California bill would mandate discussions of end-of-life options

The California State Assembly in late May passed a bill requiring physicians to have comprehensive discussions about legal end-of-life care options with terminally ill patients who request such information.

The measure, up for consideration in the Senate at AMNews press time, would be the first of its kind to gain passage nationally. A similar bill in Vermont is stuck in House committee.

The California proposal requires doctors to tell patients whose prognosis suggests less than a year to live about hospice and palliative care, and about alternatives such as palliative sedation and refusing food and water to speed the dying process. Although palliative sedation is at attempt to relieve a patient for whom pain control efforts have failed, it can, in rare instances, hasten death.

The bill "shifts the decision-making ability to the patient," said Barbara Coombs Lee, president of Compassion & Choices, the organizational sponsor of the bill.

"Without this bill, the physician is in charge of what the patient knows. After this bill, the patient gets to know their options, and then they can make a decision on the basis of that knowledge," she said.

The measure, dubbed the "Terminal Patients' Right to Know End-of-Life Options Act," garnered strong opposition from Catholic, pro-life and disability-rights groups that expressed concern it is "setting the table for future assisted-suicide legislation."

The bill's authors, Assembly members Patty Berg and Lloyd Levine, both Democrats, have in previous sessions unsuccessfully attempted to pass legislation modeled on Oregon's Death With Dignity Act.

Compassion & Choices is the country's leading advocacy organization for legal access to physician-assisted suicide, but the bill does not include any language that relates to that as an option.

Under the bill, physicians who do not "wish to comply" with their patients' end-of-life choices must refer them elsewhere and provide information on how to transfer to another doctor. The measure would become part of the state's health and safety code and failure to comply could result in medical board discipline, according to Will Shuck, chief of staff for Berg.

The California Medical Assn. does not have a position on the bill, a spokesman said. But the Assn. of Northern California Oncologists says the bill is unnecessary and could hurt patients.

"We're concerned this may be disconcerting to patients. Doctors are still talking about active treatment options, but the law says we have to talk about voluntary stopping of eating and drinking," said Robert S. Miller, MD, a Sacramento oncologist and a past president of the group. "It's the juxtaposition of some of these interventions clearly aimed at the very end of life that we'll now be required to provide to patients 12 months from the end of life that is a problem."

Dr. Miller said he routinely refers patients to hospice but argued that it is difficult to predict with certainty that a patient has less than a year to live, making compliance with the law a tricky prospect.

Inappropriate discussion?

Timothy E. Quill, MD, agreed that talking in great detail too soon could be inappropriate.

"What most people want to know about are hospice and palliative care. They may not be asking about last-resort options like palliative sedation and stopping eating and drinking," said Dr. Quill, director of the University of Rochester Medical Center's palliative care program in New York.

"The tricky thing is to give the information to people who want that information but not to everybody, because it has the risk of scaring people," he said.

But a study of more than 600 patients with advanced cancer, reported in a May 20 Journal of Clinical Oncology supplement, found that those who discussed end-of-life care options with their physicians were not more likely to be depressed or feel nervous or worried than were those who did not have such conversations. They were more likely to understand that they were terminally ill, to receive hospice care, and to forgo resuscitation and mechanical ventilation.

Meanwhile, a study of 1,144 physicians, reported in the Feb. 8, 2007, New England Journal of Medicine, found that nearly one in 10 objected to palliative sedation and felt no obligation to refer patients to another doctor willing to offer the service. But nine in 10 doctors opposed to palliative sedation did feel obliged to "disclose all possible options" to their patients.

John D. Lantos, MD, a co-author of that study, agreed that patients have a right to know their options, but said California's approach is unwise.

"Legislatures will find themselves in a deep morass if they start trying to specify in any kind of detail that would be even slightly useful what conversations must take place between doctors and patients," said Dr. Lantos, holder of the John B. Francis Chair in Bioethics at the Kansas City, Mo., Center for Practical Bioethics.

But Thomas J. Smith, MD, a Richmond, Va., oncologist and co-author of a June 11 Journal of the American Medical Association article on poor communication between cancer patients and doctors, said the proposed law "is something that could be tested in one state, and if it works, then it could potentially be applied to other states. It certainly raises awareness of the issues."

The American Medical Association has no position on the bill, but it does have policy opposing euthanasia and physician-assisted suicide while voicing strong support for improving palliative care.

At its Annual Meeting in June, the AMA House of Delegates adopted new policy saying palliative sedation to unconsciousness is ethically appropriate as a last resort in patients with uncontrollable pain at the end of life.