The new California law that makes it legal for doctors to prescribe life-ending medication to some terminally ill patients who request it takes effect Thursday.
Supporters of the End of Life Option Act, signed by Gov. Jerry Brown last fall, consider the law key to providing Californians more control over how they die. Opponents, many of whom view the law as religiously and ethically objectionable, argue that existing palliative care options can offer terminally-ill patients all of the comfort and peace they seek at the end of life.
Those arguments continue to underscore an ongoing polarization that may make it challenging for some terminally-ill patients to obtain lethal medications - at least at first. Under the law, doctors have no obligation to provide life-ending drugs, nor are they required to refer patients to those who are willing to do so.
"We expect some resistance in California from some physicians early on and from some health systems early on," says Matthew Whitaker, California Director of Compassion & Choices, the organization that sponsored the law. Among those that have announced they will not participate in the law are Catholic and Catholic-affiliated health systems, including Dignity Health and Providence Hospitals.
"I will add the caveat that we’re experiencing a great deal of support from many health systems and many physicians who have already said they’ll be supporting their patients," Whitaker says, adding that University of California hospitals, Kaiser Permanente and Sutter Health are among the large providers that have said they will provide the option to patients.
"Access is our major concern in California now," Whitaker says. "Because what good is a law if no one can actually utilize it?"
Here are answers to some key questions about the End of Life Option Act:
Q: What's required for me to use this option?
You must be a California resident at least 18 years old with a terminal disease that your doctor has determined is likely to result in your death within six months. You also must also be without a mental impairment that hinders your ability to make sound medical decisions. And if you are prescribed the drug and decide to take it, you must have the physical and mental ability to do so.
Q: If I meet those eligibility standards how do I take advantage of the law?
If your primary physician determines you meet the above criteria, you'll need to make two oral requests at least 15 days apart, directly to your doctor. And no matter his or her response, you'll want to make sure your request is recorded in writing. After that, you'll need to make a written request, on a special form, which you'll need to sign and have witnessed by two people - at least one of whom is not a relative or someone who will benefit from your estate.
The law also requires you to have a private discussion with your doctor about your decision. During that conversation, the doctor must explain several things, including: what the alternatives are to taking the drug; how the medication may affect you and that death may not come immediately; that you have the right to withdraw your request or change your mind about ending your life at any point in the process.
Q: I'm not terminally ill, but I may want to use the option someday. Should I be doing anything now?
Yes. You should ask your primary health care provider if he or she would be willing to provide lethal medications. If not, you can seek out a different primary provider.
"Lots of people don’t realize that they have a lot of power in the [provider] choices they make," says Matthew Whitaker of Compassion & Choices. "It’s not simply something that’s assigned to you."
Q: My physician is affiliated with a hospital that has decided to opt out of complying with the law. Does that mean my doctor can't prescribe the lethal medication to me if I request it?
That depends. Doctors with their own practices will likely be able to do whatever they want, assuming they're not bound by a legal agreements with the hospital stating otherwise. Even so, your doctor might not be willing to prescribe you the medication out of fear of jeopardizing a relationship with a hospital, or for religious or ethical reasons. That's why it’s essential that patients ask their doctors whether they’re willing to prescribe the medication.
Q: Are there hospice providers who are opting out of the law as well?
Yes. The same advice about asking your doctor whether he or she participates goes for hospice organizations, too. Typically, a hospice doctor works with your primary doctor. But there are situations in which the hospice physician will step into the role of your primary doctor. In those cases, their ability to provide you with lethal medication may depend on their employer's policy.
Roze Room Hospice, which serves about 250 patients throughout Los Angeles County, is trying to stake out something of a middle ground, says Alon Beker, the company's in-house counsel.
"We will not be fully participating [in the End of Life Option Act] but at the same time ... we believe it’s a very personal individual decision for a patient to make," Beker says. "So instead of saying we're not going to participate at all ... we’ve elected to refer them to organizations that actually participate."
Beker says his company made that decision, in large part, to avoid any liability associated with failing to properly comply with the many steps the law requires before lethal medication can be prescribed to a patient.
"We just want to make sure if they do want to pursue it, they're in the hands of those who are experts ... in the process," he says.
Q: Are there terminally ill people who are dealing with these challenges right now?
Yes. We spoke with the wife of one Los Angeles-area patient whose doctor has diagnosed his illness as terminal and has determined he has six months or less to live. His quality of life has diminished to such a degree that he wants access to the lethal medication. But his attending doctor and his hospice doctor aren't willing to provide him with the life-ending drugs. So the couple is scrambling to find a new primary doctor willing to prescribe the medications.
The couple asked that we not identify them. The husband is concerned that his church might not allow his family to have his funeral service there if it learns of his desire for the lethal medication, according to his wife. He's also fearful that his family might be ostracized by friends and neighbors.
Q: What are the options for terminally-ill patients who can't find a doctor willing to prescribe lethal medication?
The world of palliative medicine offers a host of options, depending on a patient's symptoms. They include pain control, comfort care and even "palliative sedation," which involves putting a patient at the end of life into a deep sleep.
"All those pieces play in to a person having a peaceful and comfortable death, that's the ultimate goal," Whitaker says. Everyone should have access to the "full range of end-of life-options."
California becomes the fifth state, behind Oregon, Washington, Vermont and Montana, to allow doctors to prescribe lethal medication to qualifying terminally ill patients.
Guidance from California Death With Dignity
The forms you and your physician need to sign are on the Medical Board of California’s website.