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HOPA 2018 | Physician-aided death in the US

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Joseph Bubalo

Speaking from the 2018 Hematology/Oncology Pharmacy Association (HOPA) Annual Meeting, in Denver, CO, Joseph Bubalo, PharmD, BCOP, BCPS, of Oregon Health and Science University Hospital, Portland, OR, talks about the introduction of physician-aided death in the United States, its current statistics and its future outlook.

Transcript (edited for clarity):

My topic of presentation here at HOPA is Death with Dignity, which is physician aid in dying. This is becoming a thing in the United States because over the last few years an increasing number of states have enacted legislation which allows patients to choose to end their life if they so desire, and Oregon was the first state that it passed in, and in 2017 it hit its 20-year anniversary.

So I was asked as a result to kind of review the Oregon experience and then talk about the current state of physician aid and dying in the United States...

My topic of presentation here at HOPA is Death with Dignity, which is physician aid in dying. This is becoming a thing in the United States because over the last few years an increasing number of states have enacted legislation which allows patients to choose to end their life if they so desire, and Oregon was the first state that it passed in, and in 2017 it hit its 20-year anniversary.

So I was asked as a result to kind of review the Oregon experience and then talk about the current state of physician aid and dying in the United States. Currently we have six states, plus the District of Columbia which is where our capital Washington is located, that have legislation which allows some form of physician aid in dying. In the United States it’s completely self administered, so someone else cannot administer it, it has to be the patient them self.

The different states have systems in place where there are steps that they go through, and within those steps they have to approach a primary physician, they have to have a couple-week waiting period, generally two weeks, there are witnesses to this whole process, they make sure that they’re mentally sound, that they’re not in the middle of a mental crisis or actually having a depressive episode or something like that.

And then from there, the physician actually writes a prescription, the patient picks it up and pays for it, and what’s the role of the pharmacist in that? We are going to be there certainly dispensing the medication, and in each state it’s a little different. The actual formulation is going to be different, and we’re kind of still developing that, there isn’t a really a literature basis on how to help someone end their life, and we kind of are all learning while the process is going on.

In the 20 year Oregon experience, about, almost I think 14 or 1500 prescriptions have been written over the 20 year period, and of those about 990 were actually taken, so about 50 patients a year. While the number of prescriptions being written is going up, we don’t actually see that many more people ending their life. So I think it really, as we find out, has to do with patient autonomy, and we’re supporting them in kind of ending their life as they feel is right for them.

I don’t know that anybody promotes this and there’s a lot of self-discovery and self searching in the pharmacy profession as to what our role is; there are guidances from our major organizations but they basically leave it up to the pharmacist, and all the states that enact it allow anybody that would want to opt out, so you can either be a participant in the process or not.

We’re never the driver of the process; that’s always going to be their physician who has the medical relationship with them, and we see all kinds of stories in in our local paper. Recently, there was a couple who, they had lived a long life together, they’ve been married many years and they were really getting farther and farther into a dementia, and while they were healthy their quality of life was diminishing, and this is kind of a, not a typical setting but I’m using just using it as an example, and in the end, over about a year process, they decided that they would end their lives together just as they had lived together, and they kind of gathered their family around and had a final dinner and and then they took their prescriptions. And once again that’s not a typical process but I think it gives an example of how far society and individuals have come in respecting each other’s individuality and maybe self autonomy.

Most patients that take it have a medical diagnosis, you know in the Oregon experience it’s almost 80 percent I think have a cancer diagnosis or other diagnosis that have used physician aid in dying include ALS or Lou Gehrig’s disease, a variety of Alzheimer’s, Parkinson’s and other really end-stage disorders where symptom control may be bad or they just have totally lost the ability to redirect their life and their life path. And that’s really where we see the greatest impact I think of this law.

For pharmacists, the organism has not been really progressive in this, Washington which is the state right next to us has come up with their own formulation of what they prescribe, and the goal of this prescription is actually for the patient to go into a coma within about five minutes of ingestion, and they’ve started including some cardiac medications to take to make sure that they don’t suffer from ongoing heart activity, and those that are with them at the time of their death don’t suffer or don’t perceive them to suffer as well, along with the more traditional sedating medications that are used, so I guess that would be a maybe not so brief summary of where we stand currently.

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