California's End of Life Option Act, which went into effect June 9, offers terminally ill people who face painful or prolonged deaths the option of ending their own lives with medication.
The act, signed into law by Gov. Jerry Brown on Oct. 5, allows a mentally capable adult with a life expectancy of six months or less to request "aid-in-dying" medication from his or her doctor for self-administration if suffering becomes unbearable.
Two physicians must agree that the person is eligible, and one of the doctors must sign the prescription after the patient has made three requests -- two oral ones at least 15 days apart and one written on a specific form -- directly to the doctor.
But finding a physician to take part in the process could prove challenging. Each doctor is free to decide if he or she will write the prescription. And some health care systems may prohibit their employees from participating in medical aid in dying, a panel of medical professionals told about 50 people recently at Avenidas senior center in Palo Alto.
For retired Stanford University professor Dick Scott, the quick death of a loved one who chose to take the medication was an eye opener, he said. Scott helped his brother, who had emphysema, to obtain the medication in Oregon while dying.
Watching his brother struggle to breathe, Scott emptied the capsules into a glass of water and handed it to his brother, who was able to drink it, he said.
"It was a very quiet death. It took four minutes," said Scott, the panel moderator and chairman of the advisory council of Avenidas Village program.
But while death came quickly, the process did not come easily, he said. It took more than six weeks to mobilize a network that included the medical team and a pharmacy, get all of the paperwork signed and get the prescription filled, he said.
In California, bringing a network together to provide the medication could be equally daunting.
"There will be some physicians who don't want to have anything to do with it," said Dr. Lew Wexler, professor emeritus of radiology at Stanford Clinics.
Some audience members at Avenidas said they have already run into roadblocks. A woman broached the subject with her physician at Menlo Medical Clinic but was flatly told "no." The physician told her that Stanford Health Care, which runs the Menlo clinic, has a policy against medical aid in dying.
But Wexler said that Stanford doesn't have any such policy. The medical organization is currently discussing its policy in light of the new law, but it hasn't reached any conclusions. At Stanford Medical Group, the general feeling is that each physician will make his or her own decision on whether to participate, he added.
Palo Alto Medical Foundation (PAMF) is also in the midst of discussions, and its parent company, Sutter Health, is in the process of implementing a policy for its clinics, said Dr. Dick Maser, retired plastic surgeon at PAMF.
Missy Gallo, a licensed clinical social worker at the PAMF Geriatric and Palliative Care center, said it is likely that each entity under Sutter would make its own decision to opt in or out of the program.
"It does look like we (PAMF) will offer it," she said. But the individual physician would still ultimately choose whether to write the prescription or consult with a patient about the end-of-life option.
Wexler said that patients would likely find the most resistance from physicians who have had little experience with people who are in the terminal phase of life. But doctors and caregivers, pain clinics and palliative care centers that deal with cancer patients and patients with severe pain issues would be more likely to understand a patient's request for aid to end their suffering.
Medical aid in dying is unlikely to occur in the hospital, where patients are given medications and are not allowed to take medicine on their own, Wexler said. Most deaths will likely occur in at-home hospice or palliative care.
According to the law, patients cannot designate another person to administer the drug nor write the wishes into their Advanced Healthcare Directive. And persons with dementia or Alzheimer's disease are not eligible for the act.
Montana, Oregon, Vermont and Washington also have medical-aid-in-dying laws. In Oregon, it has legally been practiced for 18 years, and 1,500 people have opted to obtain the medication. Of those, about one-third to one-half have not taken it, however, according to Stephanie Elkins of the nonprofit group Compassion & Choices.
The best way for patients who want to exercise the option is to have a conversation -- and many conversations -- with their physicians, Gallo said.
"You have to be the best advocate and ask the right questions," she said.