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CME / ABIM MOC

Medical Aid in Dying: Your Clinical Guide and Practice Points

  • Authors: Chandana Banerjee, MD, MPA, HMDC
  • CME / ABIM MOC Released: 11/24/2020; Reviewed and Renewed: 1/6/2022
  • Valid for credit through: 1/6/2023
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, hematologists-oncologists, and pulmonologists.

The goal of this activity is to provide a foundation for healthcare providers (HCPs) on clinical criteria, standard of care, and practice points regarding medical aid in dying.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Clinical criteria for medical aid in dying
    • Patient-centric implementation of the aid-in-dying standard of care


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Chandana Banerjee, MD, MPA, HMDC

    Graduate Medical Education Director & Designated Institutional Official
    Assistant Clinical Professor, Hospice & Palliative Medicine 
    City of Hope National Medical Center
    Duarte, California

    Disclosures

    Disclosure: Chandana Banerjee, MD, MPA, has disclosed no relevant financial relationships.

Editors

  • Meghan Coulehan, MPH

    Medical Education Director, Medscape, LLC

    Disclosures

    Disclosure: Meghan Coulehan, MPH, has disclosed no relevant financial relationships.

  • Kimberly Storck, PharmD, RPh

    Senior Medical Writer, Medscape, LLC

    Disclosures

    Disclosure: Kimberly Storck, PharmD, RPh, has disclosed no relevant financial relationships.

CME Reviewer

  • Robert Morris, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: ViiV Healthcare
    Owns stock, stock options, or bonds from: GlaxoSmithKline

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

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CME / ABIM MOC

Medical Aid in Dying: Your Clinical Guide and Practice Points

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I’m Undecided or Conflicted. What Does the Evidence Show About Medical Aid in Dying?

When patients select palliation as their highest goal, HCPs should make relief of symptoms that cause suffering the highest priority.[36] Even if life may be shortened, there is strong support by medical societies to increase medications for terminally ill patients to levels that relieve pain, including the use of palliative sedation.[37] Recent voter initiatives and court decisions have also reflected public interest in and support for medical aid in dying.[4,5,9,38] A 2020 Gallup poll indicated that 74% of the American public support legalization of medical aid in dying.[38] Support for the practice among physicians across more than 29 specialties has also risen nationally, from 46% in 2010 to 58% in 2018.[39,40] Study data, however, have revealed a discrepancy between attitudes about legalization and willingness to practice. Only 15% to 22% of physicians in favor of legal access to medical aid in dying would be willing or likely to provide such assistance, with 47% citing “lack of training or expertise” as their rationale.[41,42] In addition to feeling a lack of expertise, physicians’ views toward medical aid in dying seem commonly affected by religion, religiosity, and fear of legal action.[41]

Resources are readily available to HCPs seeking personalized consultation on the best approaches to address their patients’ end-of-life questions. HCPs participating in medical aid in dying should familiarize themselves with the Compassion & Choices’ Doc2Doc line and resources from other nonprofit organizations like it. Doc2Doc offers free, confidential telephone consultation with clinicians who are experienced in providing end-of-life medical care.[43] Consultations may include unbiased information regarding

  • Hospice, palliative care, and effective pain and symptom management
  • Responding to a suffering patient’s desire to achieve a peaceful death
  • Reliable information about end-of-life issues and advance care planning
  • Communication with patients, pharmacists, and family members; current clinical practice guidelines; and specific state laws affecting end-of-life care
  • Medical aid in dying and VSED, including appropriate supportive care
  • Responding to inquiries or requests concerning withdrawal of life-sustaining treatment
  • Safeguards and best medical practices for a patient-controlled death

The practice of medical aid in dying in the United States is best studied in Oregon. Over 20 years, 2518 terminally ill patients have received prescriptions under the Death with Dignity Act, and 1657 patients (66%) have died from ingesting the medications.[17] Pain management and hospice use have improved in Oregon since passage of the Death with Dignity Act.[44,45] Opponents of medical aid in dying express concern that in Oregon, more than 70% of patients who elect medical aid in dying are elderly and have cancer--both being commonly associated with depression--but fewer than 5% are referred for psychiatric evaluation.[17] To date, there have been no documented or substantiated incidents of abuse or coercion across the authorized jurisdictions.

A provider can transfer the patient’s request to another attending provider. The waiting period starts from the date the patient makes their initial request to any attending provider as documented in the patient’s medical record.

What Is the Current Standard of Care for Practicing Medical Aid in Dying?

A consulting physician** must confirm the terminal diagnosis, prognosis of 6 months or less to live, and the person’s ability to make an informed healthcare decision before the attending physician writing a prescription.[13] Regulatory and procedural requirements that are common to all authorized states are shown in Table 3. Major differences in requirements are discussed later in this article and compared in Table 4.

** New Mexico legislation authorizes physicians, osteopathic physicians, advanced practice registered nurses and physician assistants to support patients in accessing medical aid in dying, including prescribing within their existing authority. At least one physician or osteopathic physician must serve in one of the attending or consulting provider roles.

Table 3. Common Provisions of US Statutes Legalizing Medical Aid in Dying [1-9,13]

To Practice Medical Aid in Dying, a Physician Must

  • Be licensed and practicing in California, Colorado, the District of Columbia, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, or Washington
  • Diagnose the patient with a terminal illness, with a prognosis of 6 months or less to live; terminal diagnosis and prognosis must be confirmed by a consulting physician
  • Determine that the patient is mentally capable of making his or her own healthcare decisions; confirmed by attending and consulting physicians
  • Inform the patient of alternatives, including palliative care, hospice, and others, based on jurisdictional statutes
  • Inform the patient that he or she can rescind the request for a prescription for medical aid in dying at any time and that there is no obligation to use the medication once the patient has obtained it
  • List the terminal illness, not suicide, as the cause of death on the death certificate

A Physician Must Document the Following in the Patient Medical Record:

  • First oral request
  • Qualifying diagnosis and prognosis
  • Whether the patient is capable of making an informed decision to obtain medical aid in dying
  • That the request is voluntary and the patient has been equipped with the facts to make an informed decision
  • Recommendation to seek counseling with an outside healthcare provider concerning concurrent or additional disease-specific and end-of-life treatment options
  • Discussion of the patient’s right to rescind the request for a medical aid-in-dying prescription at any time
  • Patient has demonstrated residency
  • Referral to a consulting physician for confirmation that the patient is qualified to request and receive a prescription pursuant to the medical aid-in-dying statute
  • Referral for an independent mental health capacity evaluation if it was determined that the patient “may not be” capable of making an informed decision
  • Written request by the patient for medical aid in dying
  • Any consultations concerning concurrent or additional treatment and whether the patient is currently receiving palliative care, hospice care, or pain-control treatments
  • Discussion of the patient’s obligations, including recommendation to notify next of kin of the request for medical aid-in-dying medications and to have another person present if/when the patient chooses to self-administer the medications
  • Second oral request
  • Specific medication prescribed or dispensed

Clinical criteria published in 2016 outline best practices for responding to a request for medical aid in dying.[13] Guidance begins with assessment of the patient’s decision-making capacity and understanding of palliative measures as alternatives to or concurrent with medical aid in dying. No matter the practice specialty, HCPs are trained on the art of assessing a patient’s medical decision-making capacity and their ability to understand the situation, appreciate the consequences, reason rationally, and express a choice (Figure 4).

Figure 4. Evaluating Medical Decision-Making Capacity in Practice

Decision-making capacity is the basis of informed consent.[46] If either the attending or consulting physician is concerned that a mental health condition may be impairing the patient’s judgment or decision-making capacity, the patient must be referred for additional evaluation by a licensed psychiatrist, clinical psychologist, or clinical social worker.[13] The request for aid-in-dying medication does not proceed unless the mental health professional affirms that the patient is free of mental illness, acute psychological distress, or demoralization. In Hawaii, a mental health evaluation is mandatory for all patients.[4] In New Mexico, a mental health evaluation is also required if the patient has a recent history of a mental health condition or intellectual disability.

How Do the Legal Requirements Differ Between the Authorized States at Each Step in the Medical Aid-in-Dying Process?

HCPs should be aware of the varied legal requirements in the medical aid-in-dying laws governing their state (Table 4).

Table 4. Overview of Differences in Medical Aid-in-Dying State Laws[1-9]

Proof of residency

Legal residence in any authorized state/district may be proven with any or a combination of the following:

  • State-issued identification card or driver’s license
  • State voter registration
  • Recent state tax return
  • Documents showing rental or ownership of residential property in the state (except New Jersey)

Some states/districts will accept a government record that the attending physician reasonably believes to demonstrate the individual’s current residency (District of Columbia, New Jersey, Vermont) or recent forms of mail, hunting/fishing license, or receipt of a public benefit conditioned upon residency (Maine).

Providers eligible to participate

In New Mexico, in addition to MDs and DOs, APRNs and PAs are eligible to serve as either the prescribing or the consulting physician.  However, one of the providers who acts as either the attending or consulting provider must be licensed.

Qualifying evaluation

In New Mexico, if a patient is enrolled in hospice care, the patient is deemed terminal and a second consulting provider confirmation is not required. If the patient is not in hospice care, two providers (MD, DO, APRN, PA) must confirm eligibility; one of the two providers must be a physician.

Mental health evaluation

In Hawaii, a mental health evaluation is mandatory for all patients requesting medications under the law. In New Mexico, a mental health evaluation is also required if the patient has a recent history of a mental health condition or intellectual disability.

Notification of next of kin

In Oregon, the healthcare provider should document whether the patient has informed his or her family.

First waiting period

In Colorado, the District of Columbia, Maine, Montana, New Jersey, Oregon, Vermont, and Washington, the patient must wait at least 15 d after the first oral request to make the second oral request.

In California, the patient must wait 48 h after the first oral request (goes into effect January 1, 2021).

In Hawaii, the patient must wait at least 20 d after the first oral request.

In New Mexico, there is only one waiting period, 48 hours between when the prescription is written and when it is filled.

In Oregon and New Mexico, the attending physician may waive their waiting periods if the patient is unlikely to survive it.

Patient Request

All authorized states explicitly require three requests, one of which is to be in written form, except New Mexico.

The New Mexico law only explicitly requires one request, in writing. Before the physician enters the request into the patient's chart the physician must: (1) confirm that the patient meets the eligibility criteria; (2) confirm that the patient is not being coerced; and (3) ensure the patient is making an informed decision.

Written request

In any authorized state/district, statutory forms are included in the state’s aid-in-dying law. The written request must be witnessed by 2 individuals. The attending or consulting physician is not eligible to be a witness.

States/districts differ with respect to the timing of the written request as follows:

• In the District of Columbia, the requirement is to submit the written request after the first and before the second oral request.

• In California, Colorado, Hawaii, Maine, New Mexico, Oregon, Vermont, and Washington, it is recommended that the written request be dated and submitted after both physicians have qualified the patient and submitted their respective paperwork.

• In New Jersey, the written request can be made at the same time as the first oral request or at any time thereafter.

Second waiting period

Under the District of Columbia, Hawaii, Maine, New Jersey, and Washington statutes, the physician must wait 48 h from the time of receiving the written request to write the prescription. In California and Colorado, there is no such waiting period.

In Vermont, the prescription may not be filled until 48 hours after the last of the following three events occur: (1) written request; (2) second oral request; or (3) physician offering the patient the opportunity to rescind the request.

In Oregon and New Mexico, the physician may waive the waiting period if a patient is unlikely to survive it.

Final attestation form

In Hawaii, completion of a final attestation form is required 48 h before the patient takes the aid-in-dying medication.

Where Can I Find State-Specific Reporting Requirements for HCPs?

The following types of fillable PDF forms and submission instructions can be found on state department of health websites or on the websites of nonprofit organizations dedicated to the expansion and improvement of end-of-life options, such as Compassion & Choices and Death with Dignity:

  • Attending physician’s checklist and compliance form
  • Attending physician’s follow-up form
  • Consulting physician’s confirmation and verification form
  • Psychiatric/psychological consultant’s compliance form
  • Pharmacy dispensing record

Which Medications Can Be Prescribed for Medical Aid in Dying?

The medical aid-in-dying protocol is a 3-step procedure that begins with antinausea and antiemetic agents to prevent vomiting. Digoxin is self-ingested 30 minutes later to slow the heart, followed by a compound mixture of life-ending medications that place the patient in a coma, followed by peaceful death (Table 5).

Table 5. Medical Aid-in-Dying Medications Chart

Drug

Drug Class

Timing

Nausea/vomiting prevention

Ondansetron (Zofran®) 8 mg

Antiemetic

1 h before compounded medication

Metoclopramide (Reglan®) 20 mg

Prokinetic agent

1 h before compounded medication

Life-ending medications 

D-DMAPh/compounded medication

Digoxin 100 mg

Antiarrhythmic

This medication combination should be ingested in less than 90 seconds (4 oz; 1/2 glass of liquid).

Diazepam 1 g

Anxiolytic

Morphine sulfate 15 g

Opioid analgesic

Amitriptyline 8 g

Tricyclic antidepressant

Phenobarbital 5 g

Anticonvulsant

Not currently available*

Secobarbital (Seconal®)

Barbiturate hypnotic

Must be ingested within 90 s

Pentobarbital g

Barbiturate hypnotic

Must be ingested within 90 s

D-DMAPh = digoxin-diazepam-morphine sulfate-amitriptyline-phenobarbital.
*Because of lack of availability in US pharmacies.

What Should Be Communicated to the Pharmacy?

The attending physician is responsible for delivering a prescription for medical aid-in-dying medication to the pharmacy personally or by telephone, facsimile, or electronically.[1-9] A prescription should never be given to the patient to be filled at a pharmacy. It is recommended that the physician alert the pharmacy once the prescription has been written, keeping in mind that the pharmacist is not required by law to dispense an aid-in-dying medication.[47]

Advanced planning with the pharmacist helps ensure consistency in the instructions provided to the patient. A prescription can be held at the pharmacy for up to 6 months; this timing should be confirmed with the pharmacist. If the prescription expires, a new prescription can be written by the same attending physician without repeating the medical aid-in-dying process in its entirety. Upon dispensing an aid-in-dying medication, the pharmacist should notify the attending physician and the state department of health.[1-9]

What Guidance Should Be Provided to the Patient on Preparing His or Her Medication for Ingestion?

Educate the patient on the purpose of each medication, how it works, and when it should be self-ingested. (Refer to Table 5 for medications.) Counsel the patient on how to self-administer the medications, including the following information for patients:

  • It is best that the patient withhold food and fluids for 6 hours before digoxin-diazepam-morphine sulfate-amitriptyline- phenobarbital (D-DMAPh) ingestion.
  • Patients may take their regular medications as prescribed, if needed.
  • If the pharmacist has not premixed the powdered D-DMAPh into the suspending solution, it should be mixed shortly before ingestion.
  • Mix the D-DMAPh with the suspending solution provided by the pharmacy in a glass bowl or cup with a small spatula to achieve a smooth consistency.
  • Adding a favorite liquor may counter the bitterness of the mixture.
  • Consume the D-DMAPh mixture quickly, in less than 90 seconds.
  • A small amount of sorbet can be ingested to avoid potential post-ingestion esophageal burning or distress.
  • Prepare for the possibility that the medication may not work if not quickly and fully ingested; it is crucial that the patient who self-administers not fall asleep before consuming the full dose.
  • Patients can drink clear, fat-free liquids or liquor, as desired.
  • Patients should not take the medicine when alone or in a public place.

Medical aid-in-dying medications should be obtained shortly before the time of intended use and kept carefully out of the reach of children and vulnerable adults.[27] The antinausea medications should be kept together with the medical aid-in-dying medications. The medical aid-in-dying medications are controlled substances and must be disposed of properly if not eventually taken or if the patient dies of other causes. Returning the unused medication to a take-back program is the safest way to dispose of unused medication. Hospice personnel may also dispose of unused medication. Never flush unused medication down a toilet or drain or throw it into the trash in its original container.

What if There Are Special Circumstances--for Example, the Terminally Ill Patient Is Unable to Hold a Cup, Has a Percutaneous Endoscopic Transgastric Jejunostomy Tube, or Requires Rectal Administration?

It is legal in all jurisdictions for physicians, other HCPs, or family members to assist in medical aid in dying but not to administer medical aid-in-dying medications.[1-9] The law requires that the patient self-administer the medication through ingestible means, which may include:

  • Drinking the medication mixture
  • Ingesting through a nasograstric tube
  • Ingesting the medication through a feeding tube, or
  • Insertion through a rectal catheter

Patients are permitted to receive help in preparing or mixing the medication for self-administration, but the patient must take a voluntary, affirmative act (ie, swallowing or pushing a syringe) and administer the medication him- or herself. Medical aid-in-dying laws do not allow physicians, family members, or anyone else, including the dying person, to administer medical aid-in-dying medication by intravenous (IV) injection, parenteral injection, or infusion.

What if the Terminally Ill Patient Has a Pacemaker?

In general, pacemakers will not prevent death and do not need to be disabled.

What Should Patients and Families Expect Once the Patient Has Ingested the Medications?

Patients should be counseled that the antinausea and antiemetic medications take about 45 minutes to become effective and should be consumed--even if the patient does not feel nauseated--to prevent regurgitation of the D-DMAPh compound. Patients reportedly fall into coma within approximately 5 minutes (range, 1-90 minutes), and death generally occurs within approximately 1 hour (range, 1 minute to 47 hours) after taking the D-DMAPh mixture.[17] Families have found that it is best for the person taking the mixture to settle where he or she will be most comfortable falling asleep, with the head elevated, such as a couch, reclining chair, or bed.

These are actively dying patients; as such, complications can occur. Regurgitation, although infrequent (2%) may cause family members distress.[17] Regurgitation typically occurs when the patient does not follow protocol or ingest the medication quickly enough. Seizures have also been reported but with lessening frequency (< 1%) as treatment regimens improve. Families are encouraged to prepare for these possibilities, remain calm, and engage with hospice or other support services as needed. Families should understand that to help avoid unnecessary deployment of police and emergency medical personnel, they should not call 911.

Instances have been reported where the dying process is prolonged; families should make contingency plans for how to manage such circumstances, knowing that the patient will be comfortable without suffering. There is little that can be done except to wait for death to occur. Death is more likely to be prolonged in individuals who use pain medication pumps; are taking high levels of pain medications; have uncontrolled pain; are IV illicit drug users; consume large amounts of alcohol (> 1 case of beer/day, a fifth of liquor/day); are extremely obese (> 300 lb); have gastrointestinal cancer; are young and otherwise relatively healthy (eg, ALS); or have poorly controlled nausea and/or vomiting. Since the Oregon medical aid-in-dying law took effect in 1998, fewer than 1% of patients have regained consciousness after consuming the aid-in-dying medication.[17] Complications typically occur when the patient does not ingest the medication quickly enough or does not ingest the entire amount.

Those present at the death may witness the following changes, which frequently occur during the natural dying process: snoring; gurgling noises; changes in rate of breathing; and fluctuations in body temperature that may leave their skin cool, warm, moist, or pale.[48] Physical movements or other external signs of distress are sometimes exhibited, but the internal peace of the person is not disturbed. Muscle contractions are common after death has occurred.

Who Might Be Present at the Time of Death?

All medical aid-in-dying legislation recognizes that the patient decides who is present at the time of death. Most patients who choose to ingest medical aid-in-dying medications will have their close family and friends present. Notably, the majority of terminally ill patients who use medical aid in dying are also enrolled in hospice.[15] Many hospices in authorized states have integrated medical aid-in-dying support into their care services. Encourage patients to explore medical aid-in-dying support options with their hospice care provider.

Although not legally or medically necessary, terminally ill patients enrolled in hospice may request that a hospice-affiliated care provider be present at their death. This HCP or experienced volunteer can help by ensuring that the medication protocol is followed or by preparing the medications to make it simpler for the patient to ingest or administer. Family members may find it easier to compassionately tend to their dying loved one when provided with this type of support, but the patient must self-administer the medication. It is the decision of the patient and his or her family whether the hospice representative is present in the room at the time of death (if hospice policy allows). If a hospice representative is not present at the death, he or she should be available to enrolled patients and their families to answer questions and provide support as needed. Those present at the death should understand that they should not call 911, as previously mentioned, to avoid unnecessary deployment of police and emergency medical personnel.

Under Oregon’s Death with Dignity law, 4% of patients who have died over 20 years chose not to inform their families of their decision.[17] Support groups for patients who wish to pursue medical aid in dying strongly recommend that at least 1 other person be present if and when the patient chooses to self-administer the aid-in-dying medications. Most patients, however, will choose to be at home, surrounded by close family and friends in a peaceful, supportive environment.

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