California's End of Life Act
By Traci Clark RN BSN OCN PHN
Published 2/27/2024.
Hello, my name is Traci Clark and I have been an Oncology nurse fort over 10 years. One of the Physicians I work with who regularly serves as both an Attending and Consulting Provider for the End of Life Act generously agreed to speak with me one early morning about his experience. You can watch my full interview with End Of Life Prescriber, Dr Amer Karam, by clicking here.
Many people first heard about the idea of dying at home with self-administered medications (or Medical Aid in Dying, MAID) after hearing about Brittany Maynard, a 29 year old with Glioblastoma who was an activist to for all states to legalize Medical Aid in Dying. Brittany had surgery for her brain tumor, but after it came back within 2 months, she decided against chemotherapy or radiation. Instead, she opted to enjoy whatever time she had left while feeling well and ultimately using medications at home to end her life, her way. Unfortunately, she had to move to the state of Oregon to access the state’s Death with Dignity Act.
Following suit, the California End of Life Option Act (EOLA) was passed on June 9, 2016.
California was the fifth state to enact an aid-in-dying law.
To Be Eligible To Request A Prescription For The Aid-In-Dying Drugs, Patients Must:
Be an adult (18 years old or older).
Be a California resident.
Have a diagnosis from an attending physician of an incurable and irreversible disease which will, within reasonable medical judgement, result in death within six months.
Be able to make medical decisions for themselves as determined by health professionals.
Voluntarily request a prescription for an aid-in-dying drug without outside influence.
Be able to self-administer the aid-in-dying drug. The mixture can be given oral, rectal or G-tube.
Steps Patients must take to obtain prescription for the Aid- in-Dying Drugs:
Make two verbal requests to an Attending Provider. In October 2021, Governor Newsom signed SB 380, which updated the End of Life Option Act and reduced the waiting period between the verbal requests from 15 days to 48 hours. The changes went into effect on January 1, 2022.
See a Consulting Provider to confirm the diagnosis and prognosis.
A mental health assessment may be required only if the attending or consulting physician
determines that the patient has indications of a mental disorder that impairs judgement.
Make a written request that is signed by 2 witnesses. This is what the written request says:
“REQUEST FOR AN AID-IN-DYING DRUG TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER I, ......................................................, am an adult of sound mind and a resident of the State of California.I am suffering from ................, which my attending physician has determined is in its terminal phase and which has been medically confirmed.I have been fully informed of my diagnosis and prognosis, the nature of the aid-in-dying drug to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment options, including comfort care, hospice care, palliative care, and pain control.I request that my attending physician prescribe an aid-in-dying drug that will end my life in a humane and dignified manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.
INITIAL ONE:
............ I have informed one or more members of my family of my decision and taken their opinions into consideration
............. I have decided not to inform my family of my decision
............. I have no family to inform of my decision.I understand that I have the right to withdraw or rescind this request at any time.
I understand the full import of this request and I expect to die if I take the aid-in-dying drug to be prescribed. My attending physician has counseled me about the possibility that my death may not be immediately upon the consumption of the drug. I make this request voluntarily, without reservation, and without being coerced.
Signed:..............................................Dated:...............................................”
ADDITIONAL NOTES:
Participation in the Medication Assist in Dying (or End of Life Act) is completely voluntary and Physicians can opt-out for any reason.
“Notwithstanding any other law, a qualified individual’s act of self-administering an aid-in-dying drug shall not have an effect upon a life, health, or annuity policy other than that of a natural death from the underlying disease” (Coalition for Compassionate Care in California).
“Taking an aid-in-dying drug under the law will NOT be viewed as suicide, assisted suicide, homicide or elder abuse. If all of the requirements of the End of Life Option Act are followed, the patient’s death certificate should indicate they died from an underlying illness and that death occurred naturally” (Coalition for Compassionate Care in California).
THE ACTUAL MEDICATION
Patients are prescribed a strong antiemetic (or two) to take one hour prior to the lethal medications. For the lethal medications, “the standard medication combination is now DDMAPh (digoxin, diazepam, morphine, amitriptyline, and phenobarbital). These contain a medication to slow/stop the heart and an extremely high dose of a sedative. The powder is mixed in 2-4 oz of liquid, less than before, which is easier to swallow. Most patients pass within minutes to 2 hours after ingesting the lethal medication. A very small minority of patients will die 2-4 hours after ingesting.” (Dr Sandy Trieu, Stanford Palliative Care).
The cost around the Bay Area is approximately $750” (Dr Sandy Trieu). Insurance providers are not required to cover aid-in-dying drugs.
A special ‘compounding pharmacy’ will need to provide the mixture. Patients must fill the prescription within 6 months of receiving it and it expires within a year of being dispensed to the patient.
It’s important to note that patients who go through all the steps to obtain the prescription can ultimately decide NOT to take the drug. In California in 2022, one third of patients who were prescribed the End of Life Medications opted not to take it. (California End of Life Act Report, 2022).