California entered a new era Thursday when the state’s aid-in-dying law went into effect. The bill — co-authored by state Sen. Bill Monning, D-Carmel, who represents San Luis Obispo County — allows doctors to write a life-ending prescription for terminally ill patients who have six months or less to live. The bill was signed by Gov. Jerry Brown last October after years of legislative battles.
It was a hard-fought victory for supporters who say California’s End of Life Option Act offers peace of mind to the terminally ill and their families. But the law still has staunch opponents, including religious-based hospitals. Here are answers to eight key questions about how the law works.
Q: Can anyone request aid-in-dying drugs?
A: No. The law specifies that only terminally ill Californians, given six months or less to live by their doctor, are eligible. They must be at least 18, mentally competent to make the request and physically able to take the lethal prescription themselves, without help from anyone else.
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Patients must make the request twice verbally — at least 15 days apart — and once in writing to their physician. The written request must be submitted on a specific form, “Request For An Aid-In-Dying Drug To End My Life In A Humane And Dignified Manner,” and signed by two witnesses.
Individuals who are not terminally ill or who have a mental disability are not eligible.
Q: Can any doctor write a prescription?
A: The doctor must be the patient’s “attending physician,” the primary doctor handling care and treatment of the terminal disease. But a doctor’s participation is voluntary. Doctors who do not wish to participate for moral or ethical reasons can decline to write a prescription. The law states that they cannot be subject to civil, criminal or professional discipline or penalties for not participating.
Also, health care providers with moral or ethical objections, such as Catholic-based hospitals, can opt out and bar their physicians from issuing aid-in-dying prescriptions. Dignity Health, for example, already has stated it cannot “participate in activities intended to hasten the end of life.”
If turned down, patients can ask for a referral to another doctor willing to write a prescription.
Q: How many Californians will make a request?
A: No one knows for sure. It’s estimated there could be hundreds of qualifying Californians, based on extrapolation from Oregon’s Death With Dignity Act, which has allowed lethal prescriptions since 1998. Compassion & Choices, a Denver-based nonprofit that supports end-of-life options, says it expects up to 1,500 prescriptions will be written the first year, although not all patients will end up ingesting the medication.
Beyond the prescriptions, “We expect about 34,000 Californians will inquire about this process and start a conversation about their end-of-life options,” said Matt Whitaker, Compassion & Choice’s state director in California.
Q: What drug is used?
A: The law doesn’t stipulate what drug a doctor should prescribe, but medical experts in Oregon say it’s typically a barbiturate, such as Seconal.
For instance, Brittany Maynard, the young Bay Area woman with brain cancer who moved to Oregon to access that state’s death-with-dignity program, was prescribed 100 Seconal capsules, which were broken open and the powder dissolved in water. After drinking the medication, she passed away in her sleep about 30 minutes later, according to her husband, Dan Diaz.
Q: If someone takes the medication, what’s the official cause of death?
A: Under the law, physicians cannot list “suicide” as the cause of death. “Physicians can list the cause of death that they feel is the most accurate,” such as the underlying terminal illness, according to the California Medical Association.
Also, in cases where a patient dies from ingesting a prescribed lethal drug, insurance companies are prohibited from treating his or her life, health or annuity policies any differently than death by natural causes.
Q: What precautions are built into the law?
A: The law includes provisions intended to ensure that patients are not being coerced into obtaining a lethal prescription. It requires the attending physician to ask in private whether the patient is “feeling coerced or unduly influenced by another person.” Physicians are advised to counsel patients on other options, including hospice, palliative care and pain control.
In addition, the law requires a second “consulting” physician to confirm the terminal diagnosis and that the person is mentally and physically competent. If either doctor believes the patient may have a mental health condition that impairs judgment, an evaluation by a psychologist or psychiatrist can be required before proceeding.
On the patient’s written request form, the law requires signatures from two witnesses, at least one of whom cannot be related to the patient by marriage, blood or adoption, or be entitled to any portion of the patient’s estate upon death. Three signed documents, from the individual and two physicians, are placed in the patient’s medical record and sent to the state Department of Public Health.
Q: How will the law’s impact be tracked?
A: Once a year, the state Department of Public Health is required to issue a report stating the number of lethal prescriptions issued and how many patients died. The first report is not expected before June 2017.
Q: How does a patient initiate the process?
A: For terminally ill patients, it starts with a conversation with their primary doctor.
“We encourage all patients to initiate conversations with their physician about death and dying, their concerns and wishes for end-of-life care,” said Dr. Catherine Forest, a Stanford University medical professor and a family doctor at Stanford Health Center in Los Altos. Those conversation should cover all options, including hospice and palliative care, and not just lethal prescriptions, Forest said.
Starting Thursday, aid-in-dying forms will be available on the California Department of Public Health website, cdph.ca.gov. The nonprofit Compassion & Choices also has information at 800-893-4548 or EndofLifeoption.org