Medical Staff Affairs

Medical Aid in Dying for the Terminally Ill

A NJ law passed in April, the Medical Aid in Dying for the Terminally Ill Act, will take effect August 1, 2019. This law allows capable terminally ill patients to obtain and self-administer prescribed lethal doses of medication to bring about their own humane and dignified death. The following is a broad overview of the law’s stipulations and some guidance for physicians.

The patient must be:

  1. At least 18 years old;
  2. A NJ resident;
  3. Mentally capable of making and communicating health care decisions (Depression may make someone incapable of making this decision and a mental health care professional referral may be made to evaluate whether the patient is capable);
  4. Diagnosed with a terminal illness that will result in death within six months.

The patient must:

  1. Make two verbal requests to the doctor, at least 15 days apart
  2. Make a written request to the doctor, signed before two witnesses (one of whom is not a relative, not entitled to the patient’s estate, and not an owner, operator, employer, or resident of a health care facility at which the patient is receiving medical treatment). The attending physician cannot serve as a witness. The specific form of this request is attached.

Physician requirements:

  1. The attending physician and prescribing doctor and one other consulting doctor must confirm the diagnosis and terminal prognosis;
  2. Arrange a psychological examination if there is any question of the patient’s capacity and/or depressed state;
  3. The attending prescribing doctor and consulting doctor must confirm that the patient has made an informed and voluntary request and is not being coerced and unduly influenced by others;
  4. The attending prescribing doctors must counsel the patient about alternatives to the medications, including therapies to reduce pain and suffering, palliative care treatments and hospice care;
  5. The attending prescribing doctor must ask the patient to notify the next-of-kin of the prescription request (They cannot require it);
  6. The attending prescribing doctor must offer the patient the opportunity to withdraw the request before granting the prescription and advises the patient that they can rescind their request for aid in dying medication at any time;
  7. Document all of the above in the chart.

The physician cannot:

  1. Administer or assist the patient in taking the medications. The attending prescribing doctor can give a prescription, but the patient must be capable of self-administering the medication. (This law does NOT allow assisting in suicide, a criminal offense, and a physician administering or assisting in taking medications DOES constitute a violation of the law.)
  2. Accept the verbal or written requests from another person such as a health care proxy, family member, or messenger.

What if I have moral objections or do not feel able to help the patient with the provisions of this law?

As in other instances where moral and religious objections exist, any doctor may excuse themselves from participating. There may also be circumstances where physicians don’t have a prior relationship with the patient or do not know the patient well, and therefore don’t feel comfortable acting as the attending prescribing physician.  They must, however, offer other doctors who can help the patient with their rights under NJ law.

 

What is Englewood Health doing?

EH is currently developing a policy regarding this law for both the inpatient and outpatient setting.  This policy will be communicated to the medical staff as soon as it is finalized, and updated as needed.  Our medical ethics team is also meeting regularly to discuss the implications of this law for our organization.   Information is rapidly evolving in the state as all organizations are working to understand the interpretation of the law, and how it will be implemented in NJ, in physician practices, and whether it will be implemented in the hospital setting.

 

What are the recommended medications for medical aid in dying?

There is not a clear consensus on the medications. However, some recommendations include:

  • Secobarbital: This is an older barbiturate medication that is easy to ingest, lacks significant side effects, and works rapidly. The cost of approximately $3500 may be prohibitively expensive for some patients and insurance will generally not cover these medications.
    • Dose: 100 mg tabs.  Take 90 tabs (9 grams).  Mix powder from capsules with 4 oz of water and consume within 2 minutes
    • Pre-medicate with ondansetron 8 mg and metoclopramide 20 mg 45-60 minutes before ingestion.
  • DDMP (Digoxin, Diazepam, Morphine, and Propranolol): This combination cocktail requires a compounding pharmacy.
    • DDMP 1: Morphine Sulfate 10 grams, Diazepam 1 gram, Propranolol 2 grams, and Digoxin 50 mg
    • DDMP 2: Morphine Sulfate 15 grams, Diazepam 1 gram, Propranolol 2 grams, and Digoxin 50 mg

 

What if I have questions or I have a patient requesting a prescription for aid in dying?

The NJHA has recently published the following toolkit:
http://www.njha.com/resources/toolkits/the-nj-aid-in-dying-for-the-terminally-ill-implementation-toolkit/ 

 

In addition, the EH palliative care team can be reached at (201) 894-3896. Palliative Care at Englewood Health: Why, When, and How and the following resources are available for any of our providers who have questions:

Vinnidhy Dave, DO: Director of Palliative Care Medicine

o   Vinnidhy.Dave@EHMCHealth.org

o   201-894-8039 or 201-894-3896

 

Hillary Cohen, MD: VP of Medical Affairs

o   Hillary.Cohen@EHMCHealth.org

o   201-894-3527 (office)/917-886-1361 (cell)

 

Stephen Brunnquell, MD: President EHPN

o   Stephen.Brunnquell@EHMCHealth.org

o   201-894-3325

 

Jeff Nemeth, BsPh, PharmD, MPA: Director of Pharmacy

o   Jeff.Nemeth@EHMCHealth.org

o   201-894-3377