The California End of Life Option Act: A case series of 77 consecutive cancer patients.

Abstract

e24041 Background: California is 1 of 10 US states with legalized medical assistance in dying for the terminally ill. There is little published on the actual experience of assisting cancer patients with this intervention. Methods: 77 consecutive cancer patients for whom “End of Life Option Act” (EOLOA) prescriptions were written by one MD (onc/palliative/hospice) from 2019-2026. Results: Of 77 prescriptions written, 43 took the drugs. There were 14 prostate, 12 lung, 6 breast, 5 colorectal, 4 oral/pharynx. “Second MDs” included med oncs, PCPs, rad oncs, hospitalists, nursing home MDs, surgeons. Most frequently prescribed was a combination of 1 gm morphine, 1 gm diazepam, 50 mg digoxin, and 3.75 gm amitriptyline, all powdered by one pharmacy. At the home an 8 oz slurry was made, with vanilla ice cream and chocolate syrup to mitigate bitterness. All patients took antiemetics 30 min prior. All were on hospice at time of ingestion, and none were motivated by uncontrolled pain. The MD was at the home for 58% of patients at time of ingestion, and 21% at time of death. Patients were asleep 20 min after ingestion (5-90) and died a mean of 4.2 hours (range 1-22) after ingestion. Several patients were unable to ingest the full slurry; all succumbed. There were 3 subgroups: those who took the meds immediately (days), those who intended to after addressing affairs (weeks to months), and those who never intended to but wanted the security of having them. There was gratitude at all stages; “relief” at having the meds was the word used most. No patient who took the medications had a “bad death.” At times there was unexpected value. Family were often brought together when it would not have been feasible otherwise. The dying process was “normalized.” Physician and/or hospice team presence and involvement were instrumental in providing bereavement counseling. Minutes after one woman died, her son in law, silent throughout the process, opened up for the first time regarding the recent suicide of his own son. One woman with metastatic lung cancer had decisively quit treatment and follow up, convinced it was ineffective; after obtaining the EOLOA medications, she gradually though reluctantly was convinced to reconsider re-evaluation, which ultimately led to a return to treatment (with a 4 year-long response to immunotherapy), still alive and NED. Conclusions: 1) The EOLOA intervention was without serious complication in all 77 cancer patients; 2) There were 3 subpopulations of patients with regard to intent and outcome; 3) Virtually all patients and families were grateful; the anxiolytic effect of having the meds was obvious; 4) There appeared to be much benefit in the MD assisting with prep of meds and facilitating on-site bereavement; 5) There were patients/families for whom the process was clearly therapeutic; 6) MDs and their teams are encouraged to consider playing a meaningful role in their patients’ end of life care for patients who wish to implement the EOLOA.