Helen Rippier Wheeler,
Thursday November 19, 2015 - 08:11:00 PM

Physician- assisted suicide in California

Governor Jerry Brown has signed a measure allowing physicians to prescribe lethal doses of drugs to terminally ill patients who want to hasten their deaths. The new law is modeled after one that went into effect in 1997 in Oregon, where last year 105 people took their lives with drugs prescribed for that purpose. The California assisted suicide law will permit physicians to provide lethal prescriptions to mentally competent adults who have been diagnosed with a terminal illness and face the expectation that they will die within six months. The law will take effect 90 days after the Legislature adjourns its special session on healthcare, which may not be until 2016. It is also allowed in Washington, Vermont and Montana, although in Montana it was by a court decision. 

Critics predicted the bill would be abused by greedy heirs pressuring elderly people to end their lives prematurely. (Why assume that every elder has a family?!) Supporters of the new law point out that such problems have not occurred in Oregon, where in the last 17 years, doctors have written 1,173 prescriptions. Of these, 752 patients have used the medication to bring about their deaths and 421 have chosen not to use it, according to Compassion & Choices.  


The popular vote 

A referendum is an election device in which a law can be either accepted or repealed based on the popular vote of people. In this process, voters can reject or accept a law or statute passed by a legislature by taking a popular vote on the issue. 

One day after Gov. Brown signed the bill allowing assisted suicides for the terminally ill in California, opponents filed papers to seek a referendum to overturn the measure on the November 2016 ballot. A group called Seniors Against Suicide filed papers with the state attorney general’s office to get an official title and summary for the referendum, the first step toward collecting signatures. The group would have 90 days or until Jan. 3, 2016 to collect the signatures of 365,880 registered voters. The measure was also opposed by a group called Californians Against Assisted Suicide, consisting of doctors, disability activists and religious groups, which has said it is considering a referendum among other options.  

The right to try 

Despite his landmark decision to grant terminally ill patients the right to end their lives with a doctor's help, Gov. Brown rejected Assembly Bill 159, the so-called "Right To Try'' bill, which sought to allow terminally ill patients who have exhausted all other options to access experimental drugs, products or devices that have not yet been approved by the U.S. Food and Drug Administration. The measure has already been adopted in 24 states, most recently in Oregon in August 2015 . 

California residents counting on the bill's passage were devastated by the news. Proponents insisted that dying patients do not have time to wait for the FDA to approve new therapies, or tolerate the red tape that can complicate the agency's "expanded access" program, which provides experimental drugs to patients with life-threatening illnesses. The FDA did not take a position on the legislation, but it has announced that it is taking steps to simplify and more clearly communicate how physicians can request to get their patients experimental drugs. 

How-To … Provide Aid In Dying 

Now that California has legalized aid in dying for some, advocacy groups are planning statewide education campaigns so that physicians know what to do when patients ask for lethal medication to end their lives. One of the first stops is a doctor-to-doctor toll-free helpline, staffed by physicians from states where the practice is legal, who have experience writing prescriptions for lethal medication. 

"We try to answer any doctor's phone call within 24 hours," David Grube, a retired family doctor in Oregon who accepts calls says. "I might answer questions about the dose of medicine, the timing of the giving of the medicine, things to avoid, certain kinds of foods." He recommends prescribing a specific dose of sleeping pills, along with anti-nausea medication. People usually fall asleep within five minutes after taking the drug, and usually die within an hour. 

This kind of information will also be shared in training sessions, online and at hospitals and medical schools throughout the state before and after the law takes effect in 2016. "Health care systems should start preparing now for their patients who are going to be requesting and demanding information about the End of Life Option Act," according to Compassion & Choices, the advocacy group that led the charge for legalization in California and is spearheading the education campaign. Kaiser Permanente in Oregon and Seattle Cancer Care in Washington hired patient advocates specifically to respond to requests for aid-in-dying medication and to guide patients and doctors through the process. 

DNR stands for Do Not Resuscitate.  

Do you recall The Sopranos’ DNR episode? And House, M.D., when the show's main character-- a pain medication-dependent, unconventional, misanthropic genius -- gave a bedside order that evoked his team’s cautionary “She’s DNR!” And he ignored it. There’s casual mention of DNR in 5 Flights Up… A couple’s attempts at selling their elevator-less, Brooklyn apartment. (The 2015 DVD is based on Jill Ciment’s novel, Heroic Measures.)  

Locally, Holiday baskets (translation: bags of food in November and December) have been, and perhaps will be again, distributed by firefighters, Lions, and other good souls to seniors and disabled persons. There are seasonal wreaths on some of their apartment doors. And cutesy cat pictures functioning as don’t let the cat out warnings. And a DNR door sign addressed to paramedics.  

Do-not-resuscitate orders are often established for and with patients whose prognosis is poor. An example is in-hospital cardiac arrest, which affects nearly 200,000 patients in the United States annually, with rates of favorable neurological survival (i.e., survival without severe cognitive disability) of less than 20%. In a recent study, almost two-thirds of hospital patients with the worst prognosis did not have DNR orders in place. (September 22/29, 2015 JAM A)  

DNR orders often do not align with poor prognosis, however. A routine pre-surgery exam might introduce a DNR reference. Or it might not. Ask for it.  

A DNR differs from an advance health care directive, also known as a living will, which is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In providing the patient with this albeit limited control aspect, it differs from a DNR. In the U.S. it has legal status in itself, whereas in some countries it is legally persuasive without being a legal document.  

POLST stands for Physician Order[s] for Life-Sustaining Treatment.  

A POLST is an approach to improving end-of-life care in the United States, encouraging doctors to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and is currently promoted in over 26 states through national and statewide initiatives. The POLST document is a standardized, portable, brightly colored (pink is apparently the California POLST color) single page form which documents a conversation between a doctor and a seriously ill patient or their surrogate decision-maker. It is a medical order, always signed by a doctor and, depending upon the state, the patient. 

A difference between a POLST form and an advance directive is that the POLST is designed to be actionable throughout an entire community. It is immediately recognizable and can be used by doctors and first responders (including paramedics, fire departments, police, emergency rooms, hospitals and nursing homes). POLST forms are recommended for patients with life-limiting illnesses or progressive frailty.  

What’s so great about a POLST? While presumably intended to influence medical personal, mainly physicians, the POLST is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Signed by both doctor and patient, a POLST can prevent unwanted or ineffective treatments, reduce patient suffering, and increase the likelihood that a patient's wishes are honored. 


“How assisted suicide will work in California," by Patrick McGreevy (Los Angeles Times, Oct. 6, 2015). 

"Referendum papers filed on assisted suicide law," by Patrick McGreevy (Los Angeles Times, Oct. 7, 2015).  

"'Right To Try' bill: Brown rejects proposal to let terminal patients use unapproved drugs and devices," by Tracy Seipel (San Jose Mercury News, Oct. 12, 2015). 

"California Doctors Get Advice On How To Provide Aid In Dying," (KQED via US National Public Radio, Oct. 13, 2015).