1. End-of-Life Options and Medical Aid in Dying
Cory D. Carroll, M.D.
Foothills Family Care, LLC
3213 Nelson Lane
Fort Collins, CO 80525
Cell
Office
Introduce self
I provide education on the End-of-Life Options Act to other healthcare providers and Colorado residents on behalf of Compassion & Choices’ Colorado Access Campaign.
End-of-Life Options and Medical Aid in Dying

2. About Compassion & Choices
C&C is the nation’s oldest, largest and most active nonprofit organization committed to improving care and expanding choice at the end of life.
C&C supports, educates and advocates.
C&C is the nation’s oldest, largest and most active nonprofit organization committed to improving care and expanding choice at the end of life.
C&C advocates for patient-centered care and patients having the full range of end-of-life options.

3. “Life is meaningful because it is a story …
… and in stories, endings matter.
~Atul Gawande, Being Mortal
Tell your personal story in 1-2 minutes:
The conversation around medical aid in dying (or end-of-life options) changed for me when...

4. Talking about Death
It’s hard to talk about death. But It’s better to be proactive.
discuss your wishes with your loved ones,
2) create your advanced directives AND
3) talk with your doctor about MAiD.
If you wait to talk to your doctor until you need to, it might be too late, and you don’t want to be in the position of having to re-establish care with a new healthcare team during a difficult and emotional time.

5. Dying in America

6. Pursuing Life-Sustaining Treatment Refusing Treatment
End-of-Life Options
Pursuing Life-Sustaining Treatment
Refusing Treatment
Discontinuing Treatment
Hospice
VSED
Palliative Sedation
Medical Aid in Dying
To deliver patient-centered care, physicians need to inform the patient of the full range of end-of-life options - including the benefits and burdens of each care option.
So let’s discuss the newly authorized option of medical aid in dying.

7. Medical aid in dying is a medical practice in which a terminally ill, mentally capable adult with a prognosis of six months or less to live may request from her or his doctor a prescription for medication which they can choose to self-ingest to bring about a peaceful death.
Medical aid in dying is a medical practice in which a terminally ill, mentally capable adult with a prognosis of six months or less to live may request from her or his doctor a prescription for medication which they can choose to self-ingest to bring about a peaceful death.
Medical aid in dying does not cause more people to die, but it does allow fewer people to suffer.

8. Majority of Americans and Doctors Support Medical Aid in Dying as an Option
68-74% of Americans agree with access to medical aid in dying
(Gallup 2015, Harris 2014)
56% of Colorado Medical Society members agree with access to medical aid in dying (2016)
For years, the majority of Americans have strongly supported medical aid in dying as an end-of-life option.
This support is strong across all demographics (age, education, gender, and political affiliation).
A 2016 survey conducted by the Colorado Medical Society demonstrated that the majority of member doctors support their patients having the option of medical aid in dying.
In 2014, a national survey conducted by Medscape also demonstrated that the majority of doctors representing 28 different specialties supported their patients having this option and would want the same option available to them if the need should arise.

9. Colorado End-of-Life Options Act
On November 8, 2016, Coloradans overwhelmingly approved medical aid in dying for terminally ill patients.
That means there is a strong public mandate to have this end-of-life option available AND accessible to terminally ill Coloradans.
Coloradans overwhelmingly authorized medical aid in dying on November 8, 2016.

10. Where Medical Aid in Dying Is Authorized
Oregon, 1997, by ballot initiative
Washington, 2008, by ballot initiative
Montana, 2009, by court ruling
Vermont, 2013, through legislation
California, 2015, through legislation
Colorado, 2016, by ballot initiative
District of Columbia, 2017, through legislation
Medical aid in dying is currently authorized in six states and in Washington DC - starting in Oregon in 1997.
Although each state’s procedural requirements differ slightly, all mandate core safeguards including eligibility requirements and provide legal immunities.
In 2017, legislation will be considered in more than half the states across the country.

11. Colorado End-of-Life Options Act: Eligibility Requirements
Adult
Terminally ill
Prognosis of 6 months or less
Mentally capable of making informed medical decisions
Colorado’s End-of-Life Options Act is modeled after Oregon’s 19 year old medical aid in dying law and very similar to the laws in CA, WA and VT .
The eligibility requirements of the law (in bold) are the same in every authorized state:
adult
terminally ill
prognosis of 6 months or less
mentally capable to make informed healthcare decisions
About a third of people who receive medical aid-in-dying prescriptions never take the medication, but benefit from the great peace of mind it provides them to have control over their suffering, should they decide to exercise it.

12. Regulatory Requirements, include:
State resident
Self-administer the medication (voluntary, conscious and physical act to take the medication into the body)
Other regulatory requirements include:
Eligible person must demonstrate they are a state resident (driver’s license or state ID, voter registration, owns or leases property, or tax return)
In addition, the patient must be able to self-administer the medication themselves which is the ultimate demonstration of voluntariness.
The individual must make the final affirmative and physical act to take the medication into their body such as sipping through a straw or pushing the plunger on a feeding tube.
It is completely permissible for medical providers or caregivers to hold a cup or straw to the person’s mouth or pour the medication into a feeding tube - as long as the terminally ill individual makes the final voluntary act to ingest the medication.
Please note: Lethal injections by third parties do not qualify as medical aid in dying.

13. CO EOLOA - Request Requirements
Two oral requests from patient at least 15 days apart (not necessarily in person, but must confirm voluntariness of the person’s request outside of the presence of a third party)
One statutory form written request signed by two witnesses (attending doctor can’t be a witness, but at least one witness can’t be employed at a facility where person is a patient/resident) - any order of requests
Three required requests for an aid-in-dying prescription - any order.
2 oral requests at least 15 days apart
1 written request (statutory form) with 2 witnesses attesting to voluntary nature of request - attending doctor can’t be one of the witnesses and at least one of the witnesses can’t be employed at a facility where the person is a patient or resident

14. Other Protections
The choice to request/take aid-in-dying medication cannot affect health or life insurance status or contracts.
Death certificate must list underlying terminal illness as the cause of death. (Attending physician or hospice medical director shall sign)
Medical aid in dying does not constitute suicide, mercy killing or homicide under the law.
Medical aid in dying may not affect a patient’s health or life insurance status.
Under the CO EOLOA, the death certificate must list the underlying terminal illness as the cause of death. And the attending physician, hospice medical director or the on-call physician signs.
Finally, by law, medical aid in dying does not constitute suicide, mercy killing or homicide.

17. 20 Years of Practice in Oregon Show that Medical Aid in Dying Works as Intended
Having a prescription for aid-in-dying medication on hand is a comfort.
People use the law to minimize pain and suffering, not to save money.
The elderly, people with disabilities and people of color have not been coerced or abused.
19 years of data from Oregon, and 30 years of combined data from all the authorized states, demonstrates that the law works as intended.
The evidence and data dispels the myths. None of the concerns or fears that opponents have raised have occurred.
Instead the data shows:
Medical aid in dying is a compassionate medical practice. Simply having a prescription for aid-in-dying medication on hand is a comfort to dying people and allows them to live their remaining days to the fullest even if the ultimately choose not to self-administer the medication.
People use the law to minimize pain and suffering, not to save money.
There has never been a single instance of abuse in a combined thirty years of authorized medical aid in dying. The elderly, people with disabilities and people of color have not been coerced into using the law.

18. Health insurance Federal prohibition: Medicare VA
Most private insurance pays
State Medicaid may pay in future
Private health insurance may or may not cover medical aid-in-dying medication and the appointments necessary to get through the process.
VA and Medicare do not cover aid-in-dying medication or appointments because of a 1997 federal law that prohibits federal dollars spent on medical aid in dying which was enacted out of unrealized fear that people would be coerced into using the law.
Oregon and California States segregate state Medicaid funds and cover aid-in-dying medication and appointments. It remains to be seen whether Colorado will follow suit.

19. Diagnosis of People Who Used the Death With Dignity Law in Oregon
2015 Oregon Public Health Division data show that the underlying illnesses were broken down as follows:
Malignant neoplasms: 95 percent
Other illnesses: 14 percent
Heart Disease: 9 percent
ALS: 8 percent
CLRD: 6 percent

20. Hospice and Palliative Care Are Improved and Better Utilized
92% enrolled in hospice
90% died at home
In Oregon, 92 percent of people who used the law were enrolled in hospice and 90 percent died at home.
The article, Geographic Variation in Hospice Use Patterns at the End of Life, found that those at the end of their lives in Oregon have benefited from improved care as measured by clinical standards, increased referrals to hospice, and the experience of hospice nurses. This is due in part to the dialogue that authorization of medical aid in dying encourages between people and their doctors, better palliative care training for physicians and more hospice care referrals.
Citation: Vol. 34 No. 3 September 2007 Journal of Pain and Symptom Management 277
Geographic Variation in Hospice Use in the United States in 2002 Stephen R. Connor, PhD, Felix Elwert, PhD, Carol Spence, RN, MSN, and Nicholas A. Christakis, MD, PhD National Hospice and Palliative Care Organization (S.R.C., C.S.), Alexandria, Virginia; and Department of Health Care Policy (F.E., N.A.C.), Harvard Medical School, Boston, Massachusetts,
[Inappropriate hospice use defined as very short enrollment, very long enrollment, or disenrollment.]

21. COLORADO END-OF-LIFE OPTIONS ACT, YEAR ONE 2017 DATA SUMMARY
Prepared by: Center for Health and Environmental Data Colorado Department of Public Health and Environment
For more information, visit

22. Participation in Colorado end-of-life options activities
During 2017, 69 patients received prescriptions for aid-in-dying medications under the provisions of the Colorado End-of-Life Options Act.
Prescriptions for aid-in-dying medication were written by 37 unique Colorado physicians.
Malignant neoplasms – (64%)
Amyotrophic lateral sclerosis (ALS) (10%)
Heart disease (including heart failure) (10%)
Chronic lower respiratory disease (including COPD) (9%)
Other illnesses/conditions (7%)

23. Participation in Colorado end-of-life options activities
Aid-in-dying medications were dispensed by 19 unique pharmacists in Colorado.
Secobarbitol (42%)
DDMP (diazepam, digoxin, morphine sulfate, propranolol) 28 (56%)
Other (morphine sulfate alone or some other combination) (2%)

24. Characteristics of patients prescribed aid-in-dying medication who have died
Sex:
Female: (46%)
Male: (54%)
Age group:
< (22%)
>65: (78%)
Race/ethnicity:
White, non-Hispanic: (96%)
Other: (4%)

25. Characteristics of patients prescribed aid-in-dying medication who have died
Educational attainment:
High school graduate or GED completed or less: (29%)
Some college credit but no degree: (18%)
College (+) degree : (53%)
Place of death:
Residence: (79%)
Nursing home/long-term care facility: (16%)
Other: (5%)
Hospice enrollment status:
Under hospice care: (93%)
Not under hospice care: (7%)

26. Dr. Carroll’s Involvement
Attending:
CS 95 F Chronic Illness +Hospice (died before qual.) 2/17
AK 65 M Lung Cancer +Hospice (died before qual.) 3/17
WK 91 M CHF (amyloidosis) +Hospice 2/18
AC 66 F Appendiceal Carcinoma +Hospice (still alive) 2/18
LN 56 F Breast Cancer +Hospice (I pronounced) 4/18
MW 86 F Biliary Cancer +Hospice (I pronounced) 5/18
Consulting:
MM 84 F CHF +Hospice 3/17
JH 79 F Ovarian Cancer +Hospice 3/18
KT 56 F Colon Cancer +Hospice 6/18

27. Dr. Carroll’s Involvement
Attending:
CS 95 F Chronic Illness +Hospice (died before qual.) 2/17
AK 65 M Lung Cancer +Hospice (died before qual.) 3/17
AC 66 F Appendiceal Carcinoma +Hospice (still alive) 2/18

28. Dr. Carroll’s Involvement
Attending:
WK 91 M CHF (amyloidosis) +Hospice 2/18
LN 56 F Breast Cancer +Hospice (I pronounced) 4/18
MW 86 F Biliary Cancer +Hospice (I pronounced) 5/18

29. Dr. Carroll’s Involvement
All three patients who I prescribed Medical Aid in Dying had extremely peaceful ends to their lives and were surrounded by family at their home.
Hospice involvement is encouraged.
I was at their bedsides (at their permission) and helped the family understand the process of dying after ingesting the medications.

30. Dr. Carroll’s Involvement
In my experience, patients (and families) were extremely grateful for my willingness to prescribe MAID. Since I attended the bedside I witnessed the process (2 out of 3) and saw the comfort that family members had surrounding their loved one on their final journey.
After the patient died the families (in attendance) were sad but very grateful that their loved one had such a peaceful death.
I will continue to offer Medical Aid in Dying to my patients. Hopefully, those of my colleagues who are supportive will participate and expand the number of physicians offering MAID to patients in Colorado who request it.

31. Colorado Access Campaign Resources:
Videos for doctors and patients
Clinical criteria + fact sheets
State forms
Request a Speaker
Find Care Tool that lists facilities that have adopted policies that honor patient choice
Doc2Doc consultation service
Pharmacist2Pharmacist consultation service
Compassion & Choices has launched the bilingual Colorado Access Campaign!
Two purposes:
Provide education and technical assistance to medical providers and facilities
Provide education to Colorado residents.
On our website, we have videos for doctors about the clinical criteria for medical aid in dying and and a video for terminally ill people interested in this option.
We also have a free and confidential Doc2Doc consultation service where physicians can talk to one of our medical directors who have years of end-of-life care and medical aid in dying experience.
If you are interested in any of these resources, I brought some information on our website and Doc2Doc service [that is also in the back of the room].

33. End-of-Life Options and Medical Aid in Dying
Cory D. Carroll, M.D.
Foothills Family Care, LLC
3213 Nelson Lane
Fort Collins, CO 80525
Cell
Office
End-of-Life Options and Medical Aid in Dying