There are many names for medical aid in dying. It has been called “assisted suicide,” but these days, the preferred terms are “Physician-assisted dying” or “medically-assisted dying.” The California legislature passed the End of Life Option Act on June 9, 2016. It authorized medical assistance in dying for terminally ill adults, and the California Senate extended the existing law past the sunset provision. The leading advocate for this law was Compassion and Choices, a non-profit organization; however, many groups have challenged it repeatedly in the courts.
The EOLA (as many call it) authorizes mentally competent adults, determined by their attending physician to be suffering from a terminal disease, to request a drug that will end their lives. It protects anyone present when the terminal patient uses this drug from civil or criminal liability.
The bill states that there must be two requests for aid-in-dying drugs between 15-48 hours apart. It protects anyone present when the terminal patient uses this drug from civil or criminal liability. Another person may assist the patient by preparing the drug but must not help the person ingest the drug. A family member can hold the bottle, but the patient must take the drug without support. If the patient cannot swallow, another person can place the medication in a feeding tube, but the patient must push the plunger. There is also a new rectal procedure where the patient can administer the medication by enema, but again, the patient must finish the push. It is a felony to forge a drug request or to alter, conceal, or destroy the authorization.
Coercing or exerting undue influence over the patient or administering the drug without the patient’s knowledge is also a felony. The patient must also file a “final attestation form” confirming their choice. Someone must also store it in a locked receptacle that prevents unauthorized people from acquiring the drug. Patients do not need to notify anyone they intend to take the drug, even if housed in a residential facility. Patients are encouraged, however, to inform their next of kin, participate in a hospice program, and have someone present when they ingest the drug. The law does not require physicians who are morally or ethically opposed to aid-in-dying to participate.
Step-by-step, the process requires that patients request a prescription from their physicians. The doctor documents the request and confirms that the patient is eligible. A consulting physician affirms that the patient is qualified. The patient must then wait 48 hours before proceeding to take the drug. During that time, the patient must submit a second oral request and turn in a written request completed during the waiting period.
This year, Hospice of Santa Barbara presented a workshop on EOLA. The workshop informed us that before ingestion, the patient should fast. The patient should also take an anti-nausea drug one hour before the medication. The time from administration to death is about 30 minutes, although the patient is usually unconscious within five minutes.
The medication tastes awful and burns the throat going down and patients must consume it quickly because there is a danger the patient could fall unconscious. A popsicle or ice cube may help the patient down the medication.
In 2021, 772 prescriptions were issued, resulting in only 468 deaths. It seems that once the patients have the option to die with assistance, they may be able to tolerate the disease better than when they do not know how long the sickness will last or how much they will deteriorate during the last months.
The debate about physician-assisted dying differs from the right to withhold or withdraw life-sustaining measures or palliative care. In these cases, physicians and the family may make such a decision when the patients cannot make decisions for themselves. It also differs from euthanasia, in which the physician performs the intervention. In physician-assisted dying, the patient must request the drugs and complete the drug administration themselves.
There are three primary arguments against physician-assisted dying. One argument is that physician-assisted dying is unnecessary since hospice and palliative care are widely available. This objection doesn’t consider that millions of people don’t have access to hospice because they may have a life expectancy of more than six months. In addition, hospice and palliative care aren’t always sufficient to treat severe suffering (www.verywellhealth.com). Statistics from Oregon, where assisted dying is legal, show that 90% of patients who opted for assisted dying had already received hospice services.
Another frequent objection concerns whether the sanctity of life outweighs any person’s decision to die sooner rather than later—that assisted dying cheapens the value of human life. In this argument, the principle of the sanctity of life outweighs a person’s wish to end their own life. For many people, this is a belief beyond debate. A related argument people make is that if we allow assisted dying, euthanasia won’t be far behind. Assisted dying is a “slippery slope” toward “mercy killing,” which often serves as a synonym for euthanasia. The distinction is that patients must control the decision and finish the administration themselves.
Finally, some people believe that assisted dying contradicts the Hippocratic Oath, which identifies as the first principle that the physician must do no harm. In response to this issue, proponents of assisted dying point out that doctors should interpret the Hippocratic Oath in terms of the patient’s needs. If the patient requests assistance in dying, the physician does no harm by honoring the patient’s decision. Verywellhealth.com explores why some people choose physician-assisted dying (Reasons for Requesting Physician-Assisted Suicide (verywellhealth.com). According to a study of 112 patients who requested medical assistance in dying, the main reasons for doing so were:
- Pain caused by the illness
- Loss of control and independence
- Loss of ability to participate in enjoyable activities
- Current suffering (nausea, difficulty breathing, etc.)
- Fear of future suffering
Most of these patients died from cancer, neurological disorders, or end-stage organ failure. Pain was the most important of these reasons, but loss of personal autonomy was also a significant consideration. If someone cannot eat, bathe, dress, take care of their needs in the bathroom, or enjoy visiting with family, they can feel trapped in their body, particularly if they cannot ease their physical suffering.
Finally, the decision to pursue assisted dying may affect a patient’s family deeply, yet family members do not have the legal power to deny a patient’s request. The best way to address such concerns is to work through them with professional assistance. For example, the patient fears being a burden upon their families. Such fears often can be allayed by honest, direct communication.
Doctors may also request a psychological evaluation if they believe a patient is suffering from a depression that clouds their judgment or if they think that the patient’s symptoms are not being adequately addressed. If this is the case, doctors can recommend alternatives such as psychological care and support, more aggressive palliative care, improved symptom management, and the withdrawal of life-sustaining therapies like dialysis.
Angela Morrow (RN, BSN, CHPN), a certified hospice and palliative care nurse, writes for verywellhealth.com. At the end of her article on physician-assisted dying, the editors noted, ” Whether physician-assisted suicide becomes a more common practice in the United States is unknown. Regardless, remaining compassionate for those who are dying and upholding their dignity to the end continue to be paramount goals for the healthcare community.”