AL Back, VA Puget Sound Health Care System and University of Washington; HE Starks, University of Washington and VA Puget Sound Health Care System; C Hsu, Seattle Institute for Biomedical and Clinical Research; J Gordon, Seattle Institute for Biomedical and Clinical Research; A Bharucha, University of Pittsburgh; RA Pearlman, VA Puget Sound Health Care System and University of Washington

Objectives: Even though VA is prevented from participating in patient requests for physician-assisted suicide (PAS), some patients with terminal illness will likely raise the issue with VA clinicians. Responding effectively to a patient request for PAS is an important clinical skill that involves careful evaluation and expertise in palliative and end-of-life care. Clinician responses to PAS requests, however, have only been described using data obtained from clinicians. The objective of this study was to describe clinician-patient interactions about requests for PAS from the patient and family perspective.

Methods: We conducted multiple, intensive, qualitative interviews with 35 families, including 12 prospective and 23 retrospective cases. The prospective cases included patients pursuing PAS and their family members; the retrospective cases included family members of deceased patients who seriously pursued PAS as an option. Participants were recruited through community-based patient advocacy organizations, hospices, and grief counselors. Interviews were conducted using a guide that included questions about patient and family interactions with health care providers regarding PAS requests, how these requests were evaluated, and the provider's involvement with PAS implementation. Interviews were audiotaped, transcribed, coded, and reviewed by a multidisciplinary research team. This analysis is based on the narrative associated with the code "interactions with health care providers," which was then organized into themes.

Results: We conducted 156 interviews with 60 participants, resulting in 3,580 pages of transcripts. Six themes were identified: (1) Clinicians often blocked PAS discussions; (2) Patients may use talking about PAS as a gateway to talking about dying; (3) Clinicians fulfilled some requests for PAS with little evaluation; (4) How clinicians frame the dying experience can contribute to patient and family interest in PAS; (5) Clinicians did not recognize some ways in which their advice and medical care failed their patients; and (6) Patients and families value therapeutic relationships with their clinicians, even if they disagree about PAS.

Conclusions: These patient and family accounts reveal many missed opportunities for clinicians to engage in therapeutic relationships involving discussions about PAS, dying, and end-of-life care. Clinician competence in responding to PAS requests should involve an ability to create safe environments in which PAS can be discussed openly; an ability to frame dying relative to patient concerns and expectations; expertise in symptom control and psychological issues; and a willingness to tailor therapy to individual preferences. Most of these elements of competent practice are generalizable to end-of-life care beyond PAS requests.

Impact: The themes represent lessons, not generalizations. Based on these themes, we propose a series of questions that clinicians should ask themselves when a patient requests PAS: (1) Am I blocking discussions about PAS? (2) Have I indicated a willingness to discuss concerns about dying, including PAS? (3) Have I evaluated the request adequately? (4) Have I addressed patient and family concerns about the dying experience? (5) Have I individualized care regarding the kind of death this patient and family want? (6) Have I attended to the relationship between myself and this patient and family, as well as my own feelings?