Medical Aid in Dying in Vermont Diana Barnard, MD Assistant - PowerPoint PPT Presentation

UVMHealth.org/MedCenter Medical Aid in Dying in Vermont Diana Barnard, MD Assistant Professor of Family Medicine Division of Palliative Medicine University of Vermont Medical Center Diana.Barnard@UVMHealth.org Paul Unger, MD, F.A.C.P Associate Professor or Medicine University of Vermont Medical Center Champlain Valley Hematology Oncology

Objectives • Identify causes of and ways to respond to suffering at end of life • Recognize qualifying conditions for participation in Vermont’s Medical Aid in Dying Law (Act 39) • Describe specific steps required of physicians who participate in Vermont’s Medical Aid in Dying law (Act 39) 2

Case 4

Medical Aid in Dying in Vermont • Became legal in May, 2013 • VDH issued first report January, 2018 – how many patients have met the requirements of the act – the underlying causes of death – the number of prescriptions that have been filled by qualified patients. • 52 events � 83% of cases are Cancer (43 total cases) � 14% of cases are ALS (7 total cases) � 3% are other causes. • 48/52 Died � 29 utilized the patient choice prescription (60%) � 17 died from the underlying disease (35%); � 1 died from other causes (2%) � 1 unknown (2%).

Who Utilizes MAID-2017 data Oregon Diagnosis: • Most patients had cancer (76.9%), • amyotrophic lateral sclerosis (ALS) (7.0%) • heart/ circulatory disease (6.3%) Characteristics: • Median age 74 years • Married (52.4%, widowed 18.2%) • White (94.4%) • Educated (48.9% had >= baccalaureate degree) https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITY ACT/Documents/year20.pdf 6

MAID data from Oregon 7

Autonomy, Activities, Dignity PATIENT CENTERED Response to SUFFERING 8

Suffering “Suffering is experienced by persons, not merely bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity...” -Eric Cassell, MD, NEJM 1982

Total Suffering

We all Die 11

Treatments that may cause suffering • Ventilators • CPR • Dialysis • Artificial Nutrition and Hydration • Acute Interventions for life threatening conditions – Surgery – Tubes – Stents – Blood Transfusions – Antibiotics • Chemotherapy, Immunotherapy, Hormone therapy – Especially in advanced illness 12

Patient and Family Issues • Explore Values, Goals • Gentle, Honest prognostic information • Explore benefit/burden/goals of Palliative interventions • Priorities • Trade offs • Quantity of Time vs. Quality of Time • Informed Consent • Shared Decision Making • Burden of Uncertainty • Living or Dying 13

Responding to a Request for MAID • See any question as an opportunity • Deepen your understanding • Ask open ended questions • Listen • Explore hopes, fears, worries • Identify and address suffering • Validate concerns • Identify patient strengths, resources • Determine your role, next steps • Use Team (MDs, nurses, SW, chaplains, Pall Care…) • Discuss Hospice

HOSPICE • A powerful program designed to address multi- dimensional suffering and to provide support to dying patients AND their loved ones • Should be discussed with ALL patients in the terminal stage of a life limiting illness • Important source of support w/n MAID is used – to address and treat suffering – for many circumstances where death is not hastened – to assist with after death care – for any unexpected circumstances – for bereavement support

Clinical Criteria 17

Responding to a Request for MAID • Discuss other options your patient has to maintain control and to minimize suffering • Normalize option to decline or to stop burdensome treatments which may prolong suffering near end of life – DNR, DNI, No MICU, dialysis, artificial nutrition • Explore opportunities and burdens of palliative interventions – chemotherapy, tubes, drains, stents, hospitalizations • Consider alternatives to MAID – Palliative Sedation – Voluntary Stopping Eating and Drinking (VSED)

Responding to a Request for MAID • Assess eligibility • Assess Understanding of the law • Determine your role, consultants • Remind your patient of the time, process • Prepare them for the possibility of losing clinical eligibility during the process • Assure them you will address suffering regardless of what happens during the process • Schedule follow up

Consider who is NOT a Good Candidate • When the patient has diminished capacity • When the patients capacity is likely to diminish • Significant or progressive dysphagia • Frequent or Uncontrolled vomiting • Significant or progressive GI function, absorption issues • Trajectory of illness too fast to complete process • Location of care dose not allow the process • Any challenges in following specific guidelines

MAID in Vermont-Eligibility • Terminal Illness, <= 6 month Prognosis* • Vermont Resident, age >=18 • Under the care of a Vermont licensed Physician • Capable of making an informed decision • Able to self administer medication to hasten death • Able to make an informed, voluntary request

MAID Process Prescribing Physician evaluates patient to confirm: – Terminal condition – Prognosis <6 months – Capable – Informed – Voluntary – Vermont resident – At least 18 years old Prescribing MD receives first request >= 15 days later, receives second request 22

MAID Process Prescribing Physician provides to Patient verbally and in writing – Diagnosis – Prognosis (including uncertainty) – Range of treatment options – If not on Hospice, other treatments, including Palliative Care – At the time of second request, remind of the right to rescind at any time – Discuss probable result of taking medication, including possible complications Prescribing Physician confirms judgment not impaired 23

MAID Process Prescribing Physician refers patient to Consulting Physician Consulting Physician confirms : • – Diagnosis – Prognosis <6 months – Capable – Informed – Voluntary – Judgment not impaired Prescribing Physician receives written request – Witnessed by two uninterested parties, 18 or older – Patient understanding nature of document – Patient was free from duress, no undue influence 24

MAID Process If either physician feels judgment impaired – STOP process (most common) – If doubt about impairment of judgment, referral to evaluate • Psychiatrist • Psychologist • Licensed Clinical Social Worker 25

MAID Process Prescribing Physician – With permission, confer with PCP – Remind patient of ability to rescind request – Assure all steps have been followed – Wait at least 48 hours after all of above complete – Write prescription • Contact pharmacist directly • Deliver the prescription directly to pharmacy • Identify specific individual to pick up medication (patient or agent) 26

MAID Process • Prescribing Physician – File a report with Vermont Department of Health – http://www.healthvermont.gov/systems/patient-choice-and-control- end-life/forms-patients-and-physicians – Within 10 days of patient’s death or 60 days of writing prescription, complete follow up form regarding status of ingestion 27

General Protocol Instructions • Well informed patient • Hospice admission strongly encouraged • COLST: DNR, DNI • Informed support team, family • Discontinue any medications interfering with absorption • Clear liquids, no fatty foods for 6 hours before ingestion • Pre medicate with anti-emetics (45-60 minutes) • Self ingest quickly (60-90 seconds) • Remain in a reclined position • Prepare for variability in time of unconsciousness, death • Back up plan for unexpected complications 28

Secobarbital Protocol • Pre-medicate 45-60 minutes prior with – Ondansetron 8 mg AND – Metoclopromide 20 mg • Then follow with – Secobarbital 10,000 mg – Suspended in 4-6 ounces of clear liquid • Highly effective – unconscious in 5-15 min, dead in 15-120 minutes • Expensive ($3,700) 29

DDMP2 Protocol • Pre-medicate 45 minutes prior with – Haldol 2 mg AND – Metoclopromide 20 mg • Then follow with compounded mixture in 4-6 ounces buffered pH neutral solution (water, with or w/o flavor) – Diazepam 1 gram Digoxin 50 mg Morphine Sulfate 15 grams Propranolol (short acting) 2 grams • Highly effective – unconscious in 15 min, dead in 45-120 minutes • More cost effective $700 • Requires COMPOUNDING pharmacy 30

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References Oregon Public Health Division: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/ Pages/index.aspx Washington State https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct/DeathwithDignity Data Compassion and Choices: http://www.compassionandchoices.org/ Compassion and Choices Doc2Doc https://www.compassionandchoices.org/research/doc2doc- program/ Patient Choices Vermont http://www.patientchoices.org/ Vermont Department of Health http://www.healthvermont.gov/systems/patient-choice-and-control-end- life/forms-patients-and-physicians Vermont Law/Act 39 http://www.leg.state.vt.us/docs/2014/Acts/ACT039.pdf