death with dignity

Death with Dignity as an End-of-Life Option

What is Death with Dignity as an end-of-life option?

Death with Dignity is an end-of-life option that allows certain terminally ill people to voluntarily and legally request and receive a prescription medication from their physician to hasten their death in a peaceful, humane, and dignified manner.

Death with Dignity is governed by state legislation.

What are some other terms used to refer to Death with Dignity?

Death with Dignity is a term originating in the title of the Oregon statute governing the prescribing of life-ending medications to eligible terminally ill people; because our founders authored the Oregon law, our family of organizations bears its name and it’s our preferred term for the practice.

Other terms include physician-assisted death, physician-assisted dying, physician-hastened death/dying, aid in dying, physician aid in dying, and medical aid in dying.

Incorrect and inaccurate terms that opponents of physician-assisted dying use in order to mislead the public include: “assisted suicide,” “doctor-assisted suicide,” “physician-assisted suicide”, and (active) “euthanasia.”

How can I use a Death with Dignity law?

A legal prescription for life-ending medications in only available in states with Death with Dignity laws. As of April 5, 2018, California, Colorado, District of Columbia, Oregon, Vermont, and Washington have physician-assisted dying statutes; the new Hawaii law, passed in 2018, goes into effect on January 1, 2019. Physician-assisted dying is also legal in Montana by way of a 2009 State Supreme Court ruling.

To qualify under Death with Dignity statutes, you must be an adult resident of a state where such a law is in effect (CA, CO, OR, VT, WA); mentally competent, i.e. capable of making and communicating your healthcare decisions; and diagnosed with a terminal illness that will lead to death within six months, as confirmed by two physicians. The process entails two oral requests, one written request, waiting periods, and other requirements.

Should I tell my family I want to use the option?

Every family is different, and many families have had strained relations. However, even if there has been little communication for years, the months or weeks before death is a time when many people attempt to open up to each other. It is amazing how many families reestablish communication and offer support.

It is truly in the best interest of those who will be left behind that you tell your family what you are planning, and give them the option to accept or reject it, or to work out personal past differences. This helps those family members cope better after you die, as they have some good, positive memories.

Even if your family cannot support you in what you are choosing to do, by starting the dialogue you have at least given them the chance to understand and grow. And most families rise to the occasion by providing help, support, and understanding.

However, if after thought and consideration, you still feel strongly that telling your family would not be helpful, we encourage you to discuss this with a neutral third party like a friend, a religious counselor, or a social worker.

How can I find a doctor in California, Colorado, District of Columbia, Hawaii, Montana, Oregon, Vermont, or Washington who will prescribe life-ending medications?

There are no lists of physicians who participate in physician-assisted dying laws, for both confidentiality and safety reasons. Doctor participation in the law is strictly voluntary.

You are more likely to find a participating physician in a non-faith-based hospital and in larger cities. End of Life Washington has compiled information about which activities each hospital in the state permits or restricts when a patient asks for assistance using their Act.

To find out if your doctor is willing to participate in the law, make an appointment with him or her to discuss your end-of-life goals and concerns, including the option available under the state’s Death with Dignity law. Ask any kind of doctor: your hospice doctor, or your oncologist, or pulmonologist, or neurologist, or even your dermatologist or psychiatrist. Any physician licensed to practice in a “Death with Dignity state” is allowed to participate if s/he agrees; the law also says every physician has the choice not to participate.

If the first physician says yes, ask them for a referral to another doctor who will participate or ask another of your (probably many) doctors if they will participate. Both physicians need to certify that you meet the criteria under the law. The first physician will be your attending physician for the law. He or she will guide you through all the requirements of the law and, if you qualify, will write the life-ending medication prescription for you. The second certifying doctor will be the consulting physician under the law who has to certify all the criteria under the law have been met.

Nurse practitioners and physician assistants, while they can treat your basic disease, are not allowed to act as licensed physicians for the law.

Where can I take the medication?

You can take (self-administer and ingest) the medications at a place of your choosing, though the law advises your physician to ask you not to do so in a public place. Most people, almost 95 percent, choose to take the medications at home; those who reside in assisted-living or nursing home facilities tend to take them there.

If you take a dose prescribed under a Death with Dignity law outside the state where you obtained it, you may lose the legal protections afforded by the law in question. For example, your death may be ruled a suicide under another state’s law.

What kind of prescription will I receive?

None of the medical aid-in-dying laws tell your physician exactly what prescription to give you, but all medications under these laws require the attending physician’s prescription. It is up to the physician to determine the prescription. To date, most patients have received a prescription for an oral dosage of a barbiturate (pentobarbital or secobarbital). Beginning in 2015, compound medications have also been used.

How much does the medication cost?

Cost varies based on medication type and availability as well as the protocol used (additional medications must be consumed prior to the lethal medications at an extra cost). The following are only estimates as prices and availability change. The actual prescription depends on the physician’s assessment.

Pentobarbital in liquid form cost about $500 until about 2012, when the price rose to between $15,000 and $25,000. The price increase was caused by the European Union’s ban on exports to the US because of the drug being used in capital punishment, a practice that is illegal and deemed deplorable there; many international pharmaceutical companies don’t export the drug to the United States for the same reason. Users then switched to the powdered form, which cost between $400 and $500.

The dose of secobarbital (brand name Seconal) prescribed under Death with Dignity laws costs $3,000 to $5,000.

Due to the increase in the cost of Seconal, alternate mixtures of medications has been developed by physicians in Washington state. The phenobarbital/chloral hydrate/morphine sulfate mix produces a lethal dose that is similar in effect to Seconal. The cost of this alternate mix is approximately $450 to $500. A second alternative, consisting of morphine sulfate, Propranolol (Inderal), Diazepam (Valium), Digoxin and a buffer suspension costs about $600. A compounding pharmacy will need to prepare each mixture.

When will I know it is the time to take the medication?

No one can answer this question for you.

Some people know when it’s time, when they’ve reached a point where their disease or the pain and suffering it causes has robbed them of the quality of life they find essential.

If you decide the time is not right, that’s fine; it only means the Death with Dignity Act is working as intended because it has given you the freedom and empowerment to set your own time frame. Some people (about 1 in 3) never take the medication. Simply knowing they have this option, if they need it, gives them comfort.

What happens with unused medications?

As controlled, Schedule 2 substances, medications prescribed under death with dignity laws are regulated by federal statutes. These medications are carefully tracked from the date they are prescribed to the date the person for whom they are prescribed dies. Physicians must report all prescriptions for lethal medications to their state’s health department. Similarly, pharmacists must report on dispensing these medications. The medications must be taken by the person prescribed to; criminal penalties may ensue if another person takes them.

One in three people who obtain medications under aid-in-dying laws choose not to take them. Anyone who chooses not to ingest a prescribed dose or anyone in possession of any portion of the unused dose must dispose of the dose in a legal manner as determined by the federal Drug Enforcement Agency or their state laws, if any.

The California End of Life Option Act stipulates that, “A person who has custody or control of any unused aid-in-dying drugs prescribed pursuant to this part after the death of the patient shall personally deliver the unused aid-in-dying drugs for disposal by delivering it to the nearest qualified facility that properly disposes of controlled substances, or if none is available, shall dispose of it by lawful means in accordance with guidelines promulgated by the California State Board of Pharmacy or a federal Drug Enforcement Administration approved take-back program.”

Because 9 in 10 of all patients who use the death with dignity laws are enrolled in hospice care at the time of their death, it is the responsibility of hospice to have a policy about drugs left after a patient’s death, including the legally prescribed lethal doses of medication, and to educate the deceased patient’s family about the disposal of such medications. In those few cases where the patient is not enrolled in hospice at his/her death any unused medications have been disposed of by those who are present at the time the patient dies. There have been no reported cases of misuse of the medications during the 20 years Oregon’s law has been in effect nor during the 10 years in Washington and the five years in Vermont.

The objection that simply having the lethal dose of medicine results in its misuse fails to account for any other medications patients around the country have, e.g. Oxycontin, Oxycodene, morphine, anti-depressants, sleeping sedatives, etc., all of which could be misused and in some cases are misused. The laws in the US are very clear: legally prescribed medications must be taken by the person for whom they are prescribed and it is illegal for such medications to be used by others.

What options do I have if my state does not allow physician aid in dying?

You can

  • voluntarily stop eating and drinking.
  • stop treatment or not start treatment at all. Every competent individual has a right to refuse medical therapies.
  • use palliative sedation.

Such measures can take anywhere from several days to several weeks to result in death. Stopping treatment or medication may lead to unanticipated effects or pain.

Your end-of-life concerns can also be addressed by hospice or palliative care.

Discuss your options with your physician.

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