6/20/2016 Outline of Talk • Defining terms associated with Physician Aid Physician Assisted Dying in in Dying (PAD) • Ethics and debates surrounding PAD California • Overview of the End of Life Options Act • How to respond to PAD requests • How PAD is administered Elizabeth Dzeng, MD, PhD, MPH • Questions to consider when responding to the Division of Hospital Medicine, UCSF law Advances in Internal Medicine June 20, 2016 What is physician aid-in-dying? Case Presentation • 72 widowed woman with metastatic breast • physician provides a competent, terminally ill cancer tells her PMD that she “no longer patient with a prescription for a lethal dose of wants to live.” She denies feeling depressed, medication, upon the patient's request, which and endorses fatigue, anorexia, insomnia, the patient intends to use to end his or her joint pain. own life. • She asks, “Have you heard of that new law? • Physician Aid in Dying (PAD) versus Physician Will you help me use it when the time Assisted Suicide (PAS) comes?” 1
6/20/2016 Other practices distinct from PAD PAD vs Euthanasia Withholding/withdrawing life-sustaining treatments: • A competent adult patient or their surrogate makes an informed Physician Aid in Dying (PAD) decision to refuse life-sustaining treatment • Patient must self-administer drug Pain medication that may hasten death: • A terminally ill, suffering patient may require doses of pain • Physician provides the medications, but the medications that cause side effect that may hasten death, such as patient decides whether and when to ingest impairing respiration • legal in Oregon, Washington, Vermont, Montana, • Principle of double effect: Primary goal is relief of suffering, secondary outcome is recognizing that death may be potentially and soon California hastened. Euthanasia Palliative sedation: • Sedating a terminally ill patient to the point of unconsciousness • Physician administers the medication or acts • Intractable pain and suffering refractory to medical management directly to end the patient’s life • Imminently dying (hours to days) • Illegal in every state in the US • Other life-sustaining interventions held, “comfort care” Did you (personally) oppose or support the End of Life Option Act 70% Ethics and debates surrounding PAD A. Yes B. No C. Undecided 16% 14% s o d e N e Y d c i e d n U 2
6/20/2016 Why have people advocated for PAD? PAD and Patient Autonomy • Brittany Maynard, 29 year old with terminal • Societal trends that support individual brain cancer who ended her life in Oregon and autonomy and self-determination advocated for PAD • Societal backlash against overly aggressive • Views that death is an process that is care at the end of life invariably painful and full of suffering. • Is PAD a societal attempt to regain control • Inadequate access to palliative care over death? • Is more choice, rather than guidance and support or a more humanistic profession that fosters a “good death” the best? 3
6/20/2016 Physician as Healer or Harmer? Concerns about PAD • Ethical concerns included the physicians’ oath • Vulnerable populations (disability, minority of non-maleficence communities, elders, unbefriended, etc.) • “First do no harm” – overly aggressive – fear of coercion and secondary gain treatments at the end of life, treatments that – fear of being a burden as a motivation do more harm than good • Legalizing PAD without having adequate • What is the role of physician as healer? What about the role to relieve suffering palliative care resources can be seen as morally Commitment to holistic and spiritual healing? problematic Guiding patients through death? Changing norms Long-term normative effects of PAD on social norms • Perpetuates assumptions that death is an unbearably painful process • Creates an ethical norm that death can be a easy solution to problems • Influences perceptions of self-worth and the value of life, especially amongst disability community (i.e. ableism) 4
6/20/2016 “Slippery Slope” Argument • End of Life clinic in the Netherlands (second opinion clinic). In 2012, of 645 applications, California’s End of Life 25% (162) approved • Belgium has legalized PAD in children Option Act • Depression qualifies for PAD in Netherlands Timeline of the EOL Option Act Do you practice in California? • ABx2 15 was signed into law by Governor Jerry Brown on Oct 5, 2015 A. Yes 73% • Law to go into effect 90 days after the close of B. No the special legislative session • This session ended on March 10, 2016 27% • The law went into effect on June 9, 2016 s o e Y N 5
6/20/2016 California as a Watershed 1/5 of the US population now able to request PAD Who considers PAD in Population (in millions) OR? (Tolle, 2014; OHA, 2015) United States 318.9 • 98% white California 38.8 • 78% over 65 years old Washington 7.06 • 43% had at least a Oregon 3.97 college degree Montana 1.02 Vermont 0.63 End of Life Option Act If a patient were to ask you for aid in Allows terminally ill patients to request a drug that dying, would you be willing to provide will end the patient’s life it? • Must be 18 or older and a resident of California 41% • Must have a terminal disease with a prognosis of less A. Yes than 6 months to live 31% 27% • Must have the capacity to make decisions B. No • Not have impaired judgment due to a mental disorder C. Undecided • Have the ability, mentally and physically, to take the drug independently • Cannot be requested in advance directive, nor by Yes No Undecided surrogates 6
6/20/2016 Opting Out and Conscientious Moving Forward Objection • Law has passed, how can both sides come • Any provider can decline to participate for reasons of together to provide ethical care? “conscience, morality, or ethics” • Regardless of whether you support it, need to • Health care institutions can opt out respond (not necessarily implement) – May not prohibit providers from providing diagnosis, prognosis, counseling, clinical options, or referral to a prescribing physician • This will mostly be an outpatient and hospice (except VA) issue (90% of Oregon ingestions at home, 92% enrolled in hospice) Do you have concerns about the law’s implementation? 42% Getting a request for PAD 33% A. Yes 25% B. No C. Undecided s o e d N e Y d i c e d n U 7
6/20/2016 How often do patients think about Have you had a patient ask you for aid aid in dying? in dying? 10% of dying patients consider PAD A. Yes 76% B. No 1% of those patients request PAD 24% 1 in 10 of those who request ingest s e o N Y How often do patients think about Why do patients ask for aid in dying? aid in dying? • Oregon 2015 data 10% of dying patients consider PAD 1% of those patients request PAD 1 in 10 of those who request ingest http://public.health.oregon.gov/ProviderPartnerResources/Evaluation Research/DeathwithDignityAct/Documents/year18.pdf Slide courtesy of Laura Petrillo 8
6/20/2016 How prepared do you feel you are to respond to the act? 32% 32% What to do if you get a request? 29% A. Very prepared B. Moderately prepared 7% C. Not very prepared D. Completely underprepared d d d d e e e e r a r r r a a a p p p p e e e e r r r r p p p p y r y y e r l r e e e d V t v n a u r t e o y d N l e o t M e l p m o C Supporting the patient What the patient says: What the patient is thinking: • Support the patient, reinforce commitment to I’m thinking about aid in finding an acceptable solution, regardless of ? dying your personal views ? ? • Reflect on your personal views on PAD and death and how that might influence the way you communicate • Respond empathetically to emotion Slide courtesy of Laura Petrillo 9
6/20/2016 Exploring the Request Exploring the Request • Clarify what is being asked before responding • Assess understanding of diagnosis, prognosis and • Explore reasons for the request goals of care • Assess whether palliative care needs (i.e. pain and • Assess whether palliative care needs (i.e. pain symptom control) are being adequately addressed and symptom control) are being adequately • Explore other reasons that may be contributing to addressed and intensify symptom management and treatable causes of suffering unbearable suffering including family, spiritual or • Discuss alternatives - Hospice referrals, social existential crisis. Take into account patient’s work referrals, etc. support system • Help patient complete POLST, DNR or other • Evaluate for capacity and screen for depression or appropriate advanced directive forms other mental health issues What Patients Value • Openness to discussing PAD, death, and dying • They understand PAD is controversial so appreciate a physician who can transcend How is PAD Administered? taboo and discuss it maturely and professionally • Important to maintain therapeutic alliance and support patient regardless of whether clinician supports PAD 10
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