Report on First Year of California's Aid-in-Dying Law

Roxanne Nelson, RN, BSN

January 02, 2018

A report on the experience of a large California healthcare system 1 year after California passed its aid-in-dying law shows that the worst fears regarding that legislation have not come to pass. The law, passed on June 9, 2016, allows physicians to prescribe lethal medication to terminally ill patients who wish to end their lives.

The new report was published online December 26 as a research letter in JAMA Internal Medicine.

It shows that, within a large California healthcare system, the patient population seeking physician-assisted dying, and their reasons for doing so, were similar to what has previously been reported.

The majority of patients had cancer (74%) and received care primarily from specialists in the previous 12 months. More than half of these patients (55%) reported impairments in their ability to perform activities of daily living and were receiving palliative care or hospice care when they made their initial inquiry.

Most patients were white, had social support, and had attained at least a high school education. Many were college educated, spoke English, and were covered by Medicare.

The two most common reasons cited for pursuing this end-of-life option were that they did not want to suffer and that they could no longer participate in activities that made life enjoyable.

Similar to Previous Reports

"The characteristics of this sample were similar to a recent report with the exception that a higher percentage of these patients proceeded with ingesting the aid-in-dying drugs (75% vs 59%)," write the authors, led by Huong Q. Nguyen, PhD, RN, from Kaiser Permanente Southern California, Pasadena. They noted that this difference may be due to a longer follow-up time.

Dr Nguyen and colleagues also note that their findings are similar to what has been reported in Oregon, the state in which physician-assisted dying has been legal for the longest period in the United States, with regard to reasons for pursuing this end-of-life option. The most common reasons that were cited were "existential suffering, inability to enjoy life, and loss of autonomy," they write.

Oregon legalized physician-assisted dying in 1997, and several states have subsequently followed suit. California is the fifth, and most populous, state to legalize this controversial practice. The state has a population of 39 million people, more than 14% of the population of the United States. California's passage of the Aid-in-Dying law has dramatically altered the prevailing paradigm.

In addition to being much larger than the other states that permit the practice, California's population is far more diverse than those of other states. There were concerns that the more vulnerable populations might be targeted or coerced, but those fears have not come to pass, according to a 2016 California Department of Public Health report. During the first 6 months following the law's enactment, the demographics were surprisingly similar to those of Oregon, despite the increased diversity of California.

The Kaiser Experience

The current study describes the experience of California's End of Life Option Act (EOLOA) at Kaiser Permanente Southern California, a large, integrated healthcare system, and characterizes the individuals who initiated the EOLOA process.

Kaiser prepared itself for implementation of the law by forming an executive EOLOA task force 7 months before the law went into effect. The task force included representatives from bioethics, operations, quality, psychiatry, pharmacy, education, nursing, legal, and palliative care to ensure that appropriate policy and structures were in place. The key steps to implementation included surveying physicians about willingness to participate, training staff as to how to manage EOLOA requests, providing additional training for volunteer physicians, and identifying volunteer pharmacists who would dispense the drugs and provide education on their proper use. In addition, training was provided for dedicated EOLOA-licensed clinical social work coordinators.

The authors used data from June 9, 2016, through June 30, 2017, with follow-up through August 20, 2017. These data were obtained from electronic medical records, logs maintained by the EOLOA coordinators, and standard state reporting forms.

A total of 379 patients initiated an inquiry during the year after the law was passed (from June 9, 2016, through June 30, 2017). Of this group, 79 (21%) patients died or were too ill to proceed, 61 (16%) were ineligible, and 176 (46%) proceeded with their first oral request. A total of 140 patients underwent a physical examination, and 120 proceeded with a second oral request within 2 weeks of the first one. Ultimately, 108 patients received a prescription for a lethal medication.

Many of the patients who had withdrawn from the process had died or were too ill to proceed, the authors note.

Of the 92 patients who received a prescription, 68 patients (74%) ingested the drugs and died. The other patients either succumbed to their illness or the outcome was undetermined.

The sociodemographic, clinical, and end-of-life care characteristics of patients who completed the process were for the most part similar to those in other reports, the authors note.

"To our knowledge, this is the first detailed report describing the outcome and characteristics of all individuals who initiated the EOLOA process from a large health care system in California," conclude the authors.

The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 26, 2017. Abstract

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