By Patrick McGreevy
January 19, 2016
With the state’s assisted death law taking effect in months, the California Medical Assn. on Tuesday issued guidelines to physicians on writing prescriptions of lethal doses of drugs for terminally ill patients.
The 15-page guide details the complicated legal and medical path that doctors must take before they can authorize medication to hasten a patient’s death, and helps physicians understand their legal rights to participate or not participate based on their own moral or religious values.
“We are starting to get a lot of questions both from our members, the individual physicians, but also the public,” said Francisco Silva, general counsel of the medical association. “They are trying to understand how the act is going to work.”
The new law leaves some questions unanswered, including what the physician should write on the death certificate.
The End of Life Option Act was signed by Gov. Jerry Brown in October, but it does not take effect until 90 days after the end of a special legislative session on healthcare. That date has not yet been set, but the session must adjourn before November.
Citing the law, the medical association says patients who are at least 18 years old with the capacity to make medical decisions may request an aid-in-dying drug as long as their attending physician and a consulting physician have diagnosed a terminal disease that is expected to result in death within six months.
The patient is required to make two verbal requests at least 15 days apart and one written request that is signed, dated and witnessed by two adults, as well as provide proof of California residency.
The state request form is titled “Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner."
Physicians must inform the patient that he or she may rescind the request for an aid-in-dying drug at any time and in any manner.
A request for a prescription cannot be made on behalf of a patient through an agent under a power of attorney, an advance healthcare directive, a conservator or any other person.
There may be circumstances in which patients with mental disorders would qualify, according to the law. The physician must refer the patient for an assessment by a mental health expert.
At that point, “no aid-in-dying drugs may be prescribed until the mental health specialist determines that the individual has the capacity to make medical decisions and is not suffering from impaired judgment due to a mental disorder,” the guide says.
Physicians are urged to counsel patients on the importance of having another person present when the drug is ingested, and to not ingest the drug in a public place, such as a street, park or place of business.
The law is silent on what specific drug should be used. Silva said medical experts need to address this issue, probably by examining the best practices of Oregon, where a similar law has existed since 1994.
Once the prescription is filled, the patient must complete a "Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner" form within 48 hours before self-administering the drug.
While the law is silent as to what cause of death should be identified on the death certificate, it does say taking an aid-in-dying drug “shall not constitute suicide.”
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.”
The guidelines assure physicians that it is completely up to them whether to help a patient with aid-in-dying medicine.
“A healthcare provider who refuses to participate in activities under the act on the basis of conscience, morality or ethics cannot be subject to censure, discipline … or other penalty by a healthcare provider, professional association or organization,” the guidelines say.
One physician who will not participate in the new law is Michael J. Schlutz, a Newport Beach oncologist. Advances in pain-control and hospice care address many of the issues terminally ill patients may be concerned about, he said.
“We think that people who are properly taken care of don’t need to end their own lives,” said Schlutz, who is a member of the Medical Oncologist Assn. of Southern California, which opposed the law.
The guide says that physicians who participate are protected by the new law from criminal, civil and administrative liability if they follow the requirements.
Physicians are warned that they and others may be subject to criminal penalties if they coerce patients to take aid-in-dying medication, alter or forge a patient’s request for a prescription or destroy a recission request by the patient.
“It is expected and appropriate” that the California Medical Assn. would put out guidelines to help physicians comply with the law, said Tim Rosales, a spokesman for Californians Against Assisted Suicide, which opposed the law.
An employer or hospital may prohibit its employees from participating in the law while they are on premises owned or under management of the prohibiting employer.
Providence Health & Services, which owns six hospitals in Southern California, will not allow physicians to prescribe lethal drugs on hospital grounds and prescriptions won’t be filled on hospital grounds, according to spokeswoman Patricia Aidem.
“As a Catholic healthcare provider, we believe that intentionally ending a person’s life is not consistent with the core principles of the professions of medicine and nursing,” said a statement by the hospital chain, which added, “Providence does not participate in any way in assisted suicide.”
The guidelines can be reached on the CMA website.