As Aid-in-Dying Bills Become Law, What is the Role of Health Decision Making?

By: Marie Chesaniuk & Lisa Henderson | Published: April 13, 2017

California Gov. Jerry Brown signed the “End of Life Act” on October 5, making it legal for doctors in California to prescribe life-ending drugs to terminally ill patients who choose to die. Oregon, Washington, Vermont, and Montana have passed similar laws, and 23 other states have aid-in-dying bills in their legislatures.

Rates of desire for death among terminally ill patients vary according to population and assessment methods, but they have been estimated at 17-45%, including fleeting desire to die. These estimates are consistent with the fact that a minority of terminal patients in Oregon request lethal prescriptions. Most, but not all, of these patients go on to use their prescriptions.

End of Life Act Details

  • Two California doctors must agree the patient has 6 months or less to live
  • Patient must be mentally sound
  • Doctor and patient must have private consultation to prevent coercion
  • Patient must affirm decision 48 hours in advance
  • Patient must administer the lethal dose himself or herself, without assistance

Correlates of the desire to die among terminally ill patients include major depression, hopelessness (independent of major depression), perceiving oneself as a burden to others, poor family cohesion, and having both a small number and a poor quality of social supports.

It is impossible to determine the “efficacy” of aid-in-dying policies using ordinary case-comparisons of patients who chose to die versus those who did not. However, there are other things we can do as professionals. When a patient expresses desire to die, we can assess the underlying reasons in an effort to present all available options. And we can build an evidence base for how to best support patients and providers in this process.

Shared decision making research could increase insight into the role of family functioning and burden perception on desire to die. Better quality social support may prevent patients from developing a desire to die. Effects of intervening on predictors of patient desire to die could guide clinical decision making. Research on doctor-patient communication might inform how providers discuss this subject. Providing patients the best opportunity to make a well-informed decision is important to our role as health professionals.

We must also understand ourselves. Why do (or don’t) we support patients in this decision process? What assumptions do we make about patients’ desires to die? About their medical and mental conditions? As scientists and practitioners, we must be open to considering our work differently.

Our way forward must include integrating mental health care into primary care delivery and developing effective assessments of the desire to die. These are not simple or easy goals, but it is our duty to improve and evolve the ways in which we serve the public.

What health decision making research is most critical, right now, for helping patients better navigate aid-in-dying conversations and options? Tell us what you think by answering the poll to the right. Then view the results and join our LinkedIn discussion.