California Offers the Right to Die

California has become the fifth state to legalize the ‘right-to-die’, allowing terminally ill residents of the state to end their own lives with the aid of their physician. A sunset provision requires lawmakers to vote on renewing the bill in ten years. The other states with similar laws include Montana, Oregon, Vermont, and Washington.

The ‘Right-to-die’ movement provides another option for certain terminal patients that are able to express their desires at the end-of-life, who have determined for themselves that there is no purpose in prolonging their inevitable demise for whatever reason (pain, fear, suffering (from pain or psychological).

These laws allow terminally ill patients to seek medical aid in ending their lives as long as they have been given six months or less to live by two doctors, provided a written request and two oral requests at least 15 days apart and are deemed mentally capable of making decisions about their own health. In addition to the catch-phrase of ‘right-to-die’, the term ‘death-with-dignity’ is also being used to describe the movement.

The new law was inspired by Brittany Maynard, a 29-year-old California resident with terminal brain cancer who decided to move to Oregon and seek care under that state’s right-to-die law. “No one should have to leave their home and community for peace of mind, to escape suffering and to plan for a gentle death.”

As with hospice, it requires two doctors to sign off on the patient’s prognosis of six months or less. Those of us in hospice and palliative care know how difficult it is sometimes to determine this six-month time period. The consequence is that many patients have brief experiences with the hospice team compared to the length and extent of their illness. I am not sure how this predictive determination will change under this new regulation but it is worth study.

This law leaves out a large group of patients in the terminal phase of their lives who are unable to express their wishes, even those who up until their illness could be clear of their future wishes. One could argue that patients with dementia who expressed themselves years before their current state of the desire to die with dignity, should be offered this benefit so long as a court-system determination could be enacted, but this would be too controversial and reignite the ‘death panel’ controversy ripe in our political environment.

The controversy over legalizing the taking one’s life can be polarizing. The religion-based facilities are expected to opt out the experience, but will still be left with offering this alternative, even if it requires transfer to another location. This also seems funny, given that a person may wind up in a religious based facility not of their own choosing but due to an emergency or to the fact that it is the closest hospital to them when they needed medical care. It is hard to direct the ambulance to the nonsectarian hospital when you think you may be dying.

For the individual physician, the comfort of whether to directly participate will need to be made. Already, there is a physician that has opened a practice specifically for patients who seek guidance in ending their own lives. Without a multidisciplinary approach to this stage of life, I can only be tentative about this type of focused practice. Are these physicians looking for an economic alternative to their current practice or are they trained in hospice and palliative care?

Hospice professionals rightly believe that the dying process can be made comfortable and fulfilling for a majority (but not all) of their clients. The philosophy behind hospice care [and the regulations surrounding hospice reimbursement] do not provide an end-your-life path. These group of hospice practitioners would be an appropriate group to carry out the wishes of those who chose the ‘right-to-die’ for all of the same reasons that hospice provides a multidisciplinary, comprehensive end-of-life experience for the terminal patient. I wonder if someone suggested a mandate of hospice care prior to the initiation of the request. I also recognize that the reason for theses types of law may be the failure of the public in understanding what the hospice and palliative care movement; or our failure to explain exactly what we can offer.

© 2016 Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP