The 2015 End of Life Option Act (ELOA) authorizes an adult who meets certain qualifications, and who has been determined by his or her attending physician to be suffering from a terminal disease, to make a request for a drug prescribed pursuant to these provisions for the purpose of ending his or her life. This policy establishes parameters for end-of-life arrangements to assist Sutter Visiting Nurse Association and Hospice (SVNAH) in assuring that all such requests and responses are made in compliance with these laws, related regulations and Sutter Health policy requirements.
To provide a consistent approach for staff to discuss the ELOA process with patients while understanding that it is not part of the Medicare hospice benefit.
- Dying is a natural process. SVNAH does not hasten or prolong death. SVNAH is committed to the value of human life. We work to optimize the quality of life for all terminally ill people with quality defined by each individual receiving hospice services. This includes the avoidance of prolonged suffering.
- SVNAH supports the right of all persons to make their own decisions regarding their care, including the legal option of ingesting a lethal dose of medication as outlined in the California End of Life Option Act.
- SVNAH allows access to hospice care for terminally ill patients regardless of a patient's stated interest to pursue ELOA.
- SVNAH addresses the needs of the terminally ill with compassion, dignity, and respect.
A. Physician, Nurse, and Staff Decisions Regarding ELOA Participation
- SVNAH physicians, nurses, and staff have the right to not participate in ELOA, including the right to not provide information regarding ELOA.
- If a hospice physician decides to not participate, they should notify the hospice senior medical director or local administrator of their decision in order for SVNAH to maintain appropriate continuity of care for the patient.
- If an SVNAH nurse or staff member decides to not participate, they should notify their department manager. SVNAH leadership and management will ensure that the patient's care needs are met.
B. Documentation Requirements
Any discussion regarding a patient's interest in an Aid-in-Dying Drug, request to Self- Administer an Aid-in-Dying Drug, or use of the Aid-in-Dying Drug, will be documented as required under the law and become part of the patient's permanent medical record.
C. Role of SVNAH Hospice Physicians
- SVNAH hospice physicians may act as an ELOA Consulting Physician if the patient is currently enrolled in SVNAH's Hospice Program.
- SVNAH hospice physicians may act as the patient's ELOA Attending Physician only when they have a private practice and the patient is cared for under that physician's private practice.
- When the hospice physician acts as the attending physician for ELOA, they must relinquish their role as the patient's hospice physician and SVNAH will appoint a new physician to serve as the patient's hospice physician.
- Visits to meet criteria for the ELOA Attending Physician role will not be reimbursed by SVNAH and should not be included on the physician's SVNAH time sheet.
- Documentation will be completed in the physician's private practice medical record and attached to the SVNAH electronic health record (EHR).
- When the hospice physician serves as the Consulting Physician, visits will be documented in the SVNAH EHR and recorded on the time sheet. The consulting hospice physician will visit patients who have elected ELOA to establish:
- Hospice eligibility
- Mental capacity
- Physical ability to self-administer medications
D. Procedure if SVNAH Patient Requests ELOA Information
- If a patient requests information regarding ELOA, physicians, nurses, and staff who choose to participate in ELOA, SVNAH staff shall provide Sutter Health's ELOA Patient Education materials to the requesting patient.
- If a patient requests information about physicians participating in ELOA, the patient should be advised to contact their attending physician.
- If the patient's attending physician declines to participate in ELOA and does not refer the patient to a participating provider, a participating SVNAH hospice physician may be contacted or SVNAH will contact Sutter Health's ELOA Subject Matter Expert team. (See Resources)
E. Procedure if SVNAH Patient Requests an Aid-in-Dying Drug
- If a patient requests an Aid-in-Dying Drug, physicians, nurses, and staff should advise the patient to contact their attending physician.
- If the patient's attending physician declines to participate in ELOA and does not refer the patient to a physician participating in ELOA, the patient's hospice physician may assess eligibility during IDG and chart review prior to referral to Sutter Health's ELOA Subject Matter Expert.
- SVNAH will contact Sutter Health's ELOA Subject Matter Expert team as needed for further information. (See Resources)
- A patient must have medical decision-making capacity and be physically able to ingest the Aid-in-Dying Drug on their own. It may be advisable to have the SVNAH hospice physician assess this eligibility via chart review prior to referring the patient to an ELOA Attending Physician.
- If a patient's hospice physician decides to participate in the provision of the Aid-in-Dying Drug and act as the ELOA Attending Physician, they will need to relinquish their role as the patient's hospice physician. SVNAH will appoint a new hospice physician for the patient.
- SVNAH physicians, nurses, and other staff shall advise the patient about hospice services for ongoing end of life management and supportive care.
- If a home health patient who requests an Aid-in-Dying Drug declines a transfer to hospice, the clinician will coordinate with the clinical manager regarding transferring patient to the Advanced Illness Management (AIM) home health team, if currently not enrolled in AIM. The home health team supporting any patient remaining on home health who is requesting an Aid-in-Dying Drug may request a consult or support from the hospice team.
F. Procedure if SVNAH Patient States Intent to Self-Administer Aid-in-Dying Drug
- The law prohibits any employee, physician, or agent thereof, from assisting the patient with the administration (ingestion) of a prescribed Aid-in-Dying Drug.
- If the patient states intent to take a prescribed Aid-in-Dying Drug, and requests the presence of a member of the SVNAH clinical team, SVNAH may accommodate the patient's request, if possible. SVNAH supervisors will be informed of the patient's request and assist with coordinating any staff presence.
- If the patient requests that an SVNAH staff member be present at the time of ingestion of the Aid-in-Dying drug, the participating staff member may choose to offer support before and/or after ingestion but shall not be present to witness the patient ingesting the drug. Staff members are prohibited from assisting with the preparation or administration of the Aid-in-Dying drugs. Non-participating staff members should refer the patient's request to their supervisor.
- If the patient has any concerns about the medications, side effects, or symptoms, the SVNAH clinician should refer the patient's questions to the ELOA Attending Physician. The ELOA Attending Physician is responsible for having a discussion with the patient about possible consequences or side effects of the Aid-in-Dying Drug. The ELOA Attending Physician may prescribe additional medication to assist with symptom management.
G. Procedures After Self-Administration of Aid-in-Dying Drug
- If an SVNAH staff member receives a request from a patient, family, or caregiver following the ingestion of an Aid-in-Dying Drug, they should discuss this request with the ELOA Attending Physician, immediate supervisor, or administrator on call. All medical needs specific to or resulting from the ingestion of the Aid-in-Dying Drug should be referred to the ELOA Attending Physician. The patient or family may choose to call emergency services for assistance.
- If an SVNAH clinician is present after the patient administers the Aid-in-Dying Drug and the patient experiences symptoms from the medication, the SVNAH clinician may provide clinical support to assist in reducing symptoms within the scope of their license. For example, this may include assisting the patient with taking anti-nausea medication if already prescribed and available in the home.
- The SVNAH staff member may not administer or help administer medication that will lead to the end of the patient's life. This includes providing additional medications with the intent of ending the life of the patient. If an SVNAH staff member is present after the patient administers the Aid-in-Dying Drug and care is needed, care should be rendered within the scope of their professional practice, SVNAH guidelines, protocol, and the patient's plan of care. If there are any questions regarding the appropriateness of care being requested, or if medical assistance is needed, the ELOA Attending Physician should be contacted immediately.
- When an SVNAH patient dies as a result of administering an Aid-in-Dying Drug, supportive services should be provided to the family in accordance with SVNAH protocol. For hospice patients, a bereavement assessment and bereavement care plan with appropriate interventions should be developed. For non-hospice patients, a referral to community bereavement services for the family should be provided.
- For SVNAH physicians, staff, or volunteers, SVNAH will provide appropriate support and resources to address their needs or concerns.
H. ELOA Attending Physician
- The ELOA Attending Physician provides primary responsibility for health care and treatment of the patient during the entire duration of receiving the patient's three requests for an Aid-in-Dying Drug.
- SVNAH hospice physicians may act as the ELOA Attending Physician only if they provide the care under their private practice.
- The patient's oral request for medical aid in dying should be dated and documented in the medical record and will remain valid even if care is transferred to another attending physician.
- The ELOA Attending Physician shall make the initial determination that:
- The patient has Capacity to Make Medical Decisions. The patient:
- Must understand nature/consequence of decision,
- Must understand benefits, risks, and alternatives, and
- May not have a mental disorder impacting their ability to make Informed Decisions. If a mental disorder is indicated, an ELOA Mental Health Specialist assessment is required. The ELOA Attending Physician is responsible for referring patient to an ELOA Mental Health Specialist if a mental disorder impacting the patient's ability to make an Informed Decision is indicated.
- The patient has a terminal disease with a prognosis of six months or less.
- The patient must qualify under all of the requirements of the law. A qualified individual means an adult who has the capacity to make medical decisions, is a resident of California, and has satisfied the requirements of this part in order to obtain a prescription for a drug to end his/her life.
- The patient is making a voluntary decision without any undue influence or coercion. The ELOA Attending Physician must have a private discussion with the patient regarding end-of-life options. An interpreter must be used if there are any potential language barriers.
- The patient is making and able to communicate an Informed Decision. Confirm the patient is fully informed regarding:
- Medical diagnosis and prognosis,
- Potential risks of ingesting the drug (side effects and symptom management),
- Probable result of ingesting the drug,
- Possibility of obtaining the drug but deciding not to take it, and
- The feasible alternatives or additional treatment options.
- The patient has Capacity to Make Medical Decisions. The patient:
- If the ELOA Attending Physician determines the patient
- Is a Qualified Patient,
- Has terminal diagnosis,
- Has Capacity to Make Medical Decisions,
- Is making an Informed Decision,
- Has submitted two oral requests, made at least 48 hours apart and has submitted a written request
- The ELOA Attending Physician must then refer the patient to an ELOA Consulting Physician.
- Before writing the prescription for an Aid-in-Dying Drug, the ELOA Attending Physician must:
- Offer the patient the opportunity to change their mind about receiving or Self-Administering an Aid-in-Dying Drug. This conversation must be presented by the ELOA Attending Physician. The patient may reply to the ELOA Attending Physician verbally or in writing.
- Verify, immediately prior to writing the prescription, that the patient is making an Informed Decision.
- Counsel the patient about:
- Having another person present during ingestion,
- Not ingesting in a public place, but may be self-administered in a health care entity
- Considering notifying their Next of Kin of their decision. The patient's decision to not inform the next of kin does not disqualify the patient from an Aid-in-Dying Drug.
- Participation in a hospice program, and
- Safekeeping of the Aid-in-Dying Drug.
- Confirm all of the following requirements and steps have been met:
- The patient must have submitted two oral requests to the ELOA Attending Physician. The oral requests must be at least 48 hours apart.
- The patient must have submitted a written request for the Aid-in-Dying Drug to the ELOA Attending Physician:
- The request must be made using the CDPH "Patient's Request for Aid-in-Dying Drug" form or be written identically to the form; and
- The request shall be signed and dated by the individual seeking an Aid-in-Dying Drug, in the presence of two witnesses.
- The written request shall be witnessed by at least two other adult persons who, in the presence of the Qualified Patient, shall attest that to the best of their knowledge and belief that the Qualified Patient is all of the following:
- An individual who is personally known to them or has provided proof of identity
- An individual who they believe to be in sound mind and not under duress, fraud, or undue influence
- Not an individual for whom either of them is the ELOA Attending Physician, ELOA Consulting Physician, or ELOA Mental Health Specialist
- Only one of the two witnesses at the time the written request is signed may:
- Be related to the Qualified Patient by blood, marriage, registered domestic partnership, or adoption or be entitled to a portion of the Qualified Patient's estate upon death.
- Own, operate, or be employed at a health care facility where the Qualified Patient is receiving medical treatment or resides.
- Clinicians will follow all applicable privacy policies in regard to release of information to the witnesses.
- Obtain the patient's written consent to contact the pharmacist to inform the pharmacist of the prescription.
- Encourage the patient to complete advance care planning documents, e.g. Advance Directive and/or POLST form, and to have it included in the patient's medical records.
- Document in patient's medical record completion of the above requirements, including indicating the steps taken to carry out the request, and a notation of the Aid-in-Dying Drug prescribed.
- Ensure that the ELOA Consulting Physician's documentation is complete in the patient's medical record. The ELOA Attending Physician must have received the ELOA Consulting Physician compliance form prior to writing the prescription.
- If the ELOA Mental Health Specialist assessment referral is made by the ELOA Attending Physician, the ELOA Consulting Physician, or both, no Aid-in-Dying Drug shall be prescribed unless and until the ELOA Mental Health Specialist determines that the individual has the Capacity to Make Medical Decisions and is not suffering from impaired judgment due to a mental disorder. The ELOA Attending Physician is responsible for ensuring the ELOA Mental Health Specialist's documentation is complete in the patient's medical record before writing the prescription.
- Complete the CDPH "Attending Physician Checklist and Compliance Form" and include them in the patient's medical record prior to writing the prescription.
- Submit a copy of the patient's written request, the physician checklist, and the compliance forms from both the ELOA Attending and the Consulting Physicians to the California Department of Public Health within 30 calendar days of writing the prescription.
- Submit the CDPH "Attending Physician Follow-up Form" to the California Department of Public Health within 30 calendar days of the patient's death.
I. ELOA Consulting Physician
- SVNAH physicians may act as an ELOA Consulting Physician.
- The ELOA Consulting Physician shall:
- Examine both the individual patient and their medical records.
- Confirm in writing the ELOA Attending Physician's diagnosis and prognosis.
- Determine whether the patient has capacity, is acting voluntarily, and has made an Informed Decision.
- If there are any indications of a mental disorder, it is the ELOA Consulting Physician's responsibility to refer the patient to an ELOA Mental Health Specialist for assessment even if a mental health assessment had previously been ordered by the ELOA Attending Physician.
- Complete the medical record documentation of the above requirements.
- Submit the CDPH "Consulting Physician Compliance Form" to the ELOA Attending Physician.
J. ELOA Mental Health Specialist
- Shall examine both the individual patient and their medical records.
- Shall determine:
- Whether the patient has Capacity to Make Medical Decisions,
- Is acting voluntarily, and
- Is making an Informed Decision.
- Shall determine whether the patient is suffering from impaired judgment due to a mental disorder.
- Shall complete the medical record documentation of the above requirements.
- Shall submit the mental health assessment back to the referring physician.
K. Delivery of an Aid-in-Dying Drug
ELOA Attending Physician Delivery Methods:
- The ELOA Attending Physician may dispense the Aid-in-Dying Drug directly to the patient, including ancillary medication intended to minimize the qualified individual's discomfort, if the ELOA Attending Physician:
- Is authorized to dispense medicine under California law.
- Has a current United States Drug Enforcement Administration (USDEA) certificate.
- Complies with any applicable administrative rule or regulation.
- With the qualified individual's written consent, the ELOA Attending Physician may contact a pharmacist, inform the pharmacist of the prescriptions, and deliver the written prescriptions personally, by mail, or electronically to the pharmacist.
- The ELOA Attending Physician may NOT give the patient the Aid-In-Dying prescription.
L. Disposal of an Aid-in-Dying Drug
- SVNAH will instruct the patient and family regarding disposal of unused Aid-in-Dying Drug that complies with the instructions contained in the SVNAH Home Use and Disposal of Controlled Substances Policy.
- After the death of the patient, any unused Aid-in-Dying Drugs prescribed pursuant to ELOA shall be disposed of by delivering it to the nearest qualified facility that properly disposes controlled substances or, if none is available, shall dispose of it by lawful means in accordance with guidelines promulgated by the California State Board of Pharmacy or a federal Drug Enforcement Administration approved take-back program.
- Sutter Health ELOA Advisory Team: ELOAct@sutterhealth.org
- Sutter Health Subject Matter Expert Team: ELOAct@sutterhealth.org
- Sutter Health Program in Medicine and Human Values Ethics Hotline: (415) 600-3991
- Sutter Health Human Resources
- Reviewed and approved by the Sutter Care at Home Bioethics Committee 3/23/2021
- Reviewed and approved by Sutter Office of General Counsel 3/17/2021
An adult is 18 years of age or older.
An aid-in-dying drug is prescribed by an attending physician to patients who qualify under the law to administer it to themselves, bringing about their own deaths.
The attending doctor has primary responsibility for the patient’s healthcare and treatment of that patient’s terminal disease.
The attending physician checklist and compliance form is a document created by the End of Life Option Act to specify all of the attending doctor’s requirements under the law.
Capacity to make medical decisions is the ability to understand the nature and consequences of a healthcare decision as well as its significant benefits, risks and alternatives; and the ability to make and communicate an informed decision to healthcare providers.
A consulting doctor is a specialist or other qualified doctor who, independent from the attending doctor, can make a professional assessment of a patient’s terminal disease.
A physician is a doctor of medicine or osteopathy currently licensed to practice medicine.
Self-administering is a patient’s conscious and physical act of taking and swallowing the aid-in-dying drug to bring about his or her own death.
A terminal disease is an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, result in death within six months.