Episode 4: California's End-of-Life Options Act
California’s new End of Life Option Act – signed by Governor Jerry Brown on October 5, 2015 – went into effect on June 9, 2016. Family physicians throughout the state may face increased inquiries from patients about aid-in-dying drugs. This episode of The Talk explores the law and how physicians can have meaningful conversations with patients about all the care options available at the end of life.
The law allows California residents with a terminal diagnosis and the mental capacity to make medical decisions and both request and self-administer the lethal drugs to request a prescription. Among the law’s many requirements, patients must submit two oral requests and one written request to their attending physician. After extensive counseling and discussion about available alternatives with patients, physicians may, but are not required to, write a prescription.
Whether physicians choose to prescribe or opt out, The California Academy of Family Physician’s (CAFP) former Vice President of Health Policy, Leah Newkirk, encourages them to see this as an opportunity, “to think about what they can offer and provide their patients, and think about how they want to respond to those requests.”
Family physicians should be fully informed about the law and how to facilitate conversations about patients’ concerns, which may include pain, cognitive function, mobility and being a burden on loved ones. Family physicians are already practicing how to receive these questions and be aware of the messages their responses – including language and facial expressions – may convey.
Some physicians may be uncomfortable discussing these sensitive issues around death. As palliative care chaplain and family physician LaVera Crawley notes, “when it comes to end-of-life, one of the reasons we’re hesitant to ask those kinds of questions is we haven't asked ourselves those kinds of questions.” It is important, however, for physicians to see these inquiries as a springboard for asking patients more open-ended questions about their hopes and fears around serious illness and quality of life.
Physicians in Washington and Oregon – two states that have had death-with-dignity laws in place for years – share their stories about how the law has affected their practices. Gregg VandeKieft, a palliative care physician in Washington, had a patient who ultimately did not intend to take the prescription, but, as she said, “I just wanted my family to understand how badly I’m suffering.”
Although statistically few patients follow through with taking the prescription, there are still concerns among the disability community and other vulnerable populations about coercion to choose aid-in-dying drugs by family members or physicians who may not realize their assumptions about what constitutes a good life. It is essential to be mindful of coercion, and some physicians hope the rigorous requirements under the law will serve as protection against it. As medical ethicist Steve Heilig says, “these will be the most scrutinized of all deaths.”
Jay Lee, family physician and past President of CAFP wonders why physicians and patients alike do not pause more often to consider that “one of the options, of course, is to not choose treatment.” The law requires physicians to discuss other options with patients including, but not limited to, palliative care and hospice. Some may also want to discuss options such as voluntary stopping eating and drinking (VSED) or palliative sedation.
Ultimately, if family physicians can find greater comfort with the issues and questions around serious illness and death, they will be better prepared to handle patient inquiries about the End of Life Option Act and help patients navigate all the options and decisions at the end of life.
For more information on the End of Life Option Act, CAFP recommends the following resources: