Update on the End of Life Option Act

I have recently become the Medical Director of a small CCRC.  During a zoom Q & A session with our residents, I was asked about my thoughts on the EOL Option Act (EOLOA).  Some vocal residents said this option should be more accessible.  They were aware that Kaiser Permanente members in my community can much more readily access it.  In fact, they said a KP member in our CCRC had recently executed this option with friends and family present and no apparent adverse events. 

The EOLOA, authored by then Assemblyperson Susan Talamantes Eggman, became law in June 9, 2016 amid some controversy, and is scheduled to sunset in 2026.  This law permits mentally capable adults with a certified terminal illness (an expected life expectancy of < 6 months) to voluntarily follow a detailed one month process before a lethal prescription can be prescribed.  Physicians are not obligated to participate in the EOLOA in any way, and only a small fraction of California’s physicians have participated in prescribing or consulting on EOLOA cases to date. 

The California Department of Public Health is the repository for data, forms, and other information about the EOLOA (https://www.cdph.ca.gov/Programs/CHSI/Pages/End-of-Life-Option-Act-.aspx). In addition to previous years’ reports, the 2020 report has just become available. 

Since its inception, about 2,400 people have taken the prescribed meds.  A study by Kaiser Permanente Southern California reported late last year that about 1/3 of those requesting this option died before obtaining a prescription.  Many others have received the prescription but ultimately not ingested the medications, which now are most often a combination of digoxin, diazepam, morphine and amitriptyline (D-DMA).  Since the EOLOA was instituted, CDPH has not received reports of abuse or coercion. 

In February of this year, SB 380 (https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220SB380 ) was introduced by Senator Eggman which has subsequently been amended 4 times and is expected to go before the full Assembly in the near future.  This bill would eliminate the 2026 sunset provision and would allow a waiver of the minimum 15-day waiting period between the 2 oral requests to be reduced to 48 hours, if the certifying physician determines this patient is unlikely to survive the 15-day period.  In addition, providers would be required to document the first oral request in their records to establish the starting time of the minimum 15-day waiting period, and to transfer this document if a referral to another provider is made.  All providers would need to clearly disclose whether they are willing to provide these services.  Health care employers would still be able to prohibit their employees from providing this option while they are at work and on the employer’s property, but could not prohibit off-premises participation while not carrying out their employment.  Finally, the patient would no longer be required to complete the final attestation form prior to ingesting the lethal medication. 

In my community, this option has been hard to access, since most physicians in private practice have opted out, as has our large Catholic hospital system.  Very few of the pharmacies stock the bulk quantities of the lethal cocktail options.  The few physicians who have provided this service in my community have been reluctant to become known in the community as a provider, since there may be a stigma associated with providing this option. 

The law doesn’t stipulate reporting on the setting where the medication is ingested.  I’m not aware of its completion in local SNFs, but I wouldn’t have been aware of the death in my CCRC if I hadn’t been at the above zoom meeting.  A major barrier to uptake in nursing homes stems from 1997 legislation prohibiting Congressional “support of assisted suicide, euthanasia, and mercy killing and intend[ing] that Federal funds not be used to promote such activities (https://uscode.house.gov/view.xhtml?path=/[email protected]/chapter138&edition=prelim). Some other barriers to EOLOA completion in the SNF setting include the owner/administration opting out, the need to store the lethal meds in a private secure space for later ingestion, the support of a nursing team, and ideally, the availability of hospice services.  Even voluntarily stopping eating and drinking (VSED), another legal option for hastening death that does not require a lethal prescription, has been known to be discouraged, sometimes even actively sabotaged in nursing facilities.

In California, we now have the American Clinicians Academy on Medical Aid in Dying (www.ACAMAID.ORG ).  This organization is committed to providing improved access and completion for this option.  On their website, they have practical resources for clinicians and patients and also provide links with a patient intake form and a confidential participating physician form.  The latter may encourage more physicians to become participating providers as has occurred over time in Oregon. 

I would hope that the necessity for accessing this option would still be rare due to easy access for all our residents to excellent and effective palliative care.  However, this isn’t a current reality.  There still are failures of palliative care from the perspective of the provider and their patients and their families.  Also, under California law, our residents have a right to exercise their autonomy, and if they decide they do not wish to continue living with a progressive terminal illness, they have a right to access these medications if the criteria are met.  As health care providers, we must listen to “what matters most” to our patients and have a respectful approach to these challenging requests at the EOL, even if we do not choose to participate directly in the EOLOA.

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