To someone who has struggled over time with a terminal illness, such as cancer, neurological disease, lung disease and others, having the option to end life on their own terms may bring a sense of comfort and control as they progress in the disease. While Oregon’s Death with Dignity Act has made medical aid in dying legal since 1997, it isn’t for everyone.
What is medical aid in dying, what are some reasons people consider it and how does the process work?
What Is Medical Aid in Dying?
“Oregon adults, 18 or older, who have a terminal condition and are nearing the end of their lives, have the ability to request medication to hasten their death in a more comfortable way than they may otherwise experience,” said Dr. Kelsey Terland of Samaritan Palliative Care.
Legal in nine states and the District of Columbia, medical aid in dying in Oregon is governed by a law that requires the patient to administer the terminal medication to themselves and it must be delivered into the digestive track. The current best practice includes prescriptions of four different medications in lethal doses taken as pills and liquid in a particular sequence.
Oregon statute specifies that participation under the Death with Dignity Act is not suicide and should not affect life insurance benefits by that definition.
Along with being of legal age and a resident of Oregon to participate, patients must also be capable of making and communicating health care decisions for themselves, must be physically able to take the medications themselves, must be free of a mental illness that impairs their ability to make informed decisions, and must have a terminal diagnosis that will lead to death within six months.
“Obviously, the law is not without controversy,” Dr. Terland said.
Because the entire process depends on a patient meeting the criteria, a physician to write the prescription after determining a patient meets criteria, a second physician confirming the terminal diagnosis and recommendation, and a pharmacy to fill it, a patient must also find the medical personnel willing to participate in medical aid in dying. Participation by medical staff is voluntary; no one is required to provide the prescription. Also, some health care institutions may prohibit their staff from participating in the Death with Dignity Act.
Even after you find willing physicians and pharmacists, there are detailed steps to obtain the prescription. Thus, the time it can take to clear all the needed hurdles can take up to a month or more. Since changes made to the law in 2020, a physician can request a reduction in the waiting periods, if the prescribing physician feels the person’s life expectancy is less than the waiting period. However, even if this reduction is allowed, all steps of the law must still be followed.
Why People Consider It
Despite the barriers, for some patients, having the prescription can offer a sense of security, Dr. Terland noted.
“When you look at the data, the top reasons people cite for participating in medical aid in dying has less to do with their pain, and more frequently because they feel a loss of autonomy or a loss of the ability to do the things that make life enjoyable for them,” Dr. Terland said. “Others want it because they’ve had to live with an illness for a long time and have felt totally out of control because of it. As they anticipate the disease getting worse, they say they want some control in the final act of their lives. These are the main reasons people do it.”
So far, in Oregon’s 22-year history, the diseases these patients most commonly have, Dr. Terland noted, are cancer, neurological disease, lung disease and heart disease; however, it is the terminal diagnosis which is required and not the type of condition.
“Statistics show that only about 60% of those who collect the medication actually take it,” Dr. Terland noted. “If you look at why people get it in the first place, it is wanting to have control, and this allows them a kind of security blanket. If, at any time, they want to take it, they can. But they don’t have to.”
Process to Get a Prescription
Once a patient decides to explore the process, they begin by asking their doctor for information.
“Sometimes, all the patient wants is to know more about the option,” Dr. Terland said. “At Samaritan, we have a policy of neutrality, meaning that, if a patient asks us about medical aid in dying, we will give them the information as neutrally as possible. Our goal is not to obstruct the process, but not to actively promote it either.”
If, after obtaining information, the patient wants to continue with next steps, the average process takes a minimum of four weeks, if everything goes smoothly.
A patient will be required to make both verbal and written requests and will need two physicians to independently verify that the patient meets criteria to qualify for the medication. Additionally, a patient will need a pharmacy that agrees to fill the prescription, which may require going to a pharmacy outside their usual location. (For example, the nearest pharmacy to the Samaritan service area is in Portland.) Throughout the process of making requests and verification there are various waiting periods.
“Of course, when someone asks a physician for medical aid in dying, it is a question that prompts a very thorough and thoughtful investigation as to why a patient wants it,” said Dr. Terland. “We will ask questions to try and carefully listen to what the patient is asking for. Sometimes, for example, they may be concerned about pain, and rather than medical aid in dying, we can explore options to manage their pain better.”
Also, keep in mind that every illness does not lend itself to this process.
“It is difficult to predict how long someone has to live. Sometimes, a person will seem just fine and suddenly take a turn for the worse and quickly lose the physical or mental ability required to take the medication on their own,” she said. “Or, in the case of dementia, by the time a person has six months to live, they no longer have the capacity required. Those are some of the challenges of the journey.”
“We help patients understand all the available options at the end of life, such as ways to manage symptoms, hospice care and psycho/social supports we can offer,” said Dr. Terland. “Additionally, throughout the entire process, we remind patients that they can change their minds about any path they’ve chosen,” she noted.
What Do Patients Experience?
“If a patient does choose medical aid in dying and takes the medication, death can take anywhere from a few minutes to several hours,” said Dr. Terland. “While every person is different, in most instances, the person is asleep and comatose within 45 minutes of ingesting the medication, and death can occur within an hour or two,” she said. “The medication includes a number of sedatives, so the body doesn’t typically feel the discomfort of dying.”
Decision Requires Careful Consideration
Medical aid in dying is a decision that needs careful consideration.
“Not only does a patient need to have a serious discussion with their medical professional, but we strongly recommend discussing it with loved ones,” said Dr. Terland. “At least inform them of your decision.”
Ultimately, the Death with Dignity Act gives Oregonians an additional end-of-life option.
“Oregon voters gave patients the right to choose what’s best for them, and whether a patient chooses medical aid in dying, hospice care or another valid option, it is their choice,” said Dr. Terland.
Kelsey Terland, MD, is the medical director of Samaritan Palliative Care, a multidisciplinary team that supports patients with serious illness, and is the physician advisor for questions related to Death with Dignity. For questions, please call 541-768-2187.