California's End of Life Option Act: Opportunities and Challenges Ahead

Rethinking Medical Aid in Dying: What Does It Mean to 'Do No Harm?'

Medical aid in dying is the act of prescribing lethal medications to a consenting patient who can self-ingest them with the intent of hastening their death. A majority of patients who utilize medical aid in dying are patients with terminal cancer. As oncology patients continue to choose deaths most suitable to them, it is critical that advanced practitioners in oncology be knowledgeable regarding this end-of-life decision. With 40 states denying patients access to medical aid in dying, the purpose of this end-of-life care review is not to persuade for or against medical aid in dying, active euthanasia, or other forms of dying with dignity, but rather to shed light on patient decisions and available end-of-life options for patients where medical aid in dying is not honored. One author has succinctly named this era as "Dying in the Age of Choice," and therefore the purpose of this article is to present the current state of medical aid in dying. The article presents case studies for the reader, as well as a comparison of California's statistics with the national average. Much like other controversial subjects that intersect morality, religion, and Hippocratic medical ethics, practitioners in the healing arts must remain unbiased and honor the wishes of patients even when they differ from their own. In serving the population with the highest utilization of medical aid in dying, advanced practitioners in oncology should be familiar with the legal specifications in their state or be abreast of solutions for guiding patients through end of life in the states where medical aid in dying remains illegal.

Winging it: a qualitative study of knowledge-acquisition experiences for early adopting providers of medical assistance in dying

Background:

Medical Assistance in Dying (MAID) was legalized in Canada without a designated period for implementation. Providers did not have access to customary alternatives for training and mentorship during the first 1–3 years after legalization.

Objective:

To report on how doctors prepared for their first provision of MAID in the early period after legalization in Canada.

Design:

Qualitative research design within an interpretive phenomenological theoretical framework. We asked participants to describe their experiences preparing for first MAID provision. Analysis of transcripts elicited themes regarding training and information desired by early adopters for provision of newly legalized MAID.

Participants:

Twenty-one early adopting physician-providers in five Canadian provinces were interviewed.

Results:

Few formal training opportunities were available. Many early-adopting providers learned about the procedure from novel sources using innovative methods. They employed a variety of strategies to meet their needs, including self-training and organizing provider education groups. They acknowledged and reflected on uncertainty and knowledge gained from unexpected experiences and missteps. Key phrases from participants indicated a desire for early training and mentorship.

Limitations:

This study included only the perspective of physicians who were providers of MAID. It does not address the training needs for all health practitioners who receive requests for assisted death nor report the patient/family experience.

Conclusion:

The Canadian experience demonstrates the importance of establishing accessible guidance and training opportunities for providers at the outset of implementation of newly legalized assisted dying.

Hospital and Health System Policies Concerning the California End of Life Option Act

Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.

How Should Physicians Care for Dying Patients with Amyotrophic Lateral Sclerosis?

We discuss physician aid in dying, euthanasia, and other dimensions of palliative care decision making and define relevant terms raised by this case of a dying patient with amyotrophic lateral sclerosis in Washington State who is unable to self-administer a lethal prescription. We then present a concrete framework that clinicians can directly apply when faced with difficult cases such as this one. We outline how exploring motivations, obtaining informed consent, defining goals, and examining alternatives can help guide physicians like the one in this case. We conclude by summarizing one way in which physicians might balance these issues while still remaining within the constraints of the law.