END OF LIFE OPTION ACT OF CALIFORNIA (EOLOA)

Many of us are aware of the (controversial) new law that allows physician assisted death in California, the End of Life Option Act (EoLOA), which became legal on June 9, 2016. The new law has garnered much discussion in the news since the EoLOA came into effect and has been met with much frustration by patients as well as their physicians. Although the law is clear and has a detailed process describing the specific steps that a terminally ill person must complete in order to receive the aid-in-dying drug, there has been much confusion and misperceptions reported in the news as well as in the medical community. I will simplify the main points of the law here to hopefully give a better understanding of the EoLOA of California. The most crucial point of the law is that in order to qualify, the individual must be at least 18 years of age, have a terminal condition with a life expectancy of six months or less, and must have the capacity to make medical decisions as well as have the physical ability to self-administer the aid-in-dying drug. The steps include the following:

1. Request the aid-in-dying drug from his/her physician who will determine capacity (physical and mental) as well as the terminal condition. The physician will also ask the patient why he/she wants the aid-in-dying drug and discuss alternative options, such as hospice and palliative care. The law also requires that the physician ask the patient (on at least two occasions) if he/she would like to rescind the request. The physician will also discuss how the drug works, safety, as well as the potential side effects. The patient will also be informed that if the drug is dispensed, the patient does not have to take the drug.

2. The physician will then refer the patient to a second physician “consultant” to confirm the patient’s terminal diagnosis as well as his/her mental and physical capacity. If either physician questions the patient’s mental capacity (includes emotional), the patient must be referred to a licensed psychologist or psychiatrist prior to prescribing the aid-in-dying drug.

3. The patient must make a second verbal request to his/her physician no less than 15 days from the first request.

4. The patient must request in writing (on a specific form provided by the state of California) that he/she wishes to be prescribed the aid-in-dying drug. The patient must also have two qualified witnesses sign the form (translator signatures and qualifications are described within the EoLOA for non-English speaking individuals). The patient will also be asked and encouraged to notify next of kin as well as not be alone when he/she takes the aid-in-dying drug although it is not required by law.

5. The law does state that the patient must take the drug in a private location and complete a 48 hour attestation form (also provided by the state)  indicating his/her intent to take the drug.

6. The prescribing physician is required to complete specific forms provided by the state which also includes a post death worksheet within 30 days of the patient’s death. Many physicians and other healthcare providers have been divided as to their willingness to participate in physician-assisted death, also known as to “opt in” or “opt out”. Although only physicians are allowed to write the prescription for the aid-in-dying drug, other healthcare workers (nurses, social workers, etc.) may not wish to provide care for patients who have decided to end their own life allowed by this new law. The religious, ethical, and moral views of the medical community, as well as the terminally ill patient and their families, vary widely and is beyond the scope of this article, but suffice it to say that the law honors and respects all perspectives, protecting all persons involved whether they choose to “opt in” or “opt out”. The law specifically states that this is NOT suicide if the process is followed exactly as laid out in the EoLOA of California. However, here in the Coachella Valley, as well as many other communities across California, one of the largest obstacles for a terminally ill patient to obtain the aid-in-dying drug is locating a physician who can or is willing to write the prescription. More and more physicians have left private practice to become employees for hospitals or managed medical organizations and are bound by their corporate policy allowing or not allowing them to participate in the EoLOA of California. Most corporate policies prohibit their employed physicians to participate in the EoLOA of California, even if a physician wishes to opt in. If a physician wishes to participate, he/she would need to see the patient when off duty and off the campus/office owned by the employer. The new law specifically protects the physician to do so without any negative ramifications by his/her employer. I have worked in the field of Geriatrics and Hospice for over 15 years (board certified in emergency medicine 15 years prior to that) and have dealt with end-of-life issues on a daily basis. It has been very interesting to hear, in my own field of medicine, the division of feelings and attitudes towards physician assisted death and the patient’s right to end his/her own life despite it now being legal. In each state that has provided terminally ill patients with a law to end one’s own life (e.g., Death With Dignity Act, DWDA), the fear and controversy as well as willingness of physicians to participate in prescribing an aid-in-dying drug has settled to some degree allowing more patients access. Only time will tell how California will respond to the EoLOA but I believe that California will follow suit as Oregon, Washington, Vermont, and Montana and we will see similar numbers of patients being prescribed an aid-in-dying drug.