Physician Assisted Death: What does the new state law mean for you and your practice?

Featured Guest Contributors: Stephanie M. Harman, MD; David Magnus, MD; Jose R. Maldonado, MD; and VJ Periyakoil, MD, MBBS

On June 9, 2016, the End of Life Option Act became law in California, the fifth state to legalize Physician-Assisted Death (PAD). For patients who have a terminal illness with a predicted life expectancy of less than six months and who have decision-making capacity, their physician may now provide a lethal prescription. The law outlines a specific process for physicians, patients and health care systems to ensure that patients are receiving all of the information regarding their options for end of life care. The process also ensures that patients are not coerced or otherwise impaired as they consider such a profound decision. Because this law is controversial, physician involvement in this process is voluntary. Under the law, any physician can opt out of prescribing or consulting.

The key components of the law include the following:

1. The patient must be an adult and a resident of California; the patient must have a terminal illness with a prognosis of six months or less; and the patient must have decision-making capacity.
2. The attending physician who receives the request (if willing to prescribe) must document the initial request and include the prognosis and the patient's decision-making capacity.  The attending physician must discuss the risks/benefits of taking the "aid-in-dying" medication as well as the alternative options, which include but are not limited to hospice, palliative care and pain control.
3. If the patient has indications of a mental disorder, the attending physician must refer the patient to psychiatry or psychology for evaluation.
4. The attending physician must refer the patient to a second attending physician for consultation and to confirm the diagnosis/prognosis, decision-making capacity and compliance with this process.
5. The patient must complete a written request for PAD that is signed by two witnesses and submit it to the primary attending physician.
6. The patient must return and repeat their request orally to the attending physician a second time no sooner than 15 days after their initial request.
7. At the time of the second oral request, the attending physician must re-confirm prognosis and decision-making capacity. They must also counsel the patient on the importance of having another person present when they ingest the medication, not taking the medication in a public place, notifying their next of kin of their plan, participating in a hospice program and maintaining the aid-in-dying drug in a safe and secure place. The attending physician must also inform the patient that they can rescind the request at any time. Once these components have been fulfilled, the physician can write the prescription for the aid-in-dying drug.
8. The California Department of Public Health requires three separate forms to be submitted within 30 days of writing the PAD prescription: the attending physician compliance checklist, the consulting physician form and the patient's written request. When the patient dies, there is a final physician follow-up form that must be submitted within 30 days of death.

Stanford's Policy
As an institution, we underwent a deliberative process to incorporate the comments and views of our health care community to craft the policy and process we will follow at Stanford. We conducted a series of "town halls" to educate clinicians on the law and to gather input and comments from staff. We also conducted a survey of physicians, social workers and nurses as to their views of PAD and their willingness to participate. We heard from a wide range of perspectives. Some very thoughtful opponents raised concerns about the implications of Stanford's participation in PAD for staff, for physicians, and even for other patients. Other equally thoughtful participants defended the importance of respecting physician autonomy to provide this now legally available option to their patients without any undue interference.

The resulting Stanford Health Care policy has incorporated several components to reflect our process and our commitment to comprehensive care for our patients and our community, and for our support of the clinicians who provide the care.

Our policy includes the following features:

1. Once the attending physician has received the initial PAD request from the patient, the attending physician must consult with ethics (via phone). The ethics consultant will review compliance with the components of the law and answer questions about the process. Should the attending physician be opting out, the ethics consultant will provide information to social work, which can facilitate connecting the patient with an alternate physician.
2. The required second physician opinion will be mandated in our process to be a palliative care physician. This will allow access to palliative care services for these patients and provide the necessary evaluation for prognosis, decision-making capacity and discussion of the risks, benefits and alternatives to PAD.
3. The patient must complete an advance directive and a POLST (Physician Orders for Life-Sustaining Treatment) form prior to receiving the PAD prescription. As one can imagine, it would be devastating for all involved if a patient were to ingest the PAD medication and then be subsequently resuscitated or brought in to the ER due to the absence of the required legal documents (POLST) to prevent that. This is also a component required at other institutions in Oregon and Washington with extensive experience in PAD.
4. Patients will not be permitted to ingest the PAD medication on Stanford Health Care premises.
5. Stanford Health Care will not publicly advertise that our institution participates in PAD.
6. Stanford Health Care will not accept new patients solely for the purpose of PAD.  However, SHC will accept new patients looking to establish their care here.
7. For physicians who opt out. If an SHC physician who conscientiously objects receives a request for PAD from one of his or her patients, that physician should contact ethics. This will ensure that the patient can be referred to a physician willing to prescribe for another physician's patient. An assigned social worker will facilitate the referral. While an individual physician can opt out, he or she still has a relationship with that patient for other care aside from the specific components of the PAD process.

SHC has established an internal website on PAD and our SHC process for clinicians. SHC also has a live patient-facing website that provides additional information regarding PAD and the law.