Medical Aid in Dying (Rubin 2/26/2025)

A recording of this presentation is available HERE. 

Many thanks to Dr. Rebecca Rubin for an excellent talk on Medical Aid in Dying (MAID), California's legislation, which allows patients with terminal illness (<6 month prognosis) to request and be prescribed medication to self-administer to end their own life. 

This was a fantastic presentation that included the history of physician-assisted suicide and euthanasia as well as present moral and ethical challenges. Do watch if you have 45 minutes!

My notes from this presentation:

  

Documentary: How to Die in Oregon (2011) follows the stories of terminally ill patients in Oregon as they navigate physician assisted suicide.

Medical aid in dying, in which a patient must self-administer lethal medications, is not the same as physician-assisted suicide, in which a physician does the administration.

And yet, MAID is still controversial, brings up many social, cultural and ethical issues, including:

• patient autonomy (the right to make this choice)
• beneficence (do no harm)
• the ethical difference between prescribing medication to end someone's life vs. withdrawing life-sustaining care
• physician patient relationship

Medical Aid in Dying was legalized in California via the "End of Life Options Act", which took effect in June 2016. This followed Oregon's law, "Death with Dignity" which passed in 1997.

The AMA has formally opposed "assisted suicide" since 1993. This was affirmed in 2018 in a close vote. In the same year (2018), the AAFP broke ranks with the AMA and took a position of "engaged neutrality" and deemed the decision a personal one between a physician and patient.

Reasons patients choose MAID from a 2024 Oregon survey, The Commpasion and Choices Meidcal Aid in Dying Utilization Report:

• loss of autonomy (91.6%)
• loss of dignity (63.8%)
• control of bodily functions (46.6%)
• burden on others (43.3%)
• pain control (34.3%)
• finances (8.2%)

The most common illnesses for which people request MAID are cancer>> neurodegenerative>> cardiovascular disease. BUT disproportionate % of people with ALS choose MAID

-88% of people who choose MAID are simultaneously in hospice

-men=women (no data on non-binary, trans)

-disproportionate rates of white and college educated patients

-while rates are rising in BIPOC, still much lower than white

There are currently 11 states in the USA that legally permit MAID (see image)

There are also different policies and procedures, most notably in Europe, but also in parts of Latin America and Oceania (see image)

In California, patients must:

• Independently and voluntarily request info from two providers

• Prescriber and consulting physician

• Some states require written request with witnesses
• Mandatory waiting period of 2-15 days
• Terminal illness, life expectancy <6 months
• Be over the age of 18
• Have the mental capacity to make decision
• Physically be able to self-administer meds into GI tract

Evaluation and death must occur within a state’s borders

The Netherlands and Switzerland are both known for more liberal policies around death and dying in patients with terminal illness

• In the Netherlands, this includes: the possibility of either medical aid in dying OR physician assisted suicide, services available to patients > 12 years old

In Switzerland, their exists "altruistic assisted suicide by non-physicians", Dignitas in Zurich, is open to foreigners as well, 88% of Swiss people believe in MAID, but euthanasia is illega

Access can be an issue:

• Medication costs ~$600-$800 
• Independent physicians (private pay) charge between $2000 and $3000 for their services
• Health plans are not required to cover
• SNFs have varying rules about what can happen in their facilities

In SoCo, there are 6-7 current consulting physicians but not many prescribers

Kaiser has a robust internal referral system

Some religious intuitions forbid discussing MAID with patients

There does exist the Sonoma County End of Life Doula Initiative. "Death Doulas" help patients and families prepare for death, including planning end of life celebrations, discussing fear, writing stories, etc

Which medications?

Standard medication before 2016 was secobarbital, a potent barbiturate with a time to death that averages 30 minutes. Since 2016, a cocktail that includes medications that decrease respiratory drive, cause an arrythmia, suppress escape rhythm (+nausea meds). See slide below for dosing.

One of the current areas of controversy in MAID is assistance for "psychological suffering"-- in the Netherlands, there have been increasing numbers of patients receiving MAID for mental illness (though rates are still very low--  95% of people who apply are rejected).

Conclusions:

• MAID is legal in 10 states plus Washington D.C.

• Criteria for MAID: 

• Independently and voluntarily request info from two providers

• Life expectancy<6mo

• Waiting period 2-15

• Have capacity

• Self-administer into GI tract

• Medication protocol: DDMAPh (digoxin 100mg, diazepam 1gm, morphine 15mg, amitriptyline 8gm, phenobarbital 5gm)

Resources:

• ACAMAID for more information for clinicians and patients, https://www.aadm.org/ 

• Compassion and Choices for Advocacy, https://compassionandchoices.org/

Advancements in GLP-1 Receptor Agonists: Where we are and where we're going (Felton, 2/19/25)

 A recording of the presentation is available HERE.

***

Many thanks to Dr. Erin Felton for an excellent presentation on a hot topic: GLP-1 Receptor Agonists, the class of medications that is literally taking our nation by storm. As Dr. Felton said during her presentation, direct to patient advertising and word of mouth has led to droves of patients coming to their providers asking for these medications, most commonly, for weight loss. 

A recording is available above.

comorbidities associated w/obesity

Here are my notes:

• obesity is a chronic, relapsing , treatable multifactorial disease
• it is associated with comorbidities (e.g. HF, DM2, uterine cancer) and complications
• BMI, as we know, is not a perfect measure, but it's what we currently have
• According to 2023 CDC data: 1/5 US adults are obese
• By 2030, there are estimates that 1/3 US adults will have a BMI>30
• There are racial and socioeconomic disparities associated with obesity
• these are particularly evident in communities of color (black and Latinx)
• 

We must be aware of our own "fat bias" in medicine

• always ask patients for permission before discussing their weight
• give patients a right to decline weighing in
• focus on chronic disease aspect of obesity (rather than weight)
• consider how to create a supportive environment for obese patients

There are several FDA approved medications for obesity, the GLP-1 Receptor Agonists are the new kids on the block, but see the image below for all meds that are currently approved for long-term usage, short-term usage, and off label usage:

GLP-1 is an endogenous incretin hormone that is produced by the L cells in the distal ileum and colon in response to food intake. GLP-1 receptor agonists mimic this mechanism. In addition, GLP-1 receptors are expressed in multiple organs: GI tract, pancreas, hypothalamus, brainstem, heart, kidney, muscle, fat cells. It is thought that effects on the brain influence appetite and satiety. Receptors in the GI tract decrease gastric emptying and slow gastric motility.

Current GLP-1 Receptor Agonists:

Murphy EJ,”What’s new in Endocrinology”, Medical Management of HIV Conference, 2024

The newer kid on the block are multi-targeted incretin therapies, including GIP, which is secreted more proximally in the small intestine; it stimulates downstream GLP-1, enhances insulin, promotes satiety and seems to be associated with less nausea.

The newest agent, tirzepatide, is a combo of GIP/GLP-1. There are currently two versions of tirzepatide on the market: Mounjaro (indication: DM) and Zepbound (indication: weight loss). Zepbound is currently covered by Partnership medi-cal.

Current combos/multi-targeted incretin therapies:

Specific prescribing info for semaglutide and tirzepatide:

There are no direct head to head trials comparing semaglutide to tirzepatide.

Indirect comparisons suggest more weight loss with tirzepatide, as well as potentially lower side effect profile.

Side Effects

We should definitely be talking to our patients about side effects when we are prescribing these medications.

The most common side effects of GLP-1 medications are GI symptoms (nausea, vomiting, constipation, etc). GI symptoms are extremely common (25-40%) but do decrease over time. In many trials, a large percentage of people self-discontinued the medications due to side effects. 

Going slow can mitigate the GI side effects, as they do abate over time. Reducing meal size and adopting a low fat (and low glycemic index) diet can also reduce side effects. Patients should have some nutritional counseling (even if it's just from the PCP). Increasing fiber may also help. 

Dizziness and dehydration have  also been reported. This could be due to morning hypoglycemia. Small frequent meals and maintaining good hydration are recommended.

As mentioned above, the newer combination medications MAY be better tolerated.

Contraindications:

Contraindications to these medications include: medullary thyroid cancer/MEN2, pregnancy, hx pancreatitis or gallstone disease (relative/not absolute). Of note, there was some post-marketing signal in 2023 suggesting a correlation with suicidality, further assessment in 2024 did not confirm this signal, but consider ongoing assessment in patients with a hx of depression or SI. 

Starting/stopping

There is good evidence that discontinuing GLP-1 meds lead to gaining back a large percentage of weight that was lost (though overall, pts do maintain a small percentage of weight lost). A retrospective cohort study of 125K patients, just released in 2025 found that 53% of patients and 72% of patients had discontinued these medications at 1 and 2 years, respectively. Somewhere between 1/3 and 1/2 of these patients  resumed these medications within 1 year of stopping.

Wilding et al, Step 1 Extension, Diabetes Obes Metab 2022

About insurance:

• Medicare specifically does NOT cover weight-loss drugs. However, as of 3/24, Medicare will cover semaglutide for obese patients for CVD prevention IF they have documented CVD (e.g. prior MI, PVD, etc)
• Only about 20% of Medicaid programs cover weight loss drugs (Medi-Cal does! See the image below showing the current PHP covered medications)
• Only about 25% of employer-based insurance cover weight loss drugs
• Locally, Kaiser does NOT cover weight-loss drugs unless you have another specific indication (e.g. DM2, HFrEF, CVD)
• There has been varying pharmacy supply

Patient Counseling pearls

• There is significant weight regain after discontinuation of GLP1s, though studies so far have still showed a net loss. 
• Most patients who newly initiate treatment with GLP RA discontinue within 2 years. 
• High burden of GI side effects, gets better with time.
• Need for long term therapy due to weight regain?
• Other factors for adherence: high cost, availability of medication
• All studies done at target dose of 2.4mg

Finally, there are more and more studies being published showing benefit in outcomes other than weight loss. These include CVD, OSA, MASN/MAFLD, dementia, Parkinson's, disease, as well as substance use disorder. Stay tuned. 

Model Minority: Asian American Health (Wu, 2/12/25).

Many thanks to Dr. Jimmy Wu for a really great Grand Rounds presentation this week titled Model Minority: Asian American Health. He shared part of his personal journey as well as local and national epidemiological data to explore some of the unique health challenges of some of the diverse AAPI communities.

A recording of the presentation is available HERE.

My notes: 

• The concept of Asian Americans as "the Model Minority" was coined in the 1960s during the Civil Rights Movement when conservative politicians looked for opportunities to divide minority groups. Their goal was to curate the erroneous perception that all Asian Americans were doing well because they were hard working, and why couldn't other BIPOC communities do the same?
• This was propagated through a 1966 NY Times article on Japanese Americans and in the 1980s Time magazine feature on Asian American whiz kids.
• The ultimate goal to pit communities of color against one another, unfortunately, was quite successful.
• For Asian Americans, being labeled as a model minority is NOT a win win
• AAPI is now used as an umbrella term, including: Asian + Native Hawaiin and Pacific Islander
• Important to note that data disaggregation is a real challenge >> AAPI is NOT a huge monolith, diverse populations, cultures and needs

• 

AAPI Demographics

• 24 million AAPI people in US (7.5%), 41% growth from 2010 to 2020
• In CA, 7 million AAPI people, the fastest growing ethnic group
• In SoCo, there are 21K (5%), which is a 10% growth over the last decade
• Filipino>Chinese>Vietnamese>Indian>Japanese>Laotian>Cambodian

Portrait of Sonoma Health Development Index (HDI) is higher than other BIPOC communities:

Mental Health

-Mental health stigma runs strong in AAPI communities

-AAPI youth in SoCo have the second highest youth suicide rate among 9 Bay Area counties

-mental health during COVID was heavily impact by "Asian Hate",

-AAPI have very low help-seeking behaviors for mental health services (36.1% vs. 56.1%) 

Substance Use

-Tobacco use>> high quit attempts without help-seeking

-Gambling

-high rates of ETOH, IVDU

Barriers to Primary Care Access

-insurance (especially Fijian and Samoan caregivers/seniors)

-language

-culture/gender concordance

-use of traditional CAM therapies

-historic mistrust of Western healthcare system (e.g. experiences in Refugee camps)

Preventive Health

-preventive care is not a cultural normal

-lower rates of cancer screenings (esp in AAPI patients with limited English proficiency)

-high rates of ASCVD risk, even with normal BMI

-cancer as leading cause of death in AAPI in US (lung, liver, colon), compared to ASCVD in white population

Elderly AAPI

-caregiver burden, cultural value of filial piety

-mental health>> stigma, saving face

-end of life norms

Updates in HIV Care and Prevention: The Critical Importance of Choice (Pastor, 2/5/2025)

 A recording of this presentation is available HERE.

Check back for my notes soon!