

Q: Hospitals can opt out. It sounds like many of them have in Washington. What are the others doing?

A: Right. About a third of the hospitals are allowing their doctors and staff to participate if they want to. Another third are saying that they will allow some things but not others. They might say that you can't be the prescribing doctor but can give the second opinion. You can do it in our office buildings but not in the hospital. You can do it in the hospital, but our pharmacy won't fill the prescriptions. Reporters are pretty frustrated with this part. They want us to have a list that's a yes-no list. They want hospitals to be in, or be out. But it's not that easy, and some of the hospitals still haven't figured out exactly how they will handle it. They have to modify their bylaws to say what the repercussions are. Will someone be fired if they do this? Suspended? Will their lease be terminated?

Q: It does seem confusing. I know that at Virginia Mason Medical Center in Seattle, they are refusing life-ending medication for inpatient care but not for outpatient? It seems like patients are patients, right? If you don't want them to commit suicide, why does it matter where it happens?

A: I think one of the reasons is that in a hospital setting, a patient would be cared for by whoever is happens to be on staff at the hospital at that time. In an outpatient setting, you are going to a particular doctor's office where you have a relationship with the doctor you have known for someone time. The law is really clear that only willing providers can participate. That would include a nurse, a nurse's aide, a lab tech, even a food-service person. All those people could say that they didn't want to be part of this. The hospital could have a pretty big job to gather together only the people who are willing to care for the patient who has decided to die. The patient getting outpatient care is probably going to go home and take the prescription at home. So it really is only between the doctor and the patient in that situation.

Q: It creates headaches for the pharmacy, too.

A: Every pharmacist can also opt out of the law. So they need to be sure they have a pharmacist who would be willing to fill that prescription and they would need to be stocking those drugs all the time just in case they had a request. That creates a dilemma because these are drugs that you don't want to mix up with other drugs.

Q: This sounds like the quandaries pharmacists and doctors have with the morning-after pill.

A: Kind of. With the morning after pill, it is quite up for debate whether the pharmacist should have the right to refuse to fill a prescription. But the death with dignity law makes it clear that they don't have to fill it. I think when they were putting this ballot initiative together, they knew they had to give providers the ability to opt out or else they would have had violent opposition from healthcare.

Q: So how did the hospital association stand on the issue?

A: We were neutral. I know that seems surprising, but it's true. We were asked if we wanted to be part of the work drafting the ballot initiative and we declined. All they had to do was look at the morning-after fight to see what not to do. There have been injunctions back and forth saying they can't and then they can refuse to prescribe. The governor completely disagrees with the state pharmacy board on the issue. We haven't given any guidance to our members because it's so confusing right now.

Q: On the requirement for a second diagnosis, is there any sort of oversight of that? How do we know the proscribed steps were followed?

A: The documentation is quite extensive and has to be filed with the Washington state Department of Health.

Q: Will they make that information public?

A: It's not public. But they will keep aggregate information. We have recommended for the hospitals that are opting in that they tell their providers to inform them when they are providing a prescription.

Q: Why does this all seem to be happening in the Northwest and nowhere else? First Oregon, then Washington and now Montana.

A: Because we're kooky hippies. I don't know. I'm surprised it took this long for it to pass from Oregon to Washington. Usually it starts in California and then goes through Oregon and then to Washington. Part of it might be that Oregon and Washington are among the least religious states. We go hiking. We don't go to church.