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Life and Death Decisions

We’ve previously discussed the importance of making decisions about your life ahead of time, but what about decisions about your death? Your priorities for care during the end of your life may be quite different from what you have had previously and from what your family would want. Even if you may be very ill, as long as you are still capable everyone needs to know that final decision about your care is yours. Sometimes this requires you to be assertive about what your wishes are.

While your healthcare providers may know what is best for your medical condition, only you know what is best for your overall well-being. This includes the choice to refuse further medical care. You may even consider asserting your right to die, if you live in a state that allows medical aid in dying.

If you have granted your Healthcare Proxy the ability to make life and death decisions, much of this section will apply to them as well.

Enough Is Enough, No More Treatment

When you are ready, you can make the important decision that it is time to stop or refuse new treatments for your condition and focus on making your end of life easier. This may include stopping other life-sustaining treatments, such as tube feeding or IVs if you are not able to eat or drink.

There are many reasons you may feel your current care is no longer needed or wanted. The care may be:

  • no longer working or not working well enough to make a significant difference in quality of life;
  • doing more harm than good, such as being too uncomfortable to enjoy things; 
  • needlessly prolonging your illness and pain;
  • keeping you in the hospital or other facility and limiting your ability to be with family;
  • chronic medications that don’t make sense anymore, such as cholesterol-lowering drugs;
  • too expensive for the benefit they provide; and/or
  • against your faith or other beliefs, such as blood transfusions.

After you have committed to your decision, talk to your healthcare providers. Depending on your circumstances, they may be able to help you understand the realities of your situation and assist you with the decision, give you their medical advice on alternate treatment and your prognosis, provide you with the options for comfort or palliative care, and possibly help explain your choice to your family.

You must then take the difficult step of talking to your family and caregivers about how you would like to experience your final days. Each person will react differently to this, but you can reassure them this is what is best for you. You may also need to prevail upon them that only you can make such choices about your end of life care and it is solely your right to do so.

If you think your healthcare provider will be reluctant, it may be better served to work things out with your family first and then speak with your provider as a united front. It is a deeply personal choice, and only you will be the best one to know which approach may work better for your situation.

Once you have made your choice, have your healthcare providers support, and, hopefully, have the blessing of your loved ones, work with them to settle on the most compassionate and appropriate care that will make your remaining days as comfortable and fulfilling as possible. Some call this process “Dying Well.”

The “Hospice/Palliative Care” and “Seeking Emotional Support and Grief Counseling” sections will have details on the types of care available to you to make the most of your last days.

It is your right to make the final decision on any treatment you are offered, but the choice to stop or refuse treatment of a terminal illness is often resisted by healthcare providers and family. When this happens, you should be sensitive to their position, but also advocate for your right to decide how to experience the end of your life. Although this is not a debate, communication is the key.

While it is ultimately your call, it will be best if everyone comes around to the same page, but it may be a gradual process. To be sensitive to their position, you must first listen carefully to what they say so you know what points you have to make. Do research if you have to, but the most important thing is to intimate to them that this is about your wishes and what is best for you.

You may reach a point where you just want it to end, but merely stopping treatment will not result in your immediate death. You will want your physician to help you die. Only you can request this; your Healthcare Proxy cannot under any circumstances. As you can imagine, it is very controversial.

  • While most religions condemn suicide, it is not illegal in the United States.
  • It is illegal for anyone to assist in a suicide, unless you have a terminal illness and live one of the few states that allow a physician to aid you in dying. 

While people with a painful terminal condition may eventually find pain medication ineffective, they are rarely among those who request physician-assisted death, nor are those who have intractable suffering for other reasons or are experiencing depression. The most common feelings associated with the desire for death are a loss of dignity, the inability to experience any joy or pleasure, and a loss of control of their lives.

In states with physician-assisted death, frequently referred to as “medical aid in dying,” it is a strictly controlled process that protects both you and your physician from abuse or liability. The paperwork alone can be a hurdle, but there are safeguards in place, with little variation among states where it is legal.

These are the measures most states have to assure that physician-assisted death is right for you.

  • Not only must you have a terminal condition, the condition must be:
    • confirmed by both your attending physician and a consulting physician;
    • not responding to appropriate treatment; and
    • predicted to be fatal within 6 months.
  • You must be deemed mentally capable of understanding the decision. Although you may not need a formal evaluation, many physicians will request this if they are not absolutely sure of it.
  • While depression is normal when you have a terminal illness, you cannot make the decision if you have major depression or other diagnosed mental illness, as it may interfere with your ability to make appropriate decisions. Your primary physician may or may not request a consult with another physician or hospice to confirm this.
  • The prescribing doctor must confirm that you are not being coerced or unduly influenced by others when making the request.
  • You will need to make the request at least twice 15 or more days apart to confirm your resolve. Your final request must be in writing, using a state-specific form, and signed by two witnesses, who can’t be beneficiaries in any will or trust.
  • You must be able to administer the medication to yourself. It is considered murder for ANYONE else to give it to you.
  • You must be informed of any alternative treatment that may prevent you from needing the lethal medication, including care to relieve pain and keep you comfortable.
  • You will be asked to notify your next of kin of the prescription request, although you are not required to.
  • You can withdraw your request at any time before your request is granted. Although after you have received the prescription, the choice to take it is entirely yours.

In states where this is legal, and you meet the requirements, your physician can prescribe a medication that will quickly result in your death, although it does not always happen this way.

Although your physician makes the determination whether or not you will get the prescription, once you have it you then have the choice of taking it when the time comes. It is illegal for family members to coerce or otherwise force you to take it before you are ready. It is also against the law to give away your medication to someone else, even if they have a terminal illness. About two-thirds of people who get the prescription will eventually make the choice to take it. For the remainder that do not, it is often enough to know that they are in charge of their experience and have the option available to them.

Not all physicians are comfortable with providing aid in dying. Even those physicians who do this willingly can have mixed feelings and experience guilt. If yours is not supportive, rather than trying to urge them to do so, you should seek out a physician who is willing to assist you.

There are studies that show that stopping eating and drinking or sedation may be a more comfortable and peaceful way to die.

In 2006, the Supreme Court chose to make the legality of physician-assisted death a states matter (Gonzales v. Oregon, 546 U.S. 243). As of 2020, ten states currently have laws that allow physician-assisted death for terminally ill patients. Three states have pending legislation. Each state has slightly different rules about which patients qualify for this.

Before proceeding with this process there are other things to consider about suicide which might affect your decision.

  • What will be the effect on contracts, wills, insurance, and annuity policies?
  • The act usually provides immunities, liabilities, and exceptions that allow your healthcare provider to decline your request.
  • There may be claims against your estate for costs incurred by the government if you ingest the covered medication in public.
  • There may be criminal penalties if the provisions of the law are not followed precisely, but they are difficult to enforce.
California – In Effect

The “End of Life Option Act” 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, as defined, to make a request for a drug prescribed pursuant to these provisions for the purpose of ending their life.” This act will allow physician-assisted death for adult California citizens under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific forms that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination, if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

The Act went into effect June 9, 2016.

References

Colorado – In Effect

The “Access to Medical Aid In Dying” was approved by voters in 2016. This amends Colorado statutes to include the Colorado “End-of-life Options Act,” This act authorizes a physician to prescribe medical aid-in-dying medication to adult Colorado citizens under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

There are criminal penalties for tampering with your request for medical aid-in-dying medication or knowingly coercing you to request the medication.

The law went into effect on December 16, 2016.

References

Connecticut – Pending as of July, 2020

An Act Concerning Aid In Dying for Terminally Ill Patients is still under consideration in the Connecticut legislature. This act will allow physician-assisted death for adult Connecticut citizens under the following conditions.

  • You give two written requests to the doctor, signed in front of two qualified, adult witnesses, at least 15 days apart.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination if either doctor feels the patient’s judgment is impaired.
  • You must be able to self-administer the medication.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

References

District of Columbia – In Effect

The “D.C. Death with Dignity Act” authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in Washington under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The state sets out the specific form that you must use along with instructions to fill it out.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

The Act went into effect on February 18, 2017; implementation started on June 6, 2017.

References

Hawaii – In Effect

The “Our Choice, Our Care Act” and its amendment authorizes a physician or an advanced practice registered nurse to prescribe medical aid-in-dying medication to adult citizens in Hawaii under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart, unless you are not expected to survive the waiting period.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out a specific written request form and final attestation form that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

It went into effect on January 1, 2019.

References

Maine – In Effect

The “Maine Death with Dignity Act” authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in Maine under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.  

The act went into effect January 1, 2020.

References

Massachusetts – Pending as of July, 2020

The Massachusetts End of Life Options Act and Companion bill are still under consideration in the Massachusetts legislature. This act will allow physician-assisted death for adult Massachusetts citizens under the following conditions.

  • Individuals are not eligible for medical aid in dying because of age or disability.
  • You must make two separate requests for the medication at least 15 days apart, one oral and one written.
  • The written request must be witnessed by two people, one of whom can’t be a relative or someone who stands to benefit from the person’s estate.
  • Two doctors must confirm you have a terminal disease that will result in death within six months..
  • The attending physician must inform you about all of their end-of-life care options, including hospice and pain or symptom management.
  • Medication can’t be prescribed until your mental capacity is confirmed by a licensed mental health specialist.
  • Anyone attempting to coerce a patient is subject to criminal penalties.
  • You must be able to self-administer the medication.
  • Life insurance payments can’t be denied to the families of those who use the law.

References

Montana – In Effect

Montana does not have a death with dignity statute. However, in 2009, the Montana Supreme Court ruled that physicians may assist terminally ill adult patients in ending their lives by prescribing lethal medications to be self-administered by the patient.

References

New Jersey – In Effect

The “Aid in Dying for the Terminally Ill Act” authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in New Jersey under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that the patient must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

The Act went into effect on August 1, 2019.  A temporary restraining order was issued August 15th, but was lifted August 27th. In the 2020 session, a group of legislators introduced a bill aiming to repeal the state’s new assisted dying statute, but there is no information on the current status.

References

Oregon – In Effect

The Death with Dignity Act authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in Oregon under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart. A 2019 amendment waives the 15-day waiting period if the doctor has confirmed that the patient is fewer than 15 days from death when making the initial verbal request..
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that the patient must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).

This has been the law in Oregon since 1997.

References

Oregon’s Death With Dignity Law. NOLO website. Updated: July 24, 2019. Accessed: April 15, 2020.

Pennsylvania – Pending as of July, 2020

The Compassionate Assisted Dignified Death Act is still under consideration in the Connecticut legislature. This act will allow physician-assisted death for adult Pennsylvania citizens under the following conditions.

  • You give two written requests to the doctor, signed in front of two qualified, adult witnesses, at least 15 days apart.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

References

Vermont – In Effect

The Death with Dignity authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in Vermont under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.  

The law has been in effect since June 30, 2017.

References

Washington – In Effect

The “Death with Dignity Act” authorizes a physician to prescribe medical aid-in-dying medication to adult citizens in Washington under the following conditions.

  • You give two oral requests to the doctor at least 15 days apart.
  • You give a written request to the doctor, signed in front of two qualified, adult witnesses. The law sets out the specific form that you must use.
  • The prescribing doctor and one other doctor confirm you have a terminal disease that will result in death within six months.
  • The prescribing doctor and one other doctor determine that you are capable of making and communicating medical decisions.
  • You have a psychological examination by a physician or a mental health nurse practitioner if either doctor feels the patient’s judgment is impaired.
  • The prescribing doctor confirms that you are not being coerced or unduly influenced by others when making the request.
  • You must be able to self-administer the medication.
  • The prescribing doctor informs you of any feasible alternatives to the medication, including care to relieve pain and keep you comfortable.
  • The prescribing doctor asks you to notify their next of kin of the prescription request (they cannot require you to notify anyone, however).
  • The prescribing doctor offers you the opportunity to withdraw the request for aid-in-dying medication before granting the prescription.

This went into effect in 2009.

References

Two states have laws that are not currently in effect. Many others are working on legislation, while about half of the states are not. You can go to Death with Dignity Acts (Updated: April 16, 2020), Death With Dignity Laws in Your State, and State-By-State Death With Dignity Legislation to find out what your state is doing. 

Resources

General References