Is physician-assisted suicide (PAS) an option for patients with middle-stage Lewy Body Dementia (LBD)?

Physician-Assisted Suicide is NOT Available for Patients with Middle-Stage Lewy Body Dementia

Patients with middle-stage Lewy Body Dementia (LBD) cannot access physician-assisted suicide (PAS) because they lack the decision-making capacity required by all existing PAS laws, which mandate that patients must be mentally competent to make and communicate healthcare decisions at the time of the request. 1

Legal Requirements That Exclude Middle-Stage LBD Patients

Capacity Requirements

• All U.S. jurisdictions where PAS is legal require that patients possess full decision-making capacity at the time they request and receive the lethal medication 1
• Middle-stage dementia is characterized by pronounced symptoms including confusion about location and time, requiring assistance with daily activities, and impaired reasoning and decision-making 1
• The progressive cognitive impairment in middle-stage LBD fundamentally disqualifies patients from meeting the legal threshold for autonomous medical decision-making required for PAS 1

Terminal Illness Criteria

• PAS laws require a terminal illness with prognosis of 6 months or less 1
• LBD patients typically die within 3-4 years from diagnosis, with median survival of 3.24 ± 1.81 years, which does not meet the 6-month terminal prognosis requirement at middle-stage disease 2, 3

Why Dementia Specifically Precludes PAS Eligibility

Fluctuating Decision-Making Capacity

• The American College of Physicians emphasizes that the desire for death fluctuates over time in terminally ill patients and may be related to inadequate symptom management 1
• LBD is specifically characterized by cognitive fluctuations, making it impossible to establish the sustained, competent decision-making capacity required for PAS 4, 5
• Expression of desire for death should raise suspicion about mental health problems, particularly depression, which is common in persons approaching death 1

Vulnerability to Coercion and Influence

• Patients with dementia are particularly vulnerable to external influences, including concerns about being a burden on family, losing autonomy, or being placed in long-term care facilities 1
• The American College of Physicians notes that physicians can influence patients in ways they may not appreciate, and socially isolated vulnerable persons seek validation through physician visits 1

What IS Available: Appropriate End-of-Life Care

Palliative and Hospice Care

• The appropriate response to end-of-life concerns in middle-stage LBD is comprehensive palliative care, not PAS 1
• 90% of U.S. adults want palliative care when severely ill, yet 90% don't know what it is 1
• Approximately 78-90% of LBD patients receive hospice care, though 20% use it for less than 1 week, indicating need for earlier referral 2, 3

Withdrawal of Life-Sustaining Treatment

• Patients (or their surrogates with advance directives) retain the legal and ethical right to refuse or withdraw life-sustaining treatments 1
• This is ethically and legally distinct from PAS because the intent is freedom from unwanted intervention, with death resulting from the underlying disease rather than medication overdose 1

Symptom Management

• Vigorous management of pain, dyspnea, and neuropsychiatric symptoms is ethical even if it might foreseeably shorten life, provided the intent is symptom relief (rule of double effect) 1
• Cholinesterase inhibitors (rivastigmine, donepezil) are first-line for cognitive and neuropsychiatric symptoms in LBD 4, 5

Critical Counseling Gaps in LBD

Current Deficiencies

• Only 40-44% of LBD caregivers report helpful conversations with clinicians about what to expect at end of life 2, 3
• Caregivers usually initiate end-of-life discussions rather than physicians 3
• Fewer than half of caregivers feel prepared for what to expect despite death usually being expected 3

What Clinicians Should Discuss

• Physicians should proactively discuss prognosis, expected disease trajectory, advance care planning, and timely hospice referral rather than waiting for families to ask 2, 3
• Common symptoms worsening prior to death include: cognition, motor function, ADL dependence, behavioral features, daytime sleepiness, communication, appetite, and weight loss 2
• Failure to thrive is the most common cause of death (65%), followed by pneumonia/swallowing difficulties (23%) 3

The Ethical Position of Major Medical Organizations

The American College of Physicians opposes legalization of physician-assisted suicide, emphasizing that medicine should focus on improving palliative and hospice care access rather than expanding PAS 1

The organization's position is based on:

• Concerns about the patient-physician relationship and potential for physician influence 1
• Recognition that many end-of-life concerns (pain, isolation, depression) can and should be addressed through medical and social interventions 1
• Evidence that physicians who participate in PAS are adversely affected by the experience 1