"Death is not easy," said J. Pierre Loebel, M.D., a clinical professor of psychiatry at the University of Washington, Seattle. As a geriatric psychiatrist, he is all too aware of that deceptively simple statement. As a member of the board of trustees for the American Association for Geriatric Psychiatry, Loebel would like to do something to make death better.

At the AAGP’s annual meeting last month in Miami Beach, Loebel chaired the forum "Perspectives on End-of-Life Care" to gain an understanding of some of the key issues confronting the geriatric psychiatrist involved in providing care to patients at the end of life.

Loebel, along with a panel of geriatric psychiatrists who concentrate on end-of-life issues, asked AAGP members to join him in an effort to clarify some of the philosophical issues involved in end-of-life clinical care and look for those points that would, or should, define a "good death."

Loebel characterized a "good death" as one that "preserves the integrity and dignity of a patient’s right to choose and right to live and to die, and is surrounded by clinical efforts to eliminate or minimize pain and suffering without directly hastening the timing of death."

The forum discussed physician-assisted suicide (PAS) as a major element of concern to today’s geriatric specialists. Loebel noted that recent studies have indicated that anywhere from 12 percent to 23 percent of physicians receive at least one request for PAS a year from a patient or the patient’s family.

Loebel reviewed results from the AAGP’s poll of its members regarding PAS. Data were tabulated from 257 respondents:

• 62 percent agreed that physicians should not actively administer a deadly drug (euthanasia).

• 62 percent agreed that PAS (supplying the means for the patient to take his or her own life without any active involvement by the physician) was inconsistent with the physician’s professional role as healer.

• 95 percent agreed that a request for PAS should signal to the physician that the patient’s needs are unmet and should trigger a thorough evaluation of the patient’s care.

• 86 percent said that it was morally acceptable for a physician to administer a medication for the treatment of symptoms even when the physician knows the medication may have the unintended "side effect" of hastening the patient’s death.

• When asked by the poll to agree or disagree with the statement "PAS should be allowed to ensure the availability of a means for relieving unacceptable suffering when symptoms are refractory to palliative measures," AAGP members were split with about 46 percent agreeing, 45 percent disagreeing, and 9 percent uncertain.

The forum also addressed the need for reexamination of the issue of advanced directives and how physicians are carrying out a patient’s expressed wishes. It was noted that some studies have shown that end-of-life care decisions are made without the patient’s direct input in as many as 70 percent of cases.

According to Joel Sadavoy, M.D., a professor of psychiatry at the University of Toronto and a member of the forum panel, Canada has long struggled with the issue of a "good death."

"Where we live, the society in which we live," said Sadavoy, "does bear on these decisions. In Canada the law protects the patient’s rights, but practice is not always the same."

Often, Sadavoy explained, in both Canada and the U.S., end-of-life decisions reflect the values and opinions of the care providers, not the patient. "What we have to struggle with is the differentiation of maximizing the quality of life versus maintaining biological life."

According to Sadavoy, "A good death is a meaningful life, right to the very end."

Loebel will undoubtedly have an uphill battle trying to gain consensus on a position statement involving such difficult issues. In the AAGP poll, only 53 percent favored endorsing a position on the specific issue of PAS.