Starting June 9, 2016, a terminally ill California adult who has been diagnosed with a disease that will result in death within six months, and who is mentally competent, can request a doctor’s prescription for medications intended to end his or her life as long as all of the law's required criteria are met.
The California End of Life Option Act establishes procedures for patients making the request and for physicians who agree to prescribe aid-in-dying drugs, along with guidance on how to opt out of participation. Earlier this year, the California Medical Association (CMA) issued guidelines that explain to physicians and patients how the law works. The 15-page document can be downloaded free from the CMA website. (Nonmembers who register a new web account will have access to many, but not all, of CMA’s website features.)
The following is a brief summary of some important physicians’ obligations but cannot replace the additional information contained in the 15-page CMA document.
The Act requires two physicians, one attending and one consulting, to evaluate the patient. The attending physician is “the physician who has primary responsibility for the health care of the individual and treatment of the individual’s terminal disease.” The bulk of the legal and medical requirements must be fulfilled by the attending physician. The consulting physician is an independent second opinion evaluator of the patient’s diagnosis and prognosis.
To request a prescription for an aid-in-dying drug, a patient must submit two verbal requests at least 15 days apart and one written request signed, dated, and witnessed by two adults, to their attending physician. Once the prescription is filled, the patient must complete a “Final Attestation” form within 48 hours prior to self-administering the drug.
The law is silent on what specific drug should be used and what cause of death should be identified on the death certificate. The guide says physicians can list the cause of death “that they feel is the most accurate,” including the underlying terminal illness, or just write “pursuant to the End of Life Options Act.” But it “shall not constitute suicide.”
Participation is not compulsory – it is voluntary for all parties, individual providers, and institutions as well. A physician may refuse on the basis of conscience, morality, or ethics and cannot be subject to censure, discipline, or other penalty. Physicians who participate are also protected from criminal, civil, and administrative liability if they follow the law’s requirements.
To protect yourself from liability, closely follow the requirements of the Act, document the steps taken in the medical record, use the required forms, thoroughly review options with the patient, and provide a fully informed consent. The CMA On-Call document #3459 cited below provides detailed discussion about what is required at each step, identifies the five required forms, and the reporting requirements.
Doctors across the state are grappling with their feelings about this law and whether they will be comfortable prescribing these medications. Physicians should bring themselves up to speed on the end of life options or identify where they can refer patients. But no matter which decision, this is a good opportunity for conversations about end of life care including palliative care, advanced care planning, hospice, and more with your terminally ill patients.
Ann Whitehead is vice president, Risk Management and Patient Safety, for the Cooperative of American Physicians. Questions or comments related to this article should be directed to awhitehead@CAPphysicians.com.
1 California’s End of Life Option Act – (ABX2-15) Codified as Health & Safety Code §443 et seq.
https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520162AB15
2 California Medical Association – CMA On-Call Document #3459 – The CA End of Life Option Act -
http://www.cmanet.org/resource-library/detail/?item=the-california-end-of-life-option-act