California allows aid-in-dying drugs for terminally ill, but hospitals set barriers

(Reuters Health) - Since 2016, a California law has allowed terminally ill patients to obtain and use aid-in-dying medications from their doctors. But nearly two-thirds of California hospitals have policies against prescribing the drugs and forbid affiliated doctors from helping patients get them, a survey shows.

California’s End of Life Option Act (EOLOA), which became effective on June 9, 2016, allows terminally ill adults living in California to obtain and self-administer aid-in-dying drugs. The survey, which included 270 California hospitals, found that 235, or 87 percent, had a formal policy in place to address EOLOA. Overall, 106 hospitals, or 39 percent, permitted doctors to write EOLOA prescriptions, while 164, or 61 percent, forbade physicians from writing such prescriptions, researchers report in JAMA Internal Medicine.

“We had heard anecdotally and from news reports that patients were having trouble obtaining these medications,” said Cindy Cain, an assistant professor of sociology at the University of Alabama at Birmingham. “We didn’t know how many hospitals were allowing this to take place, so we did the survey. We were surprised by the results. A larger number of hospitals were opting out than we thought would.”

Hospitals were surveyed from September 2017 to March 2018. And although the law was not designed to be implemented in hospitals, “hospitals are often central to health care networks, and health system policies may cover physicians in affiliated settings, Cain and her colleagues explained.

The researchers also checked to see if there were any characteristics that might predict which hospitals would opt out of EOLOA and which had policies in place to provide the medications to terminally ill patients.

They found that hospitals with policies permitting the EOLOA were less likely to be religiously affiliated, more likely to be nonprofit, more likely to offer palliative care and more likely to offer EOLOA training to physicians and information for patients.

Since not every doctor will be able or willing to prescribe aid-in-dying drugs, Cain suggests that California patients bring the topic up when they discuss other end-of-life issues. “Through those conversations, the end of life act can come up and then patients can get a sense of what their doctor is willing to do,” she said. “If the doctor is not willing to prescribe, then he can help figure out where the patient can go.”

The time to talk about those subjects is “when the patient is still strong and healthy enough to have the conversation,” Cain said. “So not at the very end.”

The California law hasn’t been used much, Cain said. “During 2017 a total of 374 people got the drugs and died,” she said. “That’s 13.5 per 10,000 deaths - a very small number of people.”

This is “an important paper,” said Steven Albert, a professor and chair of the department of behavioral and community health science at the graduate school of public health at the University of Pittsburgh. “If a state has legislation that allows terminally ill adults to request medication to hasten death, there needs to be a policy from each hospital on how they will respond. This is one of the first studies to address that.”

An interesting finding was that the hospitals with policies allowing aid-in-dying prescriptions tended to already have in place programs designed to help patients with terminal illnesses, Albert said. “They were more likely to have palliative care services and bereavement support for families, and a consistent approach to the end of life. Hospitals that didn’t allow it, tended to be more haphazard in their approach to end of life.”

Ultimately, few patients end up using the aid-in-dying prescriptions, Albert said. “The main focus should be to assure the patient that they can make use of the option if they need it,” he added.

SOURCE: JAMA Internal Medicine, online April 8, 2019.