Gov. Hickenlooper signed medical aid-in-dying into law today. Now what?

Gov. John Hickenlooper signed Proposition 106 into law today, thus legalizing medical aid-in-dying in the state of Colorado. Qualified, terminally ill patients may now begin to legally obtain prescriptions for lethal doses of barbiturates to voluntarily end their lives.

Kat West, policy director of aid-in-dying advocacy group Compassion & Choices, the main backer of the measure, expects that patients will now begin requesting the life-ending medication, if they haven’t already. “I can tell you, on day one, patients are going to be asking about it,” she told The Colorado Independent last week. West used California as a model, which saw patient requests as soon as the law went into effect on June 9 this year.

Interested patients must wait 15 days from their initial request to receive a prescription, so it’s unlikely the drugs will be prescribed until the new year. If patients have already spoken to their doctors about a prescription, however, they could receive the medication sooner.

State voters passed medical aid-in-dying by a two-thirds majority on election night. Colorado is now the fifth state in the nation to pass an aid-in-dying law, along with Oregon, Washington, Vermont and California. Montana has no such law, but the state Supreme Court ruled that aid-in-dying is not illegal there.  

To qualify for medical aid-in-dying, patients must be Colorado residents, be at least 18 years old and have a terminal illness diagnosis with six months or fewer to live. They must also be of sound mind and have the approval of two different physicians. The medication must be self-administered.

In preparation, for the new law, Compassion & Choices launched “massive” outreach campaign last week, with programming for both physicians and potential patients. Eight action teams across the state are giving presentations about the law to senior centers, colleges and other locations make sure potential patients understand their rights. A medical provider advocate team, comprised mostly of physicians, is offering education and technical assistance to doctors and medical facilities across the state. The group has also developed print and online resources, videos, mailers and a series of webinars to help get the word out.

“We are trying to ensure that not only do we have a law in Colorado, but that people have access to that law,” said West. “We need to normalize it and integrate it into the standard of care.”

Hospitals, hospices and health care centers can opt out of the law, and individual care providers may choose not to participate even if their hospitals do.

What is the difference between aid-in-dying, physician-assisted suicide and euthanasia?

For the most part, the different terms reflect the groups who use them.

In developing the 2016 ballot measure, proponents used “medical aid-in-dying” to describe the process of patients self-administering prescribed medication to induce a peaceful death.

Opponents to Proposition 106, such as disability rights activists and groups affiliated with the Catholic Church, tend to use the term “assisted suicide,” arguing that “aid-in-dying” is a euphemism that inaccurately describes the process.

“Euthanasia” is the process by which a physician administers medication to assist a patient in dying, and is illegal in all 50 states. California’s aid-in-dying measure prohibits the practice from being referred to as “euthanasia” or “assisted suicide.”

What’s the timeline?

Gov. John Hickenlooper signed Proposition 106 into law today. 

Requests made starting today cannot be fulfilled immediately, however. To be able to receive aid-in-dying medication, patients must make verbal requests to two different physicians, including their primary care physician, at least 15 days apart. Both physicians must diagnose the patient as terminally ill, observe mental capability and evaluate that the patient is not being coerced into requesting the medication.

Still, said Compassion & Choice’s West, physicians need to be proactive in their preparation: “We tell providers that if you start to think about this only when your patient requests it, it’s too late.”

What kind of drugs are used, and what do they cost?

In medical literature, the two most commonly cited drugs for the purposes of aid-in-dying are Nembutal (known generically as pentobarbital) and Seconal (known generically as secobarbital).

Pentobarbital, a barbiturate, was an effective and inexpensive aid-in-dying drug for many years. However, its use as a lethal injection drug for executions recently prompted manufacturers to stop producing it for the United States. Access is now extremely limited, even for use in hospitals as a sedative.

Seconal, a barbiturate-derivative used for the treatment of epilepsy, insomnia and as an anesthetic for minor surgical procedures, is still routinely prescribed to patients seeking a painless, voluntary death. But after California passed aid-in-dying earlier this year, the drug’s manufacturer, Valeant Pharmaceuticals, took advantage of the new market and doubled the price. A lethal dose of Seconal now costs $3,000, a price that many people on fixed incomes find prohibitive. In 2009, the same dose cost only $200. There currently is no generic version of Seconal available in the U.S.

Other aid-in-dying drugs exist, but are less commonly prescribed. To combat high prices, doctors have discovered a new drug cocktail that they say works just as well — and retails for only $500. A team of physicians from aid-in-dying advocacy group Doctors with the End of Life developed a mix of three drugs — phenobarbital, chloral hydrate, and morphine sulfate — which are mixed in powdered form and taken with water, alcohol or juice.

This medication is, according to Compassion & Choices’ West, “the most affordable and available,” but it is only available from compounding pharmacies, which are more rare.

Still, West is optimistic about the range of available drugs, and insists that “there is no problem getting them.”

Does insurance cover the drugs?

Colorado’s new law doesn’t require insurance companies to cover aid-in-dying medication. Compassion & Choices’ West said most insurance companies do cover the drug, especially now that California has passed a law, but there’s no guarantee.

A patient’s decision to request aid-in-dying medication will have no effect on annuities, advanced medical directives or health, accident or life insurance policies. Physicians must list the patient’s terminal illness as the cause of death on the death certificate.

Do doctors need additional training?

No. Licensed physicians in Colorado need no additional training or certification to prescribe aid-in-dying medication or to serve as consulting physicians.

Physicians are required to make a record any time an individual requests the medication, documenting that the patient is terminally ill, has six months or fewer to live, was not coerced into requesting the medication and is in good mental health. According to the law, the primary physician must provide “full and specific information to the individual about his or her diagnosis and prognosis; alternatives or additional treatment opportunities, such as hospice or palliative care; and the potential risks and probable results associated with taking the medication.”

Doctors must also inform each patient that he or she may choose not to use the medication, even if it is prescribed, and may withdraw his or her request at any time. If either the primary or consulting physician feels a patient is not mentally capable of making an informed decision about receiving the medication, they must refer the patient to a licensed psychiatrist or psychologist, who must deem the patient mentally competent before the request process may proceed.

Compassion and Choices’ West said that physicians must be licensed and have primary responsibility for a patient’s terminal illness. In other words, she said, “a podiatrist would not qualify.” For the most part, she said, it has mostly been family practitioners who prescribe the medication in Oregon, along with some oncologists and some hospice medical directors.

Who will offer it?

It’s still too early to tell how many hospitals and physicians will participate in providing aid-in-dying to Coloradans.

According to Amber Burkhart, a policy analyst for the Colorado Hospital Association, healthcare facilities must decide whether to opt in or out of the law, and establish policies to go along with their position. Within those policies, individual physicians can always decide to opt out of participating.

Compassion & Choices has sent out mailers to inform physicians and hospitals of the new law, and ensure that they feel prepared to offer aid-in-dying if they so choose. The organization also plans to develop a “Find Care Tool” on their website, which will allow interested patients to find the nearest facilities that honor the right to aid-in-dying under the law.

“When people are thinking about getting a doctor or getting insurance, they will have the information they need to choose healthcare providers who will honor their decisions,” said Burkhart.

But the Colorado Hospital Association “does not have a position and neither encourages nor discourages” healthcare providers to provide aid-in-dying, said Burkhart. “We’re just focused on providing support,” she said.

Sonja Hix-Cortina, a spokeswoman for the Home Care Association of Colorado, said last week that the board was still discussing the issue and hadn’t formalized a policy for the association yet.

What about the Catholic Church?

Though it’s too early to tell how many physicians will provide aid-in-dying, hospitals, physicians and hospice centers affiliated with the Catholic Church will almost certainly not participate.

Catholic hospitals follow the Ethical and Religious Directives for Catholic Health Care Services, a set of rules put out by the U.S. Conference on Catholic Bishops that guides care for affiliated hospitals. The directives, which call medical aid-in-dying “intrinsically immoral,” say that “Dying patients who request euthanasia should receive loving care, psychological and spiritual support, and appropriate remedies for pain and other symptoms so that they can live with dignity until the time of natural death.”

Michael Romano, the national media relations director for Catholic Health Initiatives, isn’t ready to give a statement about participation in medical aid-in-dying, but said The Colorado Independent should read between the lines. The Catholic Health Initiatives website states that affiliated hospitals and health centers must follow the church directives. “Clearly, if Catholic Health Initiatives follows the directives, we’re not going to be doing assisted suicide,” Romero said last week.

According to the American Civil Liberties Union’s 2016 report, “Growth of Catholic hospitals and health systems,” between 30 and 39 percent of acute care beds in Colorado are in facilities that are Catholic owned or affiliated.

Is the battle over aid-in-dying finally over?

Though aid-in-dying passed nearly 2-to-1 in Colorado, the controversy surrounding it rages on. And opposition doesn’t just come from the Catholic Church — disability rights activists and physicians who simply disagree with the practice have spoken out against it. In California, some groups even filed a lawsuit looking to overturn the aid-in-dying law.

Though there is no evidence yet as to whether Colorado will see similar lawsuits, opponents continue to make their voices heard.

Dr. Bill Bolthouse, a physician at a Denver health clinic that primarily serves low-income patients, said his arguments have nothing to do with religion. “I’m not Catholic, but on this side of things I guess we’re on the same team,” he said. To him, aid-in-dying is a violation of the Hippocratic oath, in which doctors promise to do no harm to their patients.

Bolthouse also sees it as “dangerous for people on the margins,” whom he often treats at the health center. He worries that people without financial resources will see aid-in-dying as a cheap alternative to costly treatments.

Dr. Thomas Perille, a retired physician who worked as an internist for 20 years, also opposes the new law. He fears aid-in-dying will become a slippery slope, with doctors developing a tendency to encourage aid in dying for increasingly vulnerable populations. They could, he worries, begin to “resort to euthanasia instead of providing care.”

It’s hard to imagine a doctor suggesting aid-in-dying over treatment, but Bolthouse said change could be on the horizon. “If Medicaid says, ‘Well that treatment is experimental or that treatment is too expensive, we’re not going to pay for it, but we will pay for your life-ending medication,’ it kind of justifies not paying for something expensive,” he said.

Bolthouse referenced a case in 2008 of a woman named Barbara Wagner, who received a letter from her insurance company denying coverage for a new cancer treatment on the ground that it was experimental. Aid-in-dying, however, was listed in the letter as one of the treatments which the insurance company would cover in full.

Wagner ultimately received the treatment she sought, but the incident prompted California to include a provision in its law that insurance companies cannot tell patients who aren’t requesting aid-in-dying medication whether or not they cover the cost. Colorado’s new law doesn’t contain that specific provision, but it does prohibit insurance companies from refusing any treatment based on the availability of aid-in-dying medication.

Bolthouse also said the rise of aid-in-dying demonstrates a deteriorating relationship between doctors and patients. “I think as doctors become more distant from their patients, as we hide behind our screens in clinical situations, we stop touching our patients, we stop looking them in the eye, we stop treating them like human beings,” he said. “It’s not medicine. I don’t know what it is, but its not medicine.”

Dr. Cory Carroll, a physician with a private practice in Fort Collins, wholeheartedly supports medical aid-in-dying. He doesn’t think doctors should be able to make decisions on behalf of their patients, saying instead that, like the separation of church and state, “there should be a separation between church and medicine.” Carroll understands why people oppose aid-in-dying, but believes each patient should be able to make their own choices. “People can look at this as being wrong and immoral, but is it something criminal that should be denied?”

Carroll also thinks aid-in-dying will help close the gap between the humane way that medical professionals tend to die, and the prolonged suffering patients often endure in an attempt to live longer.

“What I do know is how physicians die, and the reason why is that we know what it looks like,” he said. “We don’t go to extraordinary measures to keep our bodies alive.”

Perille disagrees. “I’m quite aware of what the limitations of medical interventions are, and I don’t have any desire to be on a ventilator or chemotherapy with a low percentage chance of working,” he said. “But that doesn’t mean i want to kill myself.”

Calling aid-in-dying “false compassion,” Perille said people may request medication when there are other, solvable problems at play, like pain or depression. “There are people that I’ve met that have terminal illnesses who will tell me they want to die, and then you address the issues that cause them to feel that way, and months later they have a much different perspective,” he said.

But that argument falls flat with Carroll, who said he has seen what happens when his patients can’t access the aid-in-dying they’re looking for.

“As a physician of 25 years, I’ve had many many patients ask me to help them die,” he said. “Some have been successful — with bullets.”

Update: This story has been updated to clarify that the Montana Supreme Court ruled that aid-in-dying is not illegal, but is also not a guaranteed right under state law. 

Photo credit: Yuya Tamai, Creative Commons, Flickr