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R. Jeffery Kohlwes, MD, MPH; Thomas D. Koepsell, MD, MPH; Lorna A. Rhodes, PhD; Robert A. Pearlman, MD, MPH

Arch Intern Med. 2001;161:657-663.

Background  Studies show that patient requests for physician-assisted suicide (PAS) are a relatively common clinical occurrence. The purpose of this study was to describe how experienced physicians assess and respond to requests for assisted suicide.

Methods  Focused ethnography in the offices of 11 acquired immunodeficiency syndrome physicians, 8 oncologists, and 1 hospice physician who had received requests for assisted suicide in their practice. Ten had facilitated PAS.

Results  Informants had a similar approach to evaluating patients who requested assisted suicide, often asking, "Why do you want to die now?" Reasons for requests fell into 3 broad categories: physical symptoms, psychological issues, and existential suffering. Physicians thought they competently addressed patients' physical symptoms, and this obviated most requests. They treated depression empirically and believed they did not assist depressed patients with assisted suicide. Physicians had difficulty addressing patients' existential suffering, which led to most facilitated requests. Informants rarely talked to colleagues about requests for assisted suicide, suggesting a "professional code of silence."

Conclusions  Regardless of divergent attitudes about PAS, physicians respond similarly to requests for assisted suicide from their patients, creating a common ground for professional dialogue. Our sample addressed physical suffering aggressively, treated depression empirically, but struggled with requests arising from existential suffering. A professional code of silence regarding PAS creates professional isolation. Clinicians do not share knowledge or receive social support from peers about their decisions regarding assisted suicide. Educational strategies drawing on approaches used by experienced clinicians may create an atmosphere that enables physicians with divergent beliefs to discuss this difficult subject.

From the Department of Medicine, Veterans Affairs Medical Center, University of California, San Francisco (Dr Kohlwes); and Departments of Health Services and Epidemiology (Dr Koepsell), Medical Anthropology (Dr Rhodes), and Medicine and Medical History and Ethics, Veterans Affairs Puget Sound Health Care System (Dr Pearlman), University of Washington, Seattle.

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