EDITOR’S NOTE: This is the second of a two-part series on the decision made or facing hospitals and health care providers before the Death with Dignity Act, approved by the state’s voters, goes into effect on March 5.

PORT ANGELES — To the majority of Washington voters, Initiative 1000 is a humane approach to end-of-life health care.

To Rose Crumb, 83, the soon-to-be-enacted Death with Dignity law is physician-assisted suicide.

“It’s tough enough when they die naturally,” said Crumb, director of Volunteer Hospice of Clallam County.

“I could never bring myself to do it. No way.”

Her view may turn out to be different from that of the hospice she directs.

The Volunteer Hospice of Clallam County board of directors has not voted on the issue. The board will discuss it today, but no vote has been scheduled.

If Volunteer Hospice, as an institution, decides to provide physician-assisted suicide, then Crumb remains free to decide not to help anyone die.

Health-care providers throughout the state are grappling with the ethical issues behind the Death with Dignity act.

Under the law, which garnered 58-percent voter approval in November and takes effect on March 5, competent adults with six-months or less to live can submit formal requests for self-administered, life-ending medication prescribed by a doctor.

The state Department of Health oversees the application of the law.

Hospitals, clinics and hospice care centers can decide to “opt out” of I-1000, but cannot prohibit individual doctors from participating.

A health-care institution that decides to participate cannot require a doctor, nurse or pharmacist to take part.

Crumb will not participate because she has seen too many cases of terminally-ill patients reconnect with estranged loved ones and come to meaningful resolutions in their final days.

“I have seen wonderful things happen at the end of life,” Crumb said.

Question of ethics

“I think that what is at the center of the controversy, at least in medical circles, is the question of ethics,” said Dr. Tom Locke, health officer for Clallam and Jefferson counties.

“From my perspective, there are competing ethical duties — the duty to do no harm is in competition with the ethical duty to respect patient autonomy.”

Locke said I-1000 does a good job of making it clear that it can only be applied in cases where death is imminent, and that no doctor is obligated to participate if the law conflicts with their ethical, moral or religious beliefs.

“My personal position is the ethical duty to respect each individual’s personal choice wins out,” Locke said.

“That has to be the dominate concern.”

In the last decade, Locke said he has seen a shift from lack of support toward more support for right-to-die legislation.

“This has been a heated topic of debate,” Locke said.

“There are people that feel very strongly on both sides of the issue.”

Patient control

The law, based on Oregon’s 1998 Death with Dignity law, was created to give patients more control in their final days.

“We neither encourage or discourage them to participate, but they’re allowed to,” said Keri Johns, home and community services director for Jefferson Healthcare, which includes hospice care.

“It really is about opening dialogue. Now we can talk about it.”

Jefferson Healthcare’s hospital commissioners voted 4-0 on Wednesday to participate in I-1000. Johns said the decision was based largely on the county’s 72.15-percent approval of the measure.

At Olympic Medical Center in Port Angeles, the Ethics Advisory Committee voted unanimously on Feb. 4 to recommend approval of I-1000.

The OMC hospital commissioners will vote on whether or not to participate on March 4.

Dr. Sandra Tatro, who chairs the OMC ethics committee, presented six bullet-point recommendations for the commissioners to consider for their vote. In summary:

• A substantial majority (61 percent) of Clallam County voters approved the initiative seeking respect for end of life wishes. OMC should not conflict with those wishes.

• As the public hospital for the community, OMC should consider the significant margin of voter approval for the Death with Dignity act.

• By becoming a participating health care provider, OMC will further its ability to counsel and provide information on palliative care, comfort measures, and pain management to the public.

• OMC should recognize that only willing health care providers should participate in the Death With Dignity act and one is obligated to do so.

• The hospital should implement policies, procedures, and education for staff so the requirements are strictly followed.

• OMC should provide information and education on end of life care for patients and families considering the Death with Dignity act.

“If we had to only glean one thing from the Death with Dignity act, it is that the people of Washington state have said to us as health care entities that we don’t do a very good job of helping people in their last months of life,” Tatro said in Wednesday’s meeting.

“Really what people are asking for is help being reassured that when they’re in pain or their at the end of their lives that they’re going to be listened to, or that people are going to be able to help them die with dignity.

“I think in our community, we have a lot of elderly people, and I think it’s more prominent or more common or more fearful in our population, just because we have so many folks who are nearer that end of life.”

Like OMC, Forks Community Hospital officials are debating whether or not to participate I-1000.

“It’s not an easy decision at all,” said Camille Scott, Forks Community Hospital administrator.

“It’s not just a patient’s right to die with dignity, but it’s who it draws in to get there. That’s the tough part.”

The West End hospital’s commissioners will discuss I-1000 on Tuesday before making a decision to opt-in or opt-out.

“I’m hopeful we’ll have a decision fairly soon,” Scott said.

“We’re trying to get information from our ethics committee and our medical staff as a whole.”

Crumb predicts that very few people will use the law.

“I think it’s going to be very hard for them,” Crumb said.

Oregon data shows that 17 percent of terminally-ill patients considered the decade old law, but one-tenth of 1 percent actually pursued it.