ive care. This model assumes rational decision-making and also assumes that when patients raise the possibility of assisted dying, they are in fact, asking for a hastened death rather than using the request to manipulate their situation. Furthermore, it assumes that the patient desires and is capable of rational decision making at this emotionally difficult time. In some cases, however, none of these assumptions may be true.Recently, terminal sedation and voluntarily stopping eating and drinking have been proposed as legally acceptable alternatives to physician-assisted suicide for persons whose suffering cannot be addressed by standard pain management and cessation of life support. When a patient expresses the wish to die, exploration of the adequacy of palliative care should begin, including assessment of pain management, depression, anxiety, family burnout, and spiritual and existential issues. For patients who are genuinely ready to die, for whom suffering is intolerable despite comprehensive palliative efforts, an exploration of methods for easing death can begin. The methods will be determined by the patient's clinical situation; the values of the patient, family, and physician; and the status of current law. Many practices have been accepted as ways to hasten death. Four options can be practiced openly, with good documentation and consultations are as follows: standard pain management, forgoing life sustaining therapy, voluntarily stopping eating and drinking and terminal sedation. Other options such as physician assisted suicide and voluntary active euthanasia must be carried out covertly, except in Oregon. Clinicians faced with these difficult decisions should be aware of all of these options, including their indications, risks, benefits, and likely outcomes, and how to discuss them with patients and families. Doctors that are asked to aid in the suicide of their patients are faced with tremendous pressure and stress. It i...
