Since 2016, California’s End of Life Option Act (EoLOA) has provided terminally ill, decision-capable adults with an option to legally and safely end their suffering. But the law isn’t as simple as choosing to end one’s life; the petitioning individual must meet specific criteria and follow the steps exactly as prescribed by the law to receive the California law’s protection. As should be the case with something as critical as choosing to end one’s life, this law isn’t meant to make it easy, it’s meant to make it available. Even then, there are natural barriers to its use as well as practical and ethical considerations that must be made. We’re going to explore the key provisions of the law, considerations providers and participants should make, and how the process works.
Key Provisions of the EoLOA
The End of Life Option Act allows certain individuals to request medical assistance to end their lives. These individuals must be California residents, they must be at least 18 years old, and they must have received a diagnosis of an incurable and irreversible disease with less than six months to live. They must be able to make sound decisions as determined by a health professional, and they must be able to administer the aid-in-dying drug themselves. The person must voluntarily request the prescription, and any suspicion of coercion would be a red flag for providers. Additionally, physicians are legally required to discuss all end-of-life options, not just this one.
Key Considerations for Providers and Participants
This law has been in and out of litigation for years, and researchers and physicians have grappled with the questions it poses with vigor. There are several considerations this law requires both providers and participants to make before making this end-of-life decision.
- Participation is voluntary. To prevent abuse by coercion, participation by a patient must be found to be completely voluntary. But providers also have a choice, and that includes physicians, nurses, pharmacists as well as health systems such as HMOs, hospitals, medical offices, nursing homes, pharmacies, and hospice programs. Additionally, insurance does not have to cover this end-of-life option.Because this is voluntary, providers often grapple with the oaths they have made as healers. Is prolonging suffering but staying death doing harm to a patient? Is facilitating their decision to die doing harm to that patient? Those are difficult questions for anyone to grapple with.
- Imperfect decision-making tools. While science has come far in predicting death, it is still an imperfect science. Deciding how comfortable one is with the prognosis of life left to live with a terminal disease isn’t easy, and the results can sometimes defy the odds. Providers and patients both must decide whether they agree with the science behind the predictions.Additionally, the law has done its best to make provision to ensure the patient is cognitively able to make their own health decisions, but there’s still that nagging chance that maybe they aren’t fully aware of their options or are even slightly mentally impaired. The provider has to consider and monitor closely for someone exhibiting signs of feeling pressure from others to make a decision they wouldn’t otherwise make.
- Know the process in its entirety. This blog will discuss the process below, but this cannot be emphasized enough. Every step must be precisely followed as stipulated in the law. Furthermore, the law requires that the patient and attending physician discuss the following before any decisions can be authorized:
- They must discuss how the drug works and complications or delays that could occur.
- They must discuss any alternatives that might be appropriate for the patient including hospice, comfort care, palliative care, and pain control.
- They must discuss whether and how to withdraw a request for the medications.
- They must discuss whether and how the patient will notify family, whether they want family present when taking the drug, and whether participation in hospice is an option. The patient is not required to do any of these things, but it must be discussed with the physician.
- They must discuss that the patient must take the drug in a private place and may not take it in a public location.
- The physician also must be clear and know that the patient understands that they do not have to take the drug, even if they’ve obtained it.
How it Works
The law prescribes the exact steps an individual must take before availing oneself of this California law’s provision.
1. A patient must make two verbal requests directly to the physician directly responsible for his or her care. These requests cannot be made less than 15 days apart.
2. After making two oral requests, the patient must make one request in writing using the state’s prescribed “Patient’s Request for Aid-in-Dying” drug form. It must be signed by the patient as well as two witnesses and provided directly to the physician that is attending to his or her care. There is not a specification as to when the written request should be made.
3. Once these steps are made, the patient must then discuss the request with his or her attending physician alone, with no one else in the room with very few exceptions. This is to determine that the request has been voluntarily made.
4. The patient is then required to consult a second physician to confirm the diagnosis, prognosis, and decision-making ability. If either physician has questions or concerns about the patient’s mental faculties, they must refer him or her to a mental health specialist to determine cognitive ability.The request for this type of medicated death cannot be made in an advance directive, by a health care agent or surrogate or any other health care decision maker. It must be made by the patient, directly to the attending physician, and following the steps as outlined in the law.
The law stipulates that this kind of end-of-life decision should not adversely impact estate planning. If done correctly, the death certificate will show that the patient died due to the underlying disease. It’s important to discuss these issues and make sure everything is in order, that the physician is well-versed in the stipulations of the law before proceeding so that you and your loved ones are protected.
There is the chance, because disease diagnosis and prognosis are difficult and imperfect, that the timing required by the law causes problems for the patient. If the disease advances too quickly, or the patient delays decision-making, they may no longer qualify. Additionally, there have been instances when the physician or health care provider will not even discuss this option with a patient, and because it is voluntary, they are not required to do so. Finding a participating physician can be emotional and complicated. Finally, there have been problems finding a pharmacy that will fill the prescription for the drug. It’s important that participating individuals know what resources are available to them to find and receive the drug.
To date, the majority of people availing themselves of the EoLOA are over the age of 60 and predominately white. Roughly 60% of the people who obtain the medication use it, and most have been diagnosed with terminal cancer. Any law such as this could be easily abused which is why it is so prescriptive. End-of-life decisions are emotionally and legally fraught, and no one should feel pressure to choose one way or the other. It’s important that patients are aware of the options, the challenges, and the impact of their decision.
By Christopher E. Botti