CA End of Life Option Act
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1 CA End of Life Option Act The Experience at UC Davis Annual Advances in Oncology September 22, 2017 Nathan Fairman, MD MPH Medical Director UCDMC EOLOA Program
2 Disclosures I have no relevant financial relationships to disclose. I will disclose off-label or investigational use of all products.
3 Disclosures I believe there can be a legitimate role for PAD in the care of some dying patients within the broader context of highquality end of life care.
4 Euthanasia? Suicide? Palliative Care? Depression? Autonomy? Nonmaleficence? Role as Healer?
5 Uncharted Territory 1. Knowledge about PAD 2. Knowledge about the law 3. Knowledge about institutional policy / process 4. Awareness of personal attitudes 5. Skill in communicating with patients
6 PAD Language Physician- Assisted Suicide (PAS) Physicianassisted death (PAD) Death With Dignity (DWD) AAHPM Policy Statement (2007)
7 PAD Palliative Care Palliative Options of Last Resort Voluntarily Stopping Eating and Drinking (VSED) Palliative Sedation Physician Aid-in-Dying Voluntary Active Euthanasia Quill T et al. JAMA 1997
8 The Law: Process / Safeguards 2 independent MD assessments 2 oral requests 1 written request Mental health specialist Ability to self-administer No surrogate requests Final attestation (terminally-ill, decisionally-competent) ( 15d apart) (2 witnesses) ( indications of mental disorder )
9 The Law: Voluntariness Participation is voluntary, for all parties: Patient Physician Institution
10 UCDMC Policy Medical Staff Administration workgroup Bioethics review MSEC approval
11 LAW 2 independent MD assessments 2 oral requests 1 written request Mental health specialist assessment Ability to self administer No surrogate requests Final attestation POLICY Patient Navigator (LCSW) Psychosocial Assessment Medical Director Notifications: CMO, Bioethics, Pharmacy, Legal Affairs Oversight: Medical Staff Admin, Bioethics
12 UCDMC Policy: Implementation Provider outreach Clinic processes EOLOA rounds Iterative refinements to policy / process Participant support Undergraduate + graduate medical education? Regional collaboration?? Research? e.g. Primary Care Network, CCC e.g. EMR referral order, SmartSet e.g. prescriber dinner, hospice inservice
13 Caring for the patient Clarifying concerns, understanding request Educating about prognosis and progression Anticipating needs for care Addressing distressful symptoms Supporting decision-making (AKA primary palliative care ) vs Participating in the EOLOA Attending MD (2 assessments, RX, documentation) Consulting MD (1 assessment, documentation) Mental Health Specialist Delivering RX / Medication Present at ingestion
14
15 EMR: Navigator Referral Order
16 EMR: SmartSet
17 The UCD Experience
18 21 TOTAL 16 COMPLETE 5 IN PROCESS 5 NOT QUALIFIED 11 QUALIFIED 4 died 1 did not have capacity 7 LIVING 4 DIED 2 ingested 1 did not ingest 1 unknown
19 Disease Type Malignant neoplasm = 19 (90%) - 4 each: Breast / Lung - 2 each: Glioblastoma / Mesothelioma / Pancreas - 1 each: Colon / Kidney / Ovarian / Prostate / Nasopharyngeal Neuromuscular Disorder = 2 - Both ALS (1 did not qualify; 1 being evaluated)
20 Demographics Age: median 65 yrs; range Sex: 62 % F / 38 % M Hospice / Palliative Care 90 % enrollment % of qualified patients - 2 patients not enrolled: both ALS
21 Mental Health 28 % (6 cases) had Mental Health Specialist Assessment Provided by 5 individual psychiatrists Physician Participation Attending MD: 10 participants (8 PMD / 2 specialists) Consulting MD: 14 participants (9 specialists / 5 PMD) Total: 22 participants
22 Some Lessons Learned Each case has been: Unique Slow Challenging Poignant flexibility / open-mindedness persistence / patience thoughtful / wise compassion / trustworthiness
23 Some Challenges How to understand quality How to support participants How to balance patient-centeredness w/professional integrity How to avoid abandonment How to position within broader end of life care planning How to coordinate with hospice / palliative care
24 Thank You Nathan Fairman, MD MPH Medical Director, Supportive Oncology Program UC Davis Comprehensive Cancer Center Questions / Panel Discussion
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