California’s End of Life Option Act began in June of 2016 and was modified in 2022 to allow a shorter minimum interval (48 hours rather than 15 days) between the two verbal requests and required providers to make clear to their patients whether they participate—and for those who do not participate, they are required to record the timing of an initial request so that the time from request to receiving MAID (Medical Aid in Dying) was not delayed. Since this change, there has been a slight uptick in requests for MAID (Medical Aid In Dying) in 2022 as opposed to prior years. The required data are reported by CDPH every July with the most recent report of July 2023 available online, click here.

Our act is modeled after the Oregon law and has multiple safeguards including the requirements for intact decisional capacity, age > 18 y/o, a life expectancy < 6 months, ability to self-administer, and no evidence of coercion. In 2021, there were 863 written prescriptions and 522 deaths attributed to MAID. In 2022, the numbers were 1270 and 853, respectively. Considering that 308,015 deaths occurred in 2022 in California, this amounts to ~ 0.28 % of deaths occurring via MAID. Of those, 95.4% were receiving hospice and/or palliative care. Malignant neoplasms are the most common terminal diagnosis (66%) followed by cardiovascular disease (11.8%). The decedents were 89% white, 51.6% male, and 76.4% had some college education. In 2022, there were ten MAID deaths in California nursing homes, 71 in assisted living communities, 12 in inpatient hospice residences, three in Acute Care Hospitals, and 753 in private homes.

While the California Medical Association moved to a neutral position on MAID in 2015, the American Medical Association remains generally opposed to MAID (which they continue to refer to as Physician-Assisted Suicide). However, they now recognize that it may be morally acceptable for individual physicians to participate in the process: “Where one physician understands providing the means to hasten death to be an abrogation of the physician’s fundamental role as healer that forecloses any possibility of offering care that respects dignity, another in equally good faith understands supporting a patient’s request for aid in hastening a foreseen death to be an expression of care and compassion.” While CALTCM does not have a formal policy statement on MAID, AMDA – The Society for Post-Acute & Long-Term Care Medicine approved a policy opposing MAID in 1997, and it has not been modified or sunsetted.

I am glad that California has not moved the guardrails in this act to permit broader access to MAID. A recent GeriPal podcast focused on, “What is going on with MAID in Canada?” (https://geripal.org/tag/podcasts/ ), a country with a similar population to California, sounds an alarm about the dangers of too easy access to assisted dying. Since Canada legalized assisted dying in 2016, the number of people who have availed themselves of assisted dying (which in Canada includes euthanasia, or physician-administered lethal medication) has increased from initially 1000 annually, progressively up to 13,000 in 2022, which represents 4% of the deaths in Canada. From the start their law had major differences from California’s. To be eligible, a patient must have a grievous and irremediable condition, including disability, and there was no requirement for self-administration or a terminal illness. In fact, most deaths have occurred by provider administration.

Canada’s legislature has put a planned expansion to include mental illness as an acceptable reason to request MAID on hold until March of this year. The Canadian parliament will soon consider further expanding access to include minors. In the podcast, three Canadian physicians voice concerns about the potential abuses of this easy access such as a Canadian requesting it because he could not afford housing. Other voiced concerns included the potential for this option offered to actively suicidal persons and the disproportionate number of women experiencing assisted dying (66% vs 48.4% in CA). Canada does not have the robust reporting system mandated in our CA law, so the data are not readily available for assessing hospice, palliative care, disability benefits, and social/mental health services for those requesting MAID.

As providers, we should be advocates for high-quality medical care, including palliative care, that uses an interdisciplinary team approach for those suffering with complex medical and psychosocial problems and supports their informed decision-making regarding end-of-life choices.