California Could Be Landmark for PAD In a Diverse Population

Oregon was the first state to adopt PAD, with passage of the Death With Dignity Act in 1997. It stood alone until 2009, when a similar law was approved in Washington by public referendum. This was followed in the same year in Montana, where PAD became legal by a court ruling, then later in Colorado, Vermont, the District of Columbia, California, and Hawaii (the law in Hawaii goes into effect in 2019).

As the first state to approve PAD, Oregon has the largest database of information about people who have sought PAD. Because other states modeled their laws after Oregon’s, their experience is likely to differ mainly with respect to demographics and implementation.

Several observers who spoke with Psychiatric News said that California—by virtue of its size and demographic and socioeconomic diversity—will be a landmark for how PAD is applied in a diverse population. The most recent report from California about PAD includes only data from the first six months of the law’s application in 2016.

Fairman said it has been a learning process. As a psychiatrist with expertise in palliative care, he served as an advisor to state senators as the End of Life Option Act was being developed and participated in legislative hearings to provide feedback to legislators about implementation.

The law in California is explicit that participation in PAD by individual physicians and institutions is entirely optional. “At UC Davis we had a series of conversations with stakeholders throughout the system and decided to participate,” Fairman said.

The institution developed its own policy around PAD, including some elements beyond what is included in the state law—especially the designation of a “patient navigator,” a licensed clinical social worker who provides a psychosocial assessment, helps to identify unmet patient support needs, facilitates enrollment in hospice care, and coordinates communication among providers.

Fairman said the institution has also developed CME training and other educational resources to help physicians learn about the law and—most importantly—learn the set of communication skills necessary to talk to patients about end-of-life care and the possibility of PAD.

As an example, when “Ann” received the prescription she never took, she encountered something unanticipated. “To her surprise, having the drug at home brought a new kind of distress around knowing she could bring her suffering to an end but wanting to make sure she didn’t make the mistake of cutting it short when she might have some meaningful life left.”

Fairman added, “This is uncharted territory.”

At last year’s Annual Meeting in San Diego, Rebecca Brendel, M.D., J.D., a consultant to APA’s Ethics Committee, said the experience to date with PAD laws and the evolution of research around determinations of competence in patients with various forms of terminal illness suggest a clinical reality more complex than traditional medical/psychiatric ethics has accounted for: not all desires to die are necessarily “suicides” as traditionally defined, but—at the same time—some desires to die may be the transient wish born of a dire situation. “We have to become more sophisticated in our thinking about different phenomenologies of patients who wish to die and how we as psychiatrists engage with them,” she said.

Fairman agreed. “We need to be careful in this space, where patients face decisions that will influence the timing of death. One way to think about this is that we ought to aim for a ‘space between two mistakes’—the mistake of saying ‘yes’ too quickly and thereby shortening meaningful life, and the mistake of saying ‘no’ too quickly and prolonging meaningless suffering.” ■