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

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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

• 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)

Objectives

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Case

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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%).

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

Who Utilizes MAID-2017 data Oregon

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MAID data from Oregon

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PATIENT CENTERED Response to SUFFERING

Autonomy, Activities, Dignity

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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

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• 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

Treatments that may cause suffering

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• 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

Patient and Family Issues

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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

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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

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

MAID Process

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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

MAID Process

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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

MAID Process

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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

MAID Process

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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)

MAID Process

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• 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

MAID Process

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• 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

General Protocol Instructions

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• 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)

Secobarbital Protocol

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• 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

DDMP2 Protocol

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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

References

The Nature of Suffering and the Goals of Medicine; N Engl J Med 1982; 306:639-645; DOI: 10.1056/NEJM198203183061104 Clinical Criteria for Physician Aid in Dying; Journal of Palliative Medicine Volume 19, Number 3, 2016; Mary Ann Liebert,Inc.; DOI:10.1089/jpm.2015.0092 https://www.liebertpub.com/doi/pdf/10.1089/jpm.2015.0092 Implementing a Death with Dignity Program at a Comprehensive Cancer Center; N Engl J Med 2013; 368:1417-1424;DOI: 10.1056/NEJMsa1213398 http://www.nejm.org/doi/full/10.1056/NEJMsa1213398#t=article http://www.ericcassell.com/download/ReliefOfSuffering.pdf