California law mandates discussing end-of-life options

Physicians must talk about hospice, at the request of dying patients, but they are not required to discuss palliative sedation or refusal of food and water.

By — Posted Nov. 10, 2008

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A new California law requires physicians and health care organizations to provide terminally ill patients with "comprehensive information and counseling" about their legal end-of-life care options upon request.

The measure -- known as the Terminal Patients' Right to Know End-of-Life Options Act -- says such patients have a right to be told about hospice care and advance directives, and their right to refuse life-sustaining treatment and to continue treatment while receiving palliative care. Patients also must be informed of their "right to comprehensive pain and symptom management at the end of life," including "clinical treatments useful when a patient is actively dying."

The law, which backers said is the first of its kind nationally, was supported by the California Medical Assn. after it was substantially changed. Gov. Arnold Schwarzenegger signed the bill Sept. 30; the law takes effect Jan. 1, 2009.

An earlier version required doctors to tell patients whose prognosis suggested less than a year to live about alternatives such as palliative sedation and refusing food and water to speed the dying process. Although palliative sedation is an attempt to relieve a patient for whom pain control efforts have failed, it can, in rare instances, hasten death. (See Clarification)

"Patients have not been having completely candid conversations with doctors about end-of-life options," said Barbara Coombs Lee, president of Compassion & Choices, which sponsored the legislation and also supports legal access to physician-assisted suicide. "When patients ask the question, it means they are ready and eager to know the answers. We don't think physicians need to be afraid of overwhelming patients with too much information when they are following the patients' lead."

A Feb. 8, 2007, New England Journal of Medicine study of more than 1,000 physicians found that nearly one in 10 objected to palliative sedation and did not feel obligated to refer patients to another doctor willing to offer the service. Several recent studies have found that patient-physician communication about end-of-life care leads to more use of hospice and better symptom control during the dying process.

The Assn. of Northern California Oncologists opposed the earlier version of the bill but changed its position to neutral after modifications were made. Robert S. Miller, MD, the group's past president, said the law unduly interferes with the patient-physician relationship. But he said it is far better than the earlier version that he believed rushed the discussion of last-resort options, such as palliative sedation, that patients might find upsetting.

"I don't think [the law] changes any of the physician behaviors already happening," Dr. Miller said. "Now it just codifies it, saying you have to do it."

Lee said other states should follow California's lead.

"It's good legislation," she said.

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This article stated the law does not require physicians to tell terminally ill patients specifically about palliative sedation and voluntary refusal of water and food. However, the law does require doctors to give patients "comprehensive" information about legal end-of-life choices, which could include discussing those options.

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