Hospital and Health System Policies Concerning the California End of Life Option Act

Abstract

Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.

Medical Aid in Dying: New Frontiers in Medicine, Law, and Culture

“…In Switzerland, where assisted dying has occurred only in right-to-die organizations until very recently (Bloom 2022, Gandsman 2018, Richards 2016, the role of organized medicine has shifted over time in an incremental move toward incorporating assisted death into medical institutions (Stavrianakis 2020). In a survey of 270 California hospitals conducted between September 2017 and May 2018 regarding their policies on the End of Life Option Act, Cain et al (2020a) found that most (87%) had adopted formal policies on physicians' participation, whether or not they permitted it. Of these, 39% permitted staff physicians to write prescriptions, and 61% prohibited physicians from writing prescriptions.…”

“…Physicians play an important gatekeeping role, declining to participate if they do not think the patient meets the eligibility criteria (Buchbinder 2022, de Andrade Neves 2020, Pool 1995. Although stringent regulations reassure physicians that they are acting lawfully (Sellars et al 2022), physicians must adjudicate eligibility with few formal training opportunities, and with many ambiguities in the legal protocol (Buchbinder et al 2019, Byrnes et al 2022, Cain et al 2020a, Sellars et al 2022, Winters et al 2022. A study of psychiatrists in the Netherlands found that differentiating between suicidality and "rational death wishes" required a great deal of skill and that Dutch laws do not fully appreciate the nuances between different forms of suffering (Pronk et al 2021).…”

“…Moral ambivalence and religious opposition have complicated the implementation of MAID, with physicians and pharmacists often feeling as if they are participating in something illicit (Hannig 2022). Difficulty obtaining the required medication is a related challenge (Bryant 2016, Buchbinder 2018a, Cain et al 2020a). Such access barriers thwart the search for control over dying, highlighting that MAID always depends on assistance from others (Buchbinder 2021).…”

Winging it: a qualitative study of knowledge-acquisition experiences for early adopting providers of medical assistance in dying

“…Despite this progress, California hospitals and health systems still experienced challenges with newly legalized MAID. [17][18][19][20][21] Legalization in Victoria (Australia) came into effect in mid-2019. With an 18-month implementation period, academic literature addressing operationalization and training became available synchronously.…”