The California End of Life Option Act goes into effect on June 9, 2016. California is the fifth state in the United States to legalize Physician Aid in Dying, and it is likely that this will become a very hot this week—and in the months to come.
Physician Aid in Dying (PAD) is defined as a physician providing, at the patient’s request, a prescription for a lethal dose of medication that the patient can self-administer.
Under the terms of the law, the patient must:
- Be terminally ill, with a prognosis of 6 months or less, as confirmed by two different physicians (an Attending and a Consulting Physician). • Have the capacity to make medical decisions as confirmed by two different physicians (an Attending and a Consulting Physician). • Be adult (18 or older) residents of California • Have voluntarily expressed the wish to receive a prescription for an aid-in-dying drug and have made the request three times (twice orally at least 15 days apart, and once in writing). • Be able to self-administer and swallow the aid-in-dying drug.
At this point, there is some uncertainty in California about implementation. Unlike the Oregon experience, which offered a 2-year implementation, California has compressed this time into a matter of months.
The truth is that many healthcare agencies are not as prepared as they (or we, as a public) would like. Many healthcare providers (hospital systems, academic centers, etc.) are “opting out” of participating in PAD in any form while some are “opting in” in sort of a hybrid way. The sticking point is: who is going to write the prescription? What is likely is that large healthcare systems will have physicians who will participate and others who will not—and that there will be some sort of internal database for referrals. But really, that is just speculation and we don’t know yet.
Over time, this will sort itself out. In the short run, Physicians who are not connected with the big hospital or clinic systems will have to scramble—and those people who wish to pursue PAD in this case may have less immediate access. Incidentally, Medicare will not pay for the medications—estimated to cost $3000—while insurance companies and Medical will largely cover the costs of the medications.
Hospices are also preparing. What I have heard so far is that none of the not-for-profit hospices in the Bay Area plan on writing the prescriptions. This is notable. Again, while hospice nurses, social workers, spiritual caregivers, and physicians are the most experienced and skilled in having the important conversations with patients and families about goals of care and comfort at the end of life, the agencies that I know about are “opting out” of writing the prescription.
A few of the hospices are allowing their medical directors to act as Attending, but none are acting as the Consulting Physician. The for-profit hospices have not yet made public statements. As of June 3, the local Vitas office did not have any position, and the admission nurse said that their management was meeting next week to discuss it.
At the same time, the hospice that I work for—Pathways Home Health and Hospice—seems to be ahead of the curve, to a great degree. We will not discharge patients based on their decision to pursue PAD. In fact, we decided that we are the best equipped to have these deep conversations; best trained and positioned to support patients and families’ questions and worries.
But I also believe that ministers, rabbis, priests and other spiritual caregivers will also be having these conversations.
In PAD there is an intersection of the deeply personal with issues of control, ethics, the medical system, family systems, fear of death, dignity, medicine, government and the for profit health insurance companies. PAD is also about faith—emboided faith. It is my hope that—armed with facts—spiritual caregivers will choose take leadership as counselor and teacher.
The curricula that we wrote at Pathways started with facts of the Act. But we also determined that our staff should gain clarity about their own feelings and values so they can hold space and equanimity in working with folks who may hold different values.
It is my belief that everyone is a family system is impacted by these deep conversations about choices at the end of life. So, I recommend that you talk it out with someone and get clear—even if ‘clear’ means that you are ambivalent.
After 8 years as a hospice chaplain, I thought I knew what I believed. I cast a vote on this Act after prayer and discernment. But as I delved more deeply into this material, my position shifted to some degree.
It is complicated. I believe I have more work to do when thinking about where God will show up in these conversations and when a decision is made to pursue PAD.
What I do know is that this demands our attention, and I pray that we continue to grow in wisdom as we navigate the issues that may emerge.
–Rev. David Cowell, FCC Pastor and Manager of Spiritual Care Services at Pathways Home Health and Hospice.