Aid in Dying The process by which a capable, terminally ill person voluntarily self ingests prescribed medication to hasten death Distinguish from: Withdrawal or withholding of lifesustaining treatment accepting death Euthanasia Ethically Appropriate? Devaluing human life? Wrong solution for inadequate attention to the terminally patient and palliation? Slippery slope toward disrespecting and disproportionate burden on the vulnerable? Compatible with the professional obligation of the physician? I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Hippocratic Oath allowing physicians to participate in assisted suicide would cause more harm than good. Physician assisted suicide is fundamentally incompatible with the physician s role as healer, would be difficult or impossible to control, and would pose serious societal risks American Medical Association 1996, 2005 History of Physician Assisted Suicide in the U.S. 1997 Oregon Death with Dignity Act 2006 Supreme court overrode Justice Dept opposition to the Oregon law 2008 Washington Death with Dignity Act 2009 Montana supreme court ruled that nothing prohibited PAS, but no law 2013 Vermont Death with Dignity law "I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill." California governor Jerry Brown in letter to the California Assembly on signing the End of Life Option Act, October 5, 2015 Experience with the Oregon Death with Dignity Act As of 2014 (17 years of experience with the law): 1,327 terminally ill patients had received prescriptions (0.2% of all deaths in Oregon) 859 (65%) of these patients ingested the prescribed medications to hasten their death Main reason patients request aid in dying: Desire to maintain control over their final days
Experience with the Oregon Death with Dignity Act Among terminally ill patients in Oregon: 1 in 6 talks with their family about aid in dying 1 in 50 talks with their physician about aid indying 1 in 425 received aid in dying medications 1 in 640 ingested aid in dying medications Adapted from Tolle SW, et al. Characteristics and proportion of dying Oregonians who personally consider physician assisted suicide. J Clin Ethics. 2004;15: 111 8. Characteristics of Patients Receiving Aid in Dying in Oregon (1998 2013) Age, median 71 years (Range 25 96) Male 53% White 98% College or higher 72% Insured 98% Died at home 95% Enrolled in hospice 91% Oregon Department of Human Services, 2013 California End of Life Option Act Capable adult suffering from a terminal disease may request a drug for aid in dying Procedures Forms Medical record documentation Prohibits contracts related to aid in dying Prohibits life, health insurance affected by aid in dying Prohibits an insurance company from communicating about the availability of an aid in dying, unless asked Immunity for persons present when patient selfadministers the aid in dying drug End of Life Option Act (cont.) Felony charges Fraudulent requests Coercion or undue influence No lethal injection, mercy killing or active euthanasia Aid in dying is not suicide or homicide Physician submits forms to CDPH after writing aid indying prescription and after death Annual review and statistical report Prescribing an aid in dying drug is voluntary Goes into effect in California June 9, 2016 Law expires January 1, 2026 1. Patient seeking aid in dying drug submits two oral requests at least 15 days apart, and a written request to Attending physician All 3 requests in person to Attending physician Written request in presence of and signed by 2 witnesses 2. Attending physician does the following: Determines patient has capacity to make medical decisions If indications of a mental disorder, refer for a mental health specialist assessment Determine patient has a terminal disease (incurable condition, prognosis < 6 months) Determine pt making a voluntary and informed decision 3. Attending refers the patient to a Consulting physician 4. Consulting physician does the following: Examine the patient, medical records Confirm in writing Attending physician s diagnosis and prognosis Determine the patient has capacity, is acting voluntarily, and made an informed decision If indications of a mental disorder, refer for a mental health specialist assessment Record documentation Submit compliance form to Attending physician
5. Upon referral, the mental health specialist does the following: Examine the patient, medical records Determine the patient has capacity, is acting voluntarily, and made an informed decision Determine the patient is not suffering from impaired judgment due to a mental disorder Record documentation 6. Attending confirms that the patient s request does not arise from coercion or undue influence by another person in a private discussion 7. Attending physician counsels patient: Another person present when ingesting aid in dying drug Not ingesting aid in dying drug in a public place Notifying next of kin (but this is not required) Participating in a hospice program (complete POLST) Maintaining aid in dying drug in a secure location Patient may withdraw request for aid in dying drug at any time and in any manner Opportunity to withdraw the request before prescribing the aidin dying drug Verify, immediately before writing the prescription that patient is making an informed decision 8. Confirm that all requirements are met before writing the prescription 9. Attending physician prescribes or dispenses the aid in dying drug To prescribe: with patient s written consent, inform pharmacist and deliver prescription Secure delivery of the dispensed drug to the patient 10. Patient completes final attestation form within 48 hours before choosing to self administer the aid in dying drug 11. Attending physician medical record documentation All oral requests for aid in dying drugs All written requests for aid in dying drugs Attending physician s checklist and compliance form Consulting physician s compliance form Report of the mental health specialist s assessment, if any Attending physician s offer to withdraw request at the time of the patient s second oral request Attending physician note indicating that all requirements have been met and indicating the steps taken to carry out the request, including a notation of the aid in dying drug prescribed 12. Attending physician submission to CDPH within 30 days of writing aid in dying prescription Patient s written request Attending physician checklist and compliance form Consulting physician compliance form 13. Attending physician submission to CDPH within 30 days of death (from ingesting aid in dying drug or any other cause) Attending physician follow up form Official Cause of Death on the Death Certificate Act is silent as to the cause of death that should be written on the death certificate However, death caused by the self administration of an aid in dying drug shall NOT constitute suicide. Thus, suicide should not be listed as the cause of death. Physicians can list the cause(s) of death that they feel is most accurate. The Act does not preclude physicians from listing the underlying terminal illness and/or pursuant to the End of Life Option Act.
Using an Interpreter If an interpreter is used, the written Request form signed by the requesting patient must be written in the same language as any conversations, consultations, or interpreted conversations or consultations between a patient and his or her attending or consulting physicians. However, written Request form may be prepared in English with an attached interpreter's declaration signed under penalty of perjury. Interpreter must not be related to the patient or stand to inherit, and must meet regulatory standards. Official Cause of Death on the Death Certificate Act is silent as to the cause of death that should be written on the death certificate However, death caused by the self administration of an aid in dying drug shall NOT constitute suicide. Thus, suicide should not be listed as the cause of death. Physicians can list the cause(s) of death that they feel is most accurate. The Act does not preclude physicians from listing the underlying terminal illness and/or pursuant to the End of Life Option Act. How to Approach the Patient Requesting Aid in Dying Explore the meaning behind the question Loss of control, abandonment, financial hardship, burden to others, and personal or moral beliefs Seek to understand what constitutes unacceptable suffering in the patient s view. Pain, other physical symptoms, psychological distress and existential crisis Explore treatment for symptoms for which there are treatment options available Hospice, psychological support and other palliative care Physician should reflect on his/her own beliefs and motivations and the policies of the health care system, and consider the impact of those motivations on decision making with patients near the end of life. Health System Issues in Response to the End of Life Option Act Adequacy of advance care planning and access to palliative care? Assessing for suffering and responding to it? Structures for psychological support? Methodical, comprehensive approach to requests for aid in dying. Adapted from: The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals, 2008 Goodbye to all my dear friends and family that I love. Today is the day I have chosen to pass away with dignity in the face of my terminal illness, this terrible brain cancer that has taken so much from me... but would have taken so much more. Concluding words of Brittany Maynard before ingesting aid in dying medication as quoted in Hirschhorn D. Terminally ill woman who planned assisted suicide dies. time.com/3553770/brittany maynard dies, from JAMA. 2016;315:249 50.