California’s right-to-die law goes into effect Thursday, giving terminally ill patients the option of ending their lives with a lethal drug prescribed by their doctor.
Gov. Jerry Brown signed the bill last October that was inspired by the story of 29-year-old Brittany Maynard, who moved to Oregon to end her life under that state’s Death with Dignity Act. Maynard, who had an aggressive brain tumor, thought it was unjust to have to leave the state rather than have a painless death at home.
California also joins Washington, Montana and Vermont in legalizing assisted death for the terminally ill as public opinion has swung in favor of the option.
In Stanislaus County, some health care providers said they are preparing to support patients who exercise their rights under the End of Life Option Act, and some are still working on policies a week before it takes effect.
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“We are getting questions from physicians and members of the public,” said Francisco Silva, general counsel of the California Medical Association, which went from opposition to previous attempts to legalize assisted suicide to a neutral position on the new law.
It has issued guidelines to its 41,000 member physicians, some of whom will be confronted with the decision of writing a prescription designed to mercifully kill a patient. “I think physicians are trying to understand how the law works,” Silva said.
Catholic Church leaders, who opposed the bill, are preparing to issue a statement next week, and advocates for the disabled, who fear abuses, are educating people on other options and calling for stronger monitoring.
The law is certain to spur discussion among people dealing with a life-threatening disease. Modesto resident Glenn Frew is in a support group for people with prostate cancer that will soon have a conversation about the new law.
“I feel like I have the right to live and the right to die, and it’s my choice,” said Frew, a 72-year-old Vietnam War veteran who’s had radiation treatment for prostate cancer. “My mother-in-law was not given enough medication before she died. She had (advanced) Alzheimer’s disease, and life was hell. She had a very painful death, and there is no need for that.”
Carla Wilson of Modesto, who has stage 4 breast cancer, said she would never take her own life and noted that new cancer treatments often emerge. “I would hate to see someone take this option and then a few months later another medication has been released,” she said.
Community Hospice of Modesto, which provides palliative and end-of-life care to 2,000 patients a year, had a special committee research the law for months and reaffirmed its mission to provide compassionate hospice care, while respecting the choices of patients.
Chief Executive Officer DeSha McLeod said the hospice will provide education and resources if a patient asks about the option. Its medical staff won’t prescribe aid-in-dying drugs while acting on behalf of the hospice, but a referral can be made to a participating physician, McLeod said.
“Community Hospice stands by its philosophy that we value life, not to act in any manner to hasten the dying process,” a message on its website says. The hospice won’t allow a patient to self-administer lethal drugs at its Alexander Cohen Hospice House in Hughson, and its employees won’t be present if a patient ingests the drugs at home.
The hospice will continue to provide care for patients who exercise their rights under the law and will offer bereavement services to the family. Most patients of Community Hospice receive the care at home.
McLeod said no local physicians willing to write an aid-in-dying prescription were identified, as yet, so referrals could be made to Compassion & Choices, the leading proponent for the right-to-die law.
Matt Whitaker, California director for Compassion & Choices, said the group will not make referrals to doctors but will direct patients to health care systems with participating physicians.
“Often families have these conversations with primary care physicians that they have long and meaningful relationships with,” Whitaker said. “The physicians choose to support them in these end-of-life decisions.”
California’s law is modeled after Oregon’s Death with Dignity Act of 1994. Terminally ill adults, who have six months or less to live and are competent to make their own decisions, can obtain a prescription from a doctor to end their lives.
The opinions of two physicians are needed to determine the patient is eligible and mentally competent to make the decision. The person has to make two requests 15 days apart and make a written request signed by witnesses.
A patient following through with the decision ingests the drug at home; physicians are not permitted to administer the lethal dose. Of the 1,545 Oregon residents who obtained an aid-in-dying prescription in the past 18 years, about 65 percent took the drug to end their lives, according to the state’s health division.
Some patients issued prescriptions do not take the drug, but apparently want it as a safety net in case of excruciating pain.
Compassion & Choices suggests that people wanting to exercise their rights talk with their doctors early. It could take from two weeks to three months, with at least two doctor visits, to complete the required steps.
Physicians can opt out
Sutter Health, whose affiliates include Sutter Gould Medical Foundation clinics in Stanislaus and San Joaquin counties, said it expects some of its physicians will write the prescriptions for patients who are eligible, while others will opt out.
If a patient’s primary care doctor chooses not to participate, Sutter will help the patient find another physician, the statement said.
Sutter said it supports helping patients explore end-of-life options, including palliative care, home health and hospice, and the End of Life Option Act provides an additional choice.
“Our organization supports an open dialogue with these patients as they make end-of-life decisions,” Sutter said. “We also respect the rights of our physicians and caregivers who for personal, religious or other reasons choose not to participate.”
Kaiser Permanente said its physicians will be ready for implementation of the law, though participation is not mandatory. Patients won’t be permitted to self-administer aid-in-dying drugs in Kaiser facilities, spokeswoman Amy Thoma said.
Amy Glass, a nurse at Kaiser’s Modesto hospital and a union representative, said management has not provided information to staff members on how the law will be implemented.
According to aid-in-dying advocates, assisted deaths usually don’t take place in hospitals. Dallas-based Tenet Healthcare Corp. was still developing a policy for its hospitals including Doctors Medical Center of Modesto, Emanuel Medical Center of Turlock and Doctors Hospital of Manteca. Emanuel was a church-owned hospital before it was acquired by Tenet two years ago.
Emanuel was supposed to maintain its religious orientation under the purchase agreement with Tenet, but would not say if its End of Life Option Act policy will differ from Tenet’s.
Amarjit Dhaliwal, a Modesto oncologist and partner in Valley Cancer Medical Center in Manteca, said he is neutral on the new law and will consider requests from terminally ill patients on an individual basis. Patients who have lost the fight with a deadly disease, such as advanced pancreatic cancer, are made comfortable with palliative care, he said, but the new law will be another option.
“I will participate if that is what the patient wants. Our purpose is to help the patient and family to alleviate their pain,” Dhaliwal said. The law does not specify an aid-in-dying prescription, one issue that doctors will need to research, he said.
Priti Modi, a Modesto physician and former visiting editor for The Modesto Bee, said she wouldn’t be comfortable writing a lethal prescription for a patient. She said she believes the medications used in hospice care alleviate pain until the end.
Opponents fear abuses
Marilyn Golden, senior policy analyst for the Disability Rights Education and Defense Fund in Berkeley, which opposed the legislation, said there are not enough checks and balances to prevent abuses and coercion of vulnerable patients.
The option poses a danger for people with depression and psychiatric disabilities, said Golden, who’s concerned that people can shop for willing doctors to get around the safeguards.
She said her group will educate the public about other options, such as palliative sedation, which allows the dying process to take place without discomfort and does not incur the risks of assisted suicide. With the new law in California, “some lives will be lost without their consent through mistakes and abuse,” Golden said. “No safeguards have been enacted or proposed that can prevent this outcome, which can never be undone.”
Kim Fuentes, director of the Respect Life Office of the Catholic Diocese in Stockton, said the diocese will focus on advancing access to care that relieves pain and symptoms for the terminally ill.
“There are lot of people who don’t have coverage for that type of care,” Fuentes said. “The church does not say you have to do everything humanly possible to extend life, but you can’t intentionally take life, either. There is a balance there.”
Attorney Alexandra Snyder, director of the Life Legal Defense Foundation of Napa, said a lawsuit will be filed next week seeking an injunction to delay implementation of the law. A judge would consider the suit’s merits before deciding on an injunction, and people who follow the issue expect the law will go into effect Thursday.
A report from the UCLA Center for Health Policy Research said people in Oregon who choose assisted death are primarily white and college-educated and have private insurance. Citing a law journal article, the May policy brief said that people in Oregon with depression have asked for and obtained an aid-in-dying prescription and used it.
Leaders with Compassion & Choices are helping groups such as the California Academy of Family Physicians prepare medical practitioners for the assisted-death option in this state. The Medical Board of California will have the required forms on its website. Doctors who assist patients with a prescription are supposed to file paperwork with the medical board.
“This is going to mean a great deal more open and honest communication about what our wishes are,” said Whitaker, the state director for Compassion & Choices. “What we see as the law goes into effect is palliative care gets better, end-of-life care gets better and hospice utilization goes up because patients are empowered to have this conversation.”
Ken Carlson: 209-578-2321
By the numbers
Profile of people who chose aid in dying in Oregon, 1998-2013
Less than high school 6%
High school graduate 22%
Some college 26%
Baccalaureate or higher 46%
Medicare, Medicaid 38%
No insurance 2%
Source: UCLA Center for Health Policy Research
Policy brief on assisted-death laws in California, other states at www.healthpolicy.ucla.edu under “latest publications”