San Francisco health officials are developing a city policy to comply with a new state law that allows terminally ill patients to legally end their lives, shedding light on how the quality of life for a patient in his or her final days might be improved because of the law.
The law, which took effect last summer, has also opened the door for further communication between doctor and patient, potentially allowing a patient to better articulate the final, painful stages of disease, according to a San Francisco doctor who is opting in to the program.
“When patients ask about this, I think about what’s leading to their request,” said Dr. Kara Bischoff, an assistant professor at UC San Francisco and a palliative care physician, noting patients typically are “motivated by fears of dying [and] discomfort.”
In September 2015, California became the fifth state in the U.S. to allow doctors to prescribe life-ending medication after Gov. Jerry Brown signed into law the California End of Life Option Act.
The process, known as “aid in dying,” was formally enacted on June 9, 2016, following the highly publicized case of Brittany Maynard, a 29-year-old woman diagnosed with a brain tumor who moved from California to Oregon to legally end her life.
The City’s Department of Public Health has since tasked its Office of Policy and Planning with establishing a policy for patients and doctors in the San Francisco Health Network who wish to opt in to the voluntary program.
Health officials earlier this month presented a draft of the policy to the Health Commission. A final draft of the policy is slated to be approved by July.
To opt in to the program, a patient must be at least 18 year old, reside in California, have been diagnosed with a terminal illness with a prognosis of less than six months to live and be able to make medical decisions and self-administer the medication, which is usually Seconal.
As soon as the law was passed, Bischoff said she knew she wanted to provide the right to die for her terminally ill patients.
The life-ending medication, she explained, is “just one more tool in a very large tool belt of ways to provide patients care at the end of their lives.”
“I feel strongly about providing care to patients that’s consistent with their values and priorities,” Bischoff said.
Since the law took effect, several dozen of Bischoff’s patients — mainly those who have been diagnosed with cancer, heart failure or lung diseases — have inquired about the right to end their own lives, but very few have taken any steps beyond that, she said.
“There’s a very big difference between patients who have inquired about it … and patients who have actually been interested in pursuing the formal process,” Bischoff said.
In fact, just one of her patients has followed the exhaustive process through to the point the patient ingested the life-ending medication. Bischoff couldn’t release many details about that case, but said the patient was experiencing “absolutely tremendous, excruciating physical symptoms.”
But the law has also opened the door for further communication between a doctor and a patient about the patient’s pain level, Bischoff emphasized.
“When I hear about such concerns, that is really an opportunity to engage in a conversation about services … that provide comfort and control at the end of life,” she said.
Terminally ill patients also seem to take comfort in the fact that they have the right legally to choose when their life will end.
“Being able to have the option of life-ending medication in and of itself has provided comfort and peace of mind, even if the medication itself isn’t more accessed,” Bischoff said.
When the law took effect last summer, the California Hospital Association recommended that hospitals develop a local policy to comply with the End of Life Option Act. However, the association does not track whether a hospital develops a policy or what that policy is.
But in San Francisco, a city known for pioneering health care — the first treatment unit in the U.S. for patients with AIDS opened at San Francisco General Hospital in 1983 — the End of Life Option Act is becoming clearer by the day.
Dr. Alice Chen, chief medical officer for the San Francisco Health Network, said there’s no formal list of physicians who have opted in to the program, but an internal survey indicated there are enough physicians willing to participate to warrant a city policy.
“Because the law is written in a way that is very decentralized, any patient can approach any physician,” Chen said. “[We are] really making sure all of our physicians know that we want to keep this centralized, so that we have a sense of what the demand is from our patients.”
As of mid-January, Chen was aware of one patient in The City’s Health Network who had been prescribed the medication, but had not yet taken it. She didn’t know of any patients who had taken the medication.
“The number is going to be very small, is our expectation,” said Dr. Anne Kinderman, director of Supportive and Palliative Care at Zuckerberg San Francisco General Hospital.
This is also somewhat the case in states that also legally allow patients the right to end their lives: In 2015, of the 218 patients in Oregon who requested the medication 132 — 60 percent — ingested it. Of the 213 patients in Washington who requested it that same year, 166 — 77.9 percent — took the medication.
It’s anticipated that 66 percent of the patients in California who request the medication will ingest it, though Chen noted that the state’s population is more diverse than others.
“California and San Francisco are so unique in its diversity that I think it merits watching how it unfolds,” Chen said. “When you look at the data from other states where this type of law has been implemented, it’s typically white, college-educated” patients who opt in.
“It bears watching how it plays out in California because we are so different,” she said.