Dr. Charles Blanke makes house calls.
But the oncologist and Oregon Health and Science University professor’s visits aren’t for illnesses like the flu or chicken pox.
He visits his patients when they’re ready to end their lives with a lethal dose of secobarbital, or a similar drug.
The visits are relatively new for him. He has been prescribing drugs under Oregon’s Death with Dignity Act for nearly two decades.
At first, he says, “I didn’t ask patients if they wanted me to be present, and I never offered.”
But the more he worked with patients, he realized that they might benefit from his presence:
“I realized that they and their families are very concerned that something may go wrong: ‘What if I vomit the medications? What if I wake up? What if I turn a funny color — will it scare my family?’”
Now he says that every patient he’s offered to be with at the end of their life has taken him up on it.
But Blanke is an anomaly. According to a new study by Blanke and other researchers in his SWOG network of oncologists, physicians are present at the time of ingestion only 16 percent of the time in Death with Dignity cases.
Blanke embarked on the study to answer the many open questions that still exist nearly 20 years after Oregon’s Death with Dignity Act. He recently talked about the results on OPB’s “Think Out Loud.”
“The medical community just didn’t have the answers to some very basic questions,” he told host Dave Miller. Questions like “Are the drugs as effective as they need to be? What’s the trend in the prescriptions written and the prescriptions taken?”
Blanke used publicly available data from the Oregon Health Authority, and the findings were published in “JAMA Oncology.”
One of the big takeaways from the study is the increase in prescriptions for lethal medication. In 1998, 24 patients filled prescriptions and 16 used the medication. Recent years saw massive increases, with 218 prescriptions filled in 2015.
Blanke sees it as a sign that Death with Dignity is becoming more mainstream.
“I think we are thinking of it less and less as suicide and more and more as a natural death,” he said, “so there may actually be less of a stigma attached to it.”
That shift in thinking extends even to the death certificates of patients using physician aid in dying. The cause of death used to be “suicide,” but now it’s the underlying illness that led the patient to hasten their death (which also helps patients’ families avoid legal issues when collecting on life insurance policies).
One factor that may have helped spread awareness of Death with Dignity, according to Blanke, was the story of Brittany Maynard, who moved to Oregon from California in 2014 to use the Oregon law. The story gained national attention, and now nearly every new patient Blanke sees mentions her.
“We had a huge spike in referrals after that happened, and we actually had people who tried to move to Oregon to use Death with Dignity.”
Blanke found the disparity between patients filling prescriptions and using them intriguing. On average, about one-third of patients who get prescriptions don’t actually use them.
“A big reason for patients to use Death with Dignity is they feel they don’t have control over their disease and they don’t have control over their death,” he said. “If they fill this prescription … it gives them that control, even if they don’t ultimately utilize the act.”
He says he has patients that just put the prescription in their sock drawer, and they look at it and touch it every day to remind themselves that they can use it if needed.
Blanke doesn’t think the stigma around the law is being reduced among his fellow physicians, however.
“There are too many physicians who say, ‘I don’t practice. I don’t prescribe. I don’t know anybody who does. Good luck with that,’” he said.
He said he thinks that’s particularly common for non-oncologists: “I think they are not quite as used to their patients dying as we are.” Whereas, he says, as an oncologist, “You realize probably half of them or so, depending on your field, are actually going to die.”
Because so many physicians won’t prescribe or refer, there’s a small group of physicians that has come to specialize in the treatment, including Blanke.
“You do develop a bit of an expertise when you do this,” he said, “and I actually ultimately wound up as a so-called ‘end-of-life expert.’” The OHA data showed one doctor in the state prescribed Death with Dignity drugs 71 times. Overall 336 physicians wrote lethal prescriptions, averaging 3.4 prescriptions per doctor.
That specialization means that although Blanke is an oncologist focused on stomach and large bowel cancer, his expertise has allowed him to see patients suffering entirely different illnesses. His research found 77 percent of Death with Dignity patients have cancer, but many of them have neurological diseases, heart disease, lung disease and HIV.
Treatment being confined to a small number of doctors can make things difficult for patients.
“Many times patients tell me that it took them four months, five months to find me.”
That can be “a huge fraction of their meaningful time and it’s a shame,” when patients only have a few months to live.
The connections that he makes with his patients experiencing various ailments has been a fulfilling turn in his career that he never anticipating.
“I’ve found that the relationships that I’ve developed with these patients are so deep and satisfying that it’s difficult to even describe,” he said.
Blanke still has a number of questions he wants to be answered. Some 3.3 percent of cases had unintended complications, including six cases where the patient awakened after slipping into a coma. Sometimes patients would be in a coma for days before passing away. Blanke wants to examine cases like these to find out if there’s anything to be learned from them and if there are ways families can be warned about the possible complications of the medicine.
He also wants to look more deeply into the reasons people use the act: 89.7 percent of people said they used the Death with Dignity Act because the activities of daily living were not enjoyable; 91.6 percent cited their loss of autonomy; 78.7 percent their loss of dignity as their reasons for hastening their death. Blanke hopes to find out whether there are other ways to relieve those concerns.