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/