Nicolais: Severe enduring anorexia patients should have access to medical aid-in-dying meds

Over the past several weeks, death seems to have lurked in my life.

My cousin died just over a month ago. The 23-year-old daughter of my wife’s friend passed away. A colleague suffered the unimaginable loss of his high school senior son.

Maybe that drew me to Jennifer Brown’s exceptional article on a Denver doctor working with patients suffering from severe and enduring anorexia nervosa (SE-AN) seeking medical aid-in-dying (MAID) drugs. 

It is a subject that sets off immediate emotional reactions for people on both sides of the debate. Some are vehemently opposed and believe it is tantamount to a crime to prescribe MAID drugs to someone suffering from a mental disorder. Others feel that self-autonomy is most important for those facing imminent death.

While I do not discount the arguments from the former, after reading the case presentation in the Journal of Eating Disorders that created the uproar I am firmly in the latter category. Providing the MAID option makes sense in the extraordinary circumstances detailed.

I spent several years working as general counsel for a long-term and post-acute care provider. Residents in our skilled nursing facilities frequently faced the crippling challenges caused by disease attacking their body. Consequently, when Colorado adopted a MAID law in 2016 we had immediate interest from many people in our communities.

Many did not qualify. There is a strict six-month or less life expectancy requirement for anyone seeking MAID drugs. That is the same period necessary to qualify for hospice care. Without such a prognosis, they cannot be prescribed.

Even as patients faced debilitating disease such as late-stage cancer, heart-failure and degenerative neurological diseases, many doctors were reluctant to write a prescription. For some it crossed a personal, moral line. For others, it seemed to run contrary to medical ethics they swore to uphold.

While the interim years have eased some of these tensions, the debate has flared up again over an illness that many believe to be a strictly mental issue and choice that could otherwise be “cured.” Reading the case descriptions, it seems that viewpoint is overly simplistic and does not account for the most severe presentations.

The article is clear up front, MAID should be considered only for those patients for whom “no level of harm reduction proves achievable or adequately ameliorates their suffering.” Furthermore, it counsels that “anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so.”

For those rarest of cases — those that persist for decades and through multiple in-patient and out-patient recovery and rehabilitation settings without improvement — MAID should be an option. These are instances where the mental health challenge has led to a subsequent breakdown in the body. For example, one of the individuals described suffered from severe osteoporosis due to vitamin deficiencies from lack of eating. She subsequently fell on multiple occasions and fractured her hip and shattered her pelvis.

READ: Denver doctor helped patients with severe anorexia obtain aid-in-dying medication, spurring national ethics debate

These are the types of injuries I would expect to see in a nonagenarian patient. Hip and pelvis fractures are often fatal for people so elderly.

The most powerful argument came from one of the co-authors, an SE-AN patient who chose to obtain MAID drugs. Before she became unresponsive due to the natural course of her malnutrition (she had the drugs, but did not take them) she wrote extensive notes about her experience.

Like the other two patients discussed, she was intelligent and articulate. She had investigated the process and understood the consequences. As she wrote, she saw “MAID as an opportunity to select a specified time and circumstances for my death … to relieve my suffering and minimize at least some of my family’s suffering related to my death by choosing the when and how … rather than ‘wait’ for sudden death from cardiac arrest or other outcome of my illness or experience a slow and protracted death as my family and I watch my body and mind degrade.”

In the end, that was the argument that won me over. The same argument that other people suffering from other diseases used to obtain MAID prescriptions. Sometimes when death is at your doorstep the option to walk through the doorway should be available.

Mario Nicolais is an attorney and columnist who writes on law enforcement, the legal system, health care and public policy. Follow him on Twitter: @MarioNicolaiEsq