Dr. Kathryn Shade is a provider of “Aid-in-Dying” per the California law entitled the “End of Life Option Act”

What is Aid-in-Dying for Terminal Patients?

The California End of Life Option Act became law June 9, 2016. It provides that any mentally competent adult who has six months or less to live has the option to request a prescription from his/her doctor for a medication which he/she could take to end suffering and die peacefully.  This medical practice has also been called Death with Dignity. (In the past it has been labelled as Physician Assisted Suicide, but that is no longer an appropriate term since the California End of Life Option Act states specifically that physician aid-in-dying is not suicide.)

Consultation

Consultation with Dr. Shade is commonly initiated when a terminally ill patient is considering all possible options for their death, including physician-guided aid-in-dying.  This consultation can be initiated by the patient or, with the patient’s permission, by his or her doctor or family member. The most common first contact is by email or telephone.

Dr. Shade will encourage the patient not only to continue care with his/her regular physicians, but to make every attempt to have these doctors talk with and evaluate all of the patient’s end-of-life needs and choices.

If that first phone or email confirms that it is appropriate to continue, Dr. Shade will review the medical records and then arrange a first visit evaluation.  This consists of an office visit or home visit with the patient (with family or caregivers present, if desired), whichever the patient prefers. She will review all the relevant medical information, examine the patient, and discuss all potential options available to the patient as death approaches.

The goal of the first visit is to evaluate the patient’s end-of-life care. Dr. Shade highly recommends that all patients requesting an end-of-life consultation are also enrolled in a hospice program or receive care from a palliative care physician. Part of the initial evaluation is to ascertain whether, among many choices that will be described, physician aid-in-dying is appropriate and legal for the patient and his/her circumstances.

 

End of Life Option: Dr. Shade as Attending Physician

If Dr. Shade is the attending physician responsible for Aid-in-Dying, she will consult with the patient, the family, the patient’s doctors, and hospice staff.  She will guide communication to advocate for the best end-of-life care for that individual patient’s needs and desires.  She will maintain communication with the patient and caregivers by phone, email, and, when suitable, home visits.

This can occur only if:

  • The patient is no longer participating in any curative or life-prolonging treatment of their underlying terminal disease, but rather has chosen to receive intensive treatment of symptoms as death approaches. This signifies that the patient understands and agrees that his/her end-of-life care no longer requires the specialist’s treatment of the underlying disease, but rather treatment of the symptoms of dying.
  • All medical and legal criteria are met.
  • The patient has an appropriate and persistent desire to consider the possibility of ending his/her life with an aid-in-dying medication, and the patient’s usual physicians will not or cannot provide physician aid-in-dying.
  • The patient agrees, if at all possible, to be in a hospice program.

If the patient does choose to take an aid-in-dying medication, Dr. Shade will write the prescription for that medication, supervise the process and, if the patient wishes, be present at the bedside to manage the taking of medications, as well as counsel the patient and family on the day of the patient’s death.

 

Consulting Physician Requirement

If the patient does work with Dr. Shade as the attending physician for the End of Life Option Act, he or she must have a second opinion from another doctor, a “consulting physician.”  This may be the patient’s primary care physician, surgeon, hospice physician, or other contracted physician who agrees to consult.  That consulting doctor may or may not charge an additional fee.

Some patients already have an attending physician and have asked Dr. Shade to be the second or consulting physician to review the medical records and examine the patient to confirm the diagnosis, prognosis, and mental capacity of the patient.  If Dr. Shade provides this service as consulting physician only, there is a one-time fee of $600.

 

Medication for Aid-In-Dying

The medications allow for a peaceful patient-controlled death.  Unconsciousness within 1 to 3 minutes is typical for patients.  The time until death is variable and often related to the patient’s underlying medical condition.  There is no pain.  Fifteen (15) days must pass from the first signed request before the aid-in-dying medication can be used.

The cost of the aid-in-dying medication is usually about $650 and prepared by a pharmacist.

This is not included in Dr. Shade’s charges.

The medicine is sent by Fed Ex to the patient’s home, typically 1-2 days before ingestion.

 

Fees

Contracting with Dr. Shade for end-of-life regardless of outcome is around $2100.

There can be negotiations to reduce costs.

Insurance does not cover Aid-in-Dying.

Consulting physician fees are $600.

Aid-in-Dying medications are $500-650 paid to the compounding pharmacy which prepares them.

 

Legal Requirements

California’s End-of-Life Option Act outlines specific requirements and procedures before an aid-in-dying prescription can be given to a patient, and before the patient can take the aid-in-dying medications:

Attending Physician: The patient must select and be cared for by an end-of-life attending physician, who supervises the entire aid-in-dying process and reports the documentation and results to the California Department of Public Health.

The attending physician can be the patient’s primary care physician, oncologist, palliative care or hospice physician, or another appropriate physician the patient chooses.

Any physician can choose not to participate in the End of Life Option Act.

The attending physician will ascertain eligibility.

The patient must be:

  • 18 years or older
  • Terminally ill with a prognosis of six months or less to live
  • Mentally competent to make medical decisions for themselves
  • Physically able to swallow about 1/2 glass (4-5 oz) of liquid medications (or to self-administer the medications through a feeding tube)
  • A resident of California

A second consulting physician:

The End of Life Options Act requires that a second-opinion physician confirms (or denies) that the patient’s diagnosis and 6-month prognosis are correct. The consulting physician must review the patient’s medical records and speak with and examine the patient. The attending physician will receive and record the opinion of the consulting physician.

Evaluation by a mental health specialist: 

If the attending or consulting physician finds any doubt about the patient’s mental or emotional capacity to make medical decisions, the attending physician will obtain a consultation from an appropriate mental health specialist.

Verbal requests:

The attending physician will accept and record the patient’s initial verbal request for aid-in-dying medications.

At least 13 days after the first verbal request, the attending physician will accept and record the patient’s second verbal request.

Written requests:

CHA Form 5-5: “Request for Aid-in-Dying Drug To End My Life in a Humane and Dignified Manner.”

The patient fills this out and signs this form and gives it to the attending physician, who records it in the patient’s medical record.

The signing must be observed by two witnesses, not including the attending physician or consulting physician. The witnesses also sign the form.

CHA Form 5-6: Final Attestation Form 

The patient fills out and signs the “Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner.”  The attending physician receives this form and enters it in the patient’s medical record. This form must be signed no longer than 48 hours before the patient takes the aid-in-dying medication.

Pharmacist contact: The patient signs a written consent for the attending physician to contact a pharmacist to fill the aid-in-dying medication for that patient.

Coercion evaluation: The attending physician must speak with the patient alone to ascertain that there has been no coercion or undue influence on the patient’s decision.

Patient counseling:  The attending physician must counsel the patient on multiple aspects of the process including, but not limited to:

  • 15 15 days must pass between the first verbal request for aid-in-dying and use of the medicine by the patient.
  • Advising the patient at each of the above steps that at any time the patient may choose not to take the aid-in-dying medication.
  • The probable result of ingesting the aid-in-dying drug (rapid death).
  • The feasible alternatives or additional treatment options, including, but not limited to disease treatment, comfort care, hospice care, palliative care including (if needed) palliative sedation, and aggressive pain control.
  • The strong recommendation that another person should be present when the patient ingests the aid-in-dying medication.
  • The strong recommendation that the patient advise family and next-of-kin of the ingestion of an aid-in-dying medication.
  • The recommendation for participation in hospice or other palliative care program.
  • Keeping the medication in a safe place and using the medicine in a private setting.

 

Writing the prescription:

When all of the above requirements are fulfilled (other than signing of Form 5-6), the attending physician provides a selected pharmacist with the prescription for the aid-in-dying medications.

The attending physician arranges with the patient and pharmacist the manner in which the patient can obtain the aid-in-dying medications.

 

Taking the Aid-in-Dying medications:

The minimum interval between the first verbal request for aid-in-dying and taking the medicine is 15 days.  It can be longer or never used.

Anyone can prepare the medications (mixing capsule contents with water, adding sweetened juices, and other steps) and hand the medications to the patient.  Usually, this is already done by the pharmacist.

The patient must take the medications on his/her own, i.e. the medication must be self-administered. No one can aid the patient in doing this. The law states that: “Self-administer” means a qualified individual’s affirmative, conscious, and physical act of administering and ingesting the aid-in-dying drug to bring about his or her own death.”

The attending physician and patient can decide if the attending physician will be present during the ingestion of the aid-in-dying medication.

The Death Certificate: The attending physician or hospice physician signs the death certificate, using the terminology felt to be most accurate for this patient (i.e. cancer, heart disease, other). The California law states clearly that “…actions taken in accordance with the End of Life Option Act shall not, for any purposes, constitute suicide, homicide, or elder abuse under the law.” Life insurance and other policies cannot be affected by the decision to use an aid-in-dying medication.

Report to the California Department of Public Health: The attending physician files a full report with the California Department of Public Health, as outlined in the End of Life Option Act.

 

References:

California Department of Public Health:   End of Life Option Act

The San Jose Mercury News Articles on EOLOA :

Bay Area doctors learn to navigate California’s right-to-die law

By Tracy Seipel July 16, 2017, 12:00 pm

Over 100 Californians took their lives under new assisted suicide law

By Patrick May June 28, 2017, 8:43 am

California’s right-to-die law: Patients struggling to find doctors who will help

By Tracy Seipel June 03, 2017, 12:54 pm

Why few California doctors are assisting deaths for terminally ill

By Tracy Seipel September 17, 2016, 3:17 pm

California’s right-to-die law: Should it exclude Alzheimer’s patients?

By Lindzi Wessel November 18, 2016, 4:43 pm

SCCMA article “End of Life Option Act: A Real Experience” by Dr. Scott Benninghoven dated May/June 2017 p. 6 of the Bulletin