MASSACHUSETTS BALLOT QUESTION 2: “Prescribing Medication to End Life”

1. MASSACHUSETTS BALLOT QUESTION 2:“Prescribing Medication to End Life” A PUBLIC FORUM Division of Medical Ethics Harvard Medical School 25 October 2012

2. Objectives • Describe 2012 Massachusetts ballot question 2 on “prescribing medication to end life” • Discuss ethical concerns regarding prescriptions for informed competent patients who may request prescriptions for life-ending medications

3. What Question 2 says: “This proposed law would allow a physician licensed in Massachusetts to prescribe a medication, at a terminally ill patient’s request, to end that patient’s life. To qualify a patient would have to be ...”

4. The Patient An adult (18 or older) Resident of Massachusetts A Massachusetts driver's license A registration to vote in Massachusetts A Massachusetts resident tax return for the most recent tax year. “Mentally capable of making and communicating health care decisions” “Diagnosed by an attending and a consulting physician as having an incurable, irreversible disease that will, within reasonable medical judgment, cause death within 6 months” “Voluntarily expresses a wish to die”

5. Expressing a “wish to die” • Voluntary oral request to the attending physician for medication to end the one’s own life • To be followed, if desired, by a written, witnessed request to obtain medication; • Followed within 15 days by a second oral request and • A 48 hour waiting period before obtaining the prescription • Discuss with physician: • alternatives for end of life care • Notificaton of family • The importance of taking medication in a private place and having someone present • Self administers the medication

6. The Physician(s) • Verifies the patient is an adult resident of Massachusetts • Confirms the patient’s capacity to make health care decisions, and that patient is making voluntary request • Determines that the patient has a terminal illness that will lead to death within 6 months • Informs patient of Dx, Px, potential risks associated with taking the medication to be prescribed and the probable result • Refers patient to consulting MD (for confirmation of Dx, Px and competency)

7. The Physician(s) • Assesses whether patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment and, if so, refers for counseling • Discusses with patient • Alternatives for end-of-life care (including but limited to comfort care, hospice care and pain control) • Importance of taking medication in a private place and having another person present • Recommendation to notify next of kin • Opportunity to rescind request at any time in any manner • Writes the prescription • Documents medical record • Submits report to MA DPH

8. Some ethical arguments For • Relief of suffering • Some dying patients want to choose time and manner of their death • Allows persons NOT on life support the same option as those who may choose to die by refusing LSMT • Controlled substances for comfortable death only legally available through physicians’ prescription • Improved oversight of a practice that surveys show happens now with unknown frequency Against • Diminishes the value and sanctity of human life • Writing prescriptions to end life is contrary to the physician’s role as healer and will undermine doctor-patient relationships • Slippery slope—expect expansion to non-voluntary euthanasia • Risks confirming a terminally ill patient’s sense of personal worthlessness and abandonment • Difficulty making accurate prognoses

9. The proposed Massachusetts Death with Dignity Act is closely modeled after the current Death With Dignity Laws in Oregon (enacted in 1997)and Washington (2008).

10. Oregon’s DWDA Prescription Recipients and Deaths* 1998-2011 *as of February 2012 Source: Oregon Public Health Division Death With Dignity Act 2011 Annual Report MA pop 6.5M; OR pop 3.8M

11. Data from Oregon • Over 14 years, 935 patients requested prescriptions • 596 patients (64%) died after taking lethal medication. • 88.7% enrolled in hospice • 94% died at home (<1% in hospital) • 98% had health insurance (68% private; 1.6% none), • 98% white; 54% male; 46% female; • 81% had malignant cancer diagnosis (8% ALS) • 44% had a baccalaureate degree (68% some college; 7% less than HS) • End of life concerns • 91% Losing autonomy • 88% Losing enjoyable activities • 84% Losing dignity • 56% Losing control of bodily functions • 35% Burdening family • 21% Inadequate pain control (or fear of) • 2.5% Financial concerns

12. More data from Oregon • Median Duration of MD-Patient relationship = 10-12 weeks • 62 physicians wrote the 114 prescriptions in 2011 (1-14/MD) • Days between first request and death • Median = 46 days (range 15-1009 days) • Time to unconsciousness: Median = 5 minutes (range 1-38min) • Time to death: Median = 25 Minutes (range 1 min to 104 hours) • 7.5% referred for mental health evaluation • Medication: Secobarbital 61%; Pentobarbital 38% • Complications (none 95.6%) • 4.4% Regurgitated (2 regained consciousness in 2011) • 0% Seizures • 3 Awakened after taking prescribed medications • Calls for intervention after ingestion 0% • Calls for other reasons 4 (.8%)

13. What we have learned from Oregon* For every 1,000 adults who die • 200 ‘seriously consider’ PAS • 20 make a formal request to their MD • 10 have their request formally acknowledged • 2 get a lethal prescription • 1 takes the lethal prescription *Erik K. Fromme MD, OHSU Palliative Medicine & Comfort Care Team

14. Data from Washington Washington State Dept of Health 2011 DWDA report http://www.doh.wa.gov/dwda/

15. Other data from Massachusetts

16. Other data from Massachusetts • Proponents • The Massachusetts Death with Dignity coalition • Massachusetts chapter of the National Association of Social Workers • American Medical Students Association • Unitarian Universalist Association of Congregations* • Opponents • No on Question 2 • Second thoughts • Mass Against Assisted Suicide • The Massachusetts Medical Society & AMA • Boston Herald • Worcester Telegram • Roman Catholic Church* *No consensus within Massachusetts Council of Churches, though teachings of Christian, Jewish and Muslim faiths typically oppose ending life before natural death

17. More data from Massachusetts • IN SUPPORT: $ 469,140. • Dignity 2012: Receipts $405,479 (Expenditures $336,100) + MA Compassion & Choices $63,661 • IN OPPOSITION: $ 2,395,031. • Committee Against PAS: Receipts $2,042,398 (Expenditures $1,648,606) + MA against doctor prescribed suicide: $331,583 + Second thoughts: $21,050. http://www.efs.cpf.state.ma.us/BallotQuestionReports.aspx

18. Voting on November 6, 2012 • A YES VOTE would enact the proposed law allowing a physician licensed in Massachusetts to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that person’s life. • A NO VOTE would make no change in existing laws.