California's End-of-Life Option Act and what it means for providers
In talking with my personal friends and professional peers, I have frequently heard that people do not fear death itself but rather what they may have to endure in the death process.
Sharing a personal experience, my father died what I define as “a good death.” He experienced sudden cardiac death. Quite literally, he was here one second and gone the next. There was no suffering and no fear. In fact, when he died he was getting ready to go out with my mother to celebrate a family birthday.
Unfortunately, my mother did not share the same type of death experience. She lost her identity, her humanity, her autonomy, and her dignity to a slow death from dementia. Even though she had the excellent support of hospice this was not a peaceful or gentle death for her.
The experience we call death occurs when the body completes its natural process of shutting down, and when the spirit completes its natural process of reconciling and finishing. These two processes need to happen in a way appropriate and unique to the values, beliefs, and lifestyle of the dying person. We should have the possibility to prepare.
Unfortunately, unless vehicles of advance directive are executed or the family had previously held open and sincere discussions about individual end of life wishes, we are often left to the protocols of first responders and emergency rooms. In extreme cases, the issues of end-of-life are settled in a courtroom. No one needs to be a judge, lawyer, or law professor to understand this issue since it is one that is deeply personal and rooted in individual belief systems. Everyone faces this issue without regard to gender, state of health, or religious persuasion. The basics of any discussion about the right to die begins with respect for the person. At the core of all medical decision making is the person's autonomy or right to self-determination
Oregon, Washington and Vermont have passed right-to-die legislation. California has now passed right-to-die legislation similar to the legislation passed in Oregon in 1997.
Historically, in California, such legislation failed in 2005 and again in 2007. California's law has a lot of safe-guards as well as a sunset provision, which allows this law to expire in 10 years unless the legislature votes to extend it. The End of Life Option Act, signed into law by Gov. Jerry Brown (D) on October 5, 2015, allows an individual to seek “aid-in-dying” if they have two (2) different physicians attest in writing there is six months or less to live.
The California End-of-Life Option Act allows a “qualified individual” to request a prescription for an aid-in-dying drug. This request may only be made by the individual diagnosed with the terminal disease. No one can make this request on behalf of a terminal individual including through a power of attorney, conservator, health care agent, surrogate, or any other legally recognized health care decision maker.
The qualified individual must make a request for this prescription drug twice orally, a minimum of 15 days apart, and then a written request must also be made to the attending physician. The attending physician must receive these requests, oral and written, directly and not through any designee. The law is very explicit about the conditions of the written request and the written request must be witnessed by two individuals. There are specific criteria in the law qualifying these witnesses.
The End-of-Life Option Act includes a “REQUEST FOR AN AID-IN-DYING DRUG TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER” pre-written letter. This suggested letter even includes a declaration of witnesses section. Before the attending physician writes this prescription there is a checklist the attending and consulting physician must ensure is completed. The essential elements of this checklist are also contained in the language of the law.
The qualified individual is not obligated to use the aid-in-dying drug once the prescription has been filled by a pharmacist. Neither is taking the aid-in-dying drug considered suicide. Providers and facilities do not have to participate in this activity.
Currently federal regulations require a skilled nursing facility to allow a resident to formulate advance directives. The formulation of advance directives is a resident right. This is a discussion that usually takes place during the admission process.
SNFs may want to consider if they are going to participate with qualified individuals admitted to their facility or assist them in identifying alternative placement. Additionally, it may be necessary for skilled nursing facilities to have policies and procedures in place more specific to the End-of-Life Option Act. The policies and procedures ideally should include whether the facility chooses to participate in the End-of Life Option Act. Since the law does not mandate health care providers or health care facilities to participate, their policy should state specifically whether they do or do not participate. A facility will want to include policies that give direction to the attending physicians as well if they choose to participate in the act.
As a registered nurse I have heard family members comment there is no dignity in death. That may indeed have been true when the dying individual was subjected to life sustaining procedures that would not reverse and natural process. Now, with an individual able to exercise their ultimate autonomy and give direction on how they choose to experience the end of life, people can die a gentle, dignified death that is in harmony with their personal belief system. California now gives qualified individuals the right to die on their own terms.
Kathleen Mace, RN, is a senior clinical compliance consultant at Compliagent.