Medical aid in dying law takes effect

For the first time, certain terminally ill patients in Hawaii will have the right to end their lives, but it won’t be easy.

Beginning today, Hawaii residents with a prognosis of no more than six months to live may request lethal prescriptions under the Our Care, Our Choice Act, a controversial law passed last year as an end-of-life option.

But few doctors and pharmacies are willing to prescribe and dispense the medication to hasten death due to ethical reasons, religious beliefs or simply not being comfortable aiding the process.

“It’s very controversial. There are a number of health care providers, nurses and others, who are really uncomfortable about this, so asking anybody to participate as a patient ends their life is a really tough thing,” said Melinda Ashton, chief quality officer for Hawaii Pacific Health, one of the state’s largest health care providers with more than 70 locations that include Kapiolani Medical Center for Women & Children, Pali Momi Medical Center, Straub Medical Center and Wilcox Medical Center on Kauai. “The most recent barrier does seem to be we haven’t yet located a pharmacy willing to provide the medication. Just like other providers, pharmacists have opinions about it as well. It appears that at this point, they’re uncomfortable.”

While most health care facilities have adopted neutral policies on the issue — leaving it up to doctors on whether to participate — hospitals including Hawaii Pacific Health and The Queen’s Medical Center have both said their pharmacies will not fill the prescriptions and that hospitalized patients won’t be able to take the lethal drugs on campus.

In addition, CVS, parent company of Longs Drugs, said pharmacists in Hawaii will follow a “carefully outlined process for the filling of such prescriptions under the limited circumstances” defined by law, but that individual pharmacists can decide whether to fill the prescriptions.

Access to the medications may also be problematic. Manufacturing issues are affecting availability nationwide and drug prices have also increased due to patent issues.

The state Department of Health projects as many as 40 to 70 patients will seek medical aid in dying this year. There are about 10,500 deaths annually in the islands.

“We have had three or four cold calls from interested family members with loved ones with six month or less prognoses. Those relatives were highly motivated and appear to have done their homework in studying the text of the law so we helped as much as we could,” said Lorrin Kim, chief of the DOH Office of Planning, Policy and Program Development. “We are generally aware of three or four others who are very likely to be making their requests the first week of January.”

Patients deemed mentally capable and able to take the medication on their own will be able to request a lethal prescription after two doctors confirm the terminal illness and six-month prognosis. Patients must make two separate appeals for medication, with a 20-day waiting period between the first and second requests. Also required is a written request overseen by two witnesses, one of whom is prohibited from being a beneficiary of the patient’s estate. It is a criminal offense to tamper with a patient’s request or to coerce someone into medically assisted death.

“There’s definitely diversity of opinion. A minority of physicians feel prepared to actually participate in terms of writing a prescription,” Dr. Daniel Fischberg, medical director of the Queen’s Medical Center Pain & Palliative Care Department, said of the more than 1,700 doctors on the medical staff. “There might be some resistance initially.”

Providers as well as the Health Department are offering training sessions to medical personnel on dealing with requests for medical aid in dying. For information, visit health.hawaii.gov/opppd/ococ/.

The DOH recommends patients who are considering the option to concurrently enroll in hospice care, which helps with managing symptoms and assists family members. It also urges patients to inform and designate someone to follow up on their behalf. After taking the drugs, a final attestation form must still be returned to the attending doctor and any remaining medications must be safely disposed of.

The department said patients should find out about the cost and coverage of the drugs under their health plans. Federal law prohibits health plans funded by the federal government from paying for medical-aid-in- dying services or drugs. That includes Medicare, the health insurance program for seniors, and Medicaid, which covers low-income and disabled residents. HMSA and Kaiser Permanente Hawaii said they will cover the drugs under most commercial health plans.

At least one health care provider has agreed to not only fill and pay for the medical-aid-in-dying prescriptions, but has contracted a former oncologist to be one of the two required attending physicians.

Kaiser, the state’s largest health maintenance organization — both a medical provider and insurer — has contracted Dr. Charles Miller as a part-time attending physician to write prescriptions for the program and help educate other doctors and staff, both in and outside of the organization.

Medical-aid-in-dying requirements:

>> Must be adult resident with terminal illness with a six-month or less prognosis to live

>> Deemed mentally capable to make own health care decisions

>> Able to take medication themselves

>> Must make three voluntary death requests — two oral at least 20 days apart and one written signed by two witnesses

>> Two Hawaii doctors must agree to the request (one prescribes the medication, one provides consultation)

>> Must complete final attestation form within 48 hours of ingesting drugs, reiterating intent to take medication

Note: A patient may at any time withdraw the request for drugs or decide not to take the medication

Source: Compassion & Choices Hawaii