Aid-in-Dying Option Heightens Awareness and Provokes Discussion

I hoped that my feisty patient who prevailed over brain cancer would be spared another terminal diagnosis, but after two years in remission her mammogram showed breast cancer. She agreed to surgery, but declined further chemotherapy. When the time comes, she asked, would I help her end her life?

The End of Life Option Act goes into effect in California on June 9, 2016, joining a handful of other states with similar legislation. The law empowers a terminally ill adult to request and receive a drug to hasten death. It also outlines rigorous screening and documentation requirements designed to protect patients and physicians. However, not only is physician participation voluntary, but health care facilities and individuals are under no obligation to discuss the option at all.

Disregarding this aspect of end-of-life care feels eerily similar to insurance companies and health care corporations choosing not to provide comprehensive pregnancy options and contraception. I realize that end-of-life and reproductive care have their differences, but some striking similarities make me wonder how this health care access issue will evolve over time. It was only last year that AB 775, the Reproductive FACT Act, was signed into law in California, requiring that all reproductive health clinics post a public notice about access to abortion and birth control. It set a precedent that patients deserve comprehensive health services and the facts they need to make informed decisions.

Imagine my patient after a few years. Her cancer treatments allowed for a fairly good quality of life, but her symptoms are worsening and the cancer is progressing. She knows her prognosis is poor and wants some control over her death. She asks her doctor about aid-in-dying, but her physician opts not to participate. What can she do?

California's End of Life Option Act requires that the patient's attending physician be the doctor prescribing the lethal medication, but there is no process in place to facilitate transferring care if the physician declines to participate. What will happen in rural areas if there is no local physician willing to help? Will some of these well-intended regulations cut off access to vulnerable populations? I respect and appreciate the Act's protections to ensure that physicians are participating within the extent of the law and their personal beliefs, but what about protecting the patient's right to access care concordant with their own values?

This isn't an option that resonates with everyone, nor is it an option that will be accessible to all interested patients. In addition to having a physician willing to prescribe lethal medication, the patient must have a terminal disease with less than six months to live, the capacity to make medical decisions, and the physical ability to take the drug. These criteria seem straightforward, but an accurate prognosis is not always easy to determine.

Although there may be some access issues, similar laws in other states have resulted in dramatic improvements in end-of-life care. According to the Death with Dignity National Center, "the most significant impact of the death with dignity law in Oregon has been to improve the care for all dying patients, by increasing awareness among doctors, allowing an open and honest conversation, improving pain management and palliative care, and providing patients with a sense of control and peace of mind."

The End of Life Option Act will certainly pose dilemmas. I hope it will also provoke meaningful conversations for Californians and those in other states. We often avoid discussing death until we are personally affected, but talking openly can stimulate fascinating dialogue about aging, medicine, and dying. I urge everyone to reflect on the care they might want at end-of-life, consider creating an advanced directive such as Five Wishes, and learn about physician and facility policies on aid-in-dying when choosing who provides their care.