Theres so much more going on here than giving patients access to life-ending drugs, said Cassie Sauer, spokeswoman for the Washington State Hospital Association. There are a number of big issues and decisions to be made.
These include whether to allow patients to end their lives on the premises, whether on-site pharmacies should dispense the lethal medications, what role physicians should play and how best to communicate policies to patients and staff.
The law makes Washington state only the second, after Oregon, to allow patients diagnosed with less than six months to live to request and self-administer lethal medications prescribed by a physician to end their lives. Hospitals, physicians, pharmacists, hospice workers and other providers can decline to participate.
A number of hospital systems contacted last week said that they have not yet decided whether they will allow the medication to be administered on their premises.
Physicians employed or contracting through hospitals can give the medication on their own time but hospitals often carry liability insurance for physicians in the state, Sauer said, so a hospitals decision can influence overall provider participation. Regulators, too, are rushing to meet the deadline. The final rules on the law were issued on Feb. 20 by the Washington State Health Department.
In recent months, hospital officials across the state have discussed how to approach the law. Southwest Washington Medical Center, Vancouver, just north of the Oregon border, convened a task force of ethicists, medical staff, psychologists and others to make recommendations to the hospital board on how to proceed. Ultimately, the task force recommended the 360-bed hospital prohibit patients from taking the medications on-site to end their lives. The hospital will allow physicians to act as consultants on cases, but discourages them from being the prescribing physician. The hospital board accepted the policy in mid-February.
There was amazing consistency with the staff, said Joseph Kortum, president and chief executive officer of Southwest Washington Medical Center. All of them came out opposed to being involved across the board.
Like in Oregon, under the new Washington state law, adult state residents seeking to end their own lives must be terminally ill with less than six months to live, as verified by at least two physicians, one who acts as the prescriber, and one as a consultant. The two physicians must also verify the patient is competent and that the request for the medication was made voluntarily. The patient must make at least two requests for the drugs, one oral and one written, with a 15-day waiting period between them. The written request must be witnessed by two people, at least one who is not a relative or affiliated with the healthcare facility where the patient is being treated. After the written request is made, the patient must wait 48 hours before receiving the prescription.
The Washington State Medical Association, which opposed the initiative, is now educating members on the detailed requirements of the law, including paperwork that must be filed with the state.
We have chosen not to talk about the nuts and bolts of this, such as what drugs to use, said Cynthia Markus, president of the association and an emergency room physician. I think many times patients look for this because they are afraid they will be in pain or wont receive adequate care. If we do our jobs right, I think we wont need this.
In Oregon, where a nearly identical law has been in effect for 10 years, 341 terminally ill people have ended their own lives through its provisions as of 2007, said George Eighmey, executive director of Compassion & Choices of Oregon, a Portland-based advocacy and referral group tracking the law. In 2006, the Supreme Court upheld the law, giving a boost to the rights of physicians, patients and states in the battle over how much say the federal government has in regulating healthcare (Jan. 23, 2006, p. 6).
Another 200 people have gotten prescriptions for lethal medication under the act but did not use them. Its the comfort of knowing that, if worse came to worse, you have this available to you, Eighmey said.
To date in Oregon, no patients have self-administered the oral medications in hospitals. Overwhelmingly they have died at home, and a handful died in nursing homes or other long-term-care facilities, Eighmey said. Some 750 physicians have participated in Oregon, and 75 pharmacists statewide, he said.
Hospitals still must devise rules on participation. University of Washington Medical Center, Seattle, and its affiliates, including 368-bed Harborview Medical Center, also in Seattle, neighborhood clinics and its physician practice plan will provide all services under the law but individual physicians, pharmacists and other staff can decide not to participate. This is really a patient right, said Johnese Spisso, vice president of medical affairs for the 390-bed University of Washington Medical Center. To best meet the goals of patient- and family-centered care, we want to respect their wishes.
In Seattle, the initiative passed by a wide margin. Some hospitals in other parts of the state are looking at how constituents voted on the ballot measure to help them decide, Sauer said.
Catholic health systems are not participating, but Carl Middleton, vice president of theology and ethics for Catholic Health Initiatives, said the law is an opportunity to strengthen palliative-care programs. The Denver-based system has hospitals in both Oregon and Washington state.
In Oregon, Catholic Health Initiatives developed a so-called Q&A approach to assist employees who might be asked about the law. The system also encouraged patients to create advance directives and use physician orders for life-sustaining treatments, which carry more weight than advance directives when it comes to using extreme or heroic measures to keep a patient alive.