As California's End of Life act goes into effect, some doctors question where to draw the line

June 6, 2016
Soumya Karlamangla

 As a new law goes into effect in California allowing terminally ill patients to take medicines to kill themselves, physicians are contemplating whether they would ever write a prescription for death.

For Dr. Neil Wenger, an internal medicine doctor and director of the UCLA Health Ethics Center, physician-assisted dying blurs what had once been a clear distinction for physicians.

“We have always, up till now, been able to say we will never hasten a death,” Wenger said. “Suddenly, that bright line is not so bright.”

He added that the Hippocratic Oath doesn’t just say that doctors shouldn’t harm patients but specifically forbids providing poison to kill someone. 

Wenger’s stance is common among doctors in California: He accepts that physician-aided death is now legal -- in fact, he’s in charge of implementing the new law at UCLA -- but remains unlikely to participate himself, saying it goes against his oath to save lives.

For most of us this may be a once or twice in a lifetime, or in a career, situation.— Dr. Jay Lee, head of the California Academy of Family Physicians, on the likelihood of doctors encountering patients seeking their aid in hastening death under California's new law

Though both advocates and opponents of doctor-aided death call California’s legalization a big step -- either forward or backward – for medical care, experts predict that it would probably be a marginalized practice within the healthcare system, with few patients asking for lethal medications and few doctors furnishing them. 

“For most of us this may be a once or twice in a lifetime, or in a career, situation,” said Dr. Jay Lee, head of the California Academy of Family Physicians.

When the End of Life Option Act goes into effect Thursday, California will become the fifth state in the nation to allow patients with less than six months to live to request end-of-life drugs from their doctors. 

The law is intended to help terminally ill patients avoid suffering. When he signed the bill into law in October, Gov. Jerry Brown wrote that he believed it would be a comfort to have this option if he were “dying in prolonged and excruciating pain.” 

More than three-fourths of Californians were in favor of such a law, including 82% of Democrats and 67% of Republicans, according to a poll conducted last year by the Institute of Governmental Studies at UC Berkeley.

But doctors tend to be more wary. Neither the American Medical Assn. nor the California Medical Assn. support such legislation.

Physicians have no obligations under California’s law; they don’t have to prescribe such medications if asked or refer patients to colleagues who will. They don’t even have to discuss aid-in-dying if a patient approaches them about it.

But leaders of physicians groups say they want doctors to be able to talk about the treatment so they can properly address patients’ concerns and questions.

For the last several months, these organizations have been holding webinars and training sessions and providing educational materials about the law. The California Academy of Family Physicians launched a podcast in April about end-of-life care options.

Lee said they want doctors to be better at talking about all treatment options around death, as well as physician-aided death specifically. 

“Not everyone feels entirely comfortable yet, because it’s been, kind of, in the medical community, a taboo topic,” Lee said.

Some doctors object to the idea that a patient’s pain could be so great that they would choose to die. It’s unlikely for pain to not be controlled with palliative care or other treatments, they say.

Wenger said that sometimes a patient feels so much pain that they need to be sedated to a point of unresponsiveness. But he’s only seen one or two patients like that in his more than 20-year career, he said. 

In Oregon, only 25% of those who died from lethal medication said they were worried about pain control, according to data from the state’s public health department

More common reasons for choosing aid-in-dying were loss of autonomy (92%), being less able to engage in activities that made life enjoyable (90%) and burdening family or caregivers (41%). 

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That reveals a need for improving quality of life and social support, not legalizing aid-in-dying, said Dr. Aaron Kheriaty, a UC Irvine psychiatrist and director of the university's medical ethics program.

“It’s really another Band-Aid solution,” he said.

But Dr. Ben Rich, a professor of medicine and bioethics at the UC Davis School of Medicine, said that other kinds of suffering should be considered just as painful as physical discomfort.

He also pointed out that physician-aided death has typically been a last resort for patients who feel as though they can get no more comfort from medical care. More than 90% of Oregonians who chose aid-in-dying were already on hospice care, according to state data.

“People don’t get these prescriptions and then automatically use them without thinking, without going forward and seeing how hospice and palliative care measures can give them an acceptable quality of life,” he said.

Under the law, healthcare systems can choose to opt out and prohibit their employees from writing such prescriptions. 

Catholic and church-affiliated hospitals, which make up 13% of all acute care hospitals in the state, will not allow their physicians to prescribe such medications, said Lori Dangberg, vice president of the Alliance of Catholic Health Care.

Most hospital systems, including L.A. County’s public hospitals and Kaiser, say they will allow physicians to participate.

But Rich said he thinks that not all doctors who support the practice will write prescriptions, reluctant to wade into a hot-button issue.

In the first three years that Oregon’s aid-in-dying law was in effect, the majority of patients who received prescriptions for lethal medications were turned down by the first doctor they asked, state data shows.

Even last year, 106 doctors wrote 218 prescriptions, with at least one physician writing 27, state data shows.

Rich said that doctors who prescribe lethal medications could have to endure backlash from the community and opposition from colleagues, like those that perform another controversial medical procedure: abortions.

“In a certain sense, that’s going to be true of physicians who are willing to offer this,” he said. “They’re simply going to have to exercise moral courage and the courage of their conviction and say, ‘I think this is a legitimate end-of-life option.’”

Overall, physician aid-in-dying is extremely rare. Fewer than 1,000 people have died from lethal prescriptions in Oregon since aid-in-dying became legal there in 1998. 

Based on Oregon’s experience, California analysts estimate that 1,476 Californians will obtain prescriptions in the state in its first year.

The state health department will collect data on who takes advantage of the new law and release the first batch next July. The End of Life Option Act will expire in 2026 if the  Legislature doesn’t choose to renew it.

Experts say that even organizations that forbid their doctors from prescribing lethal medications need to be able to discuss aid-in-dying now that it’s legal, otherwise they risk having dissatisfied customers.

Dangberg with the Alliance of Catholic Health Care said the group was educating physicians about the law. “It’s not just a matter of saying ‘No, we won’t do something,’” she said. 

They’re focused on teaching physicians to ask about the concerns and fears that lead terminally ill patients to ask to end their lives. 

“If we’re doing our job well, we’ll be able to address those reasons,” she said.