Right-to-Die Laws: What Pharmacists Need to Know

California pharmacists could soon participate in dispensing lethal medications to terminally ill patients, pending Gov. Jerry Brown’s review of the state’s End of Life Option Act.

If approved, the act would apply to adults 18 and older with a terminal illness that would cause death within 6 months. The patient must also have the capacity to make his or her own medical decisions and self-administer the drug.

If the patient is referred to a mental health specialist, then that specialist must determine that the patient can make his or her own medical decisions and is not suffering from impaired judgment due to a mental disorder.

The act states that those who can dispense the lethal medication, plus additional medication to minimize the patient’s discomfort, include a pharmacist who receives the written prescriptions personally, by mail, or electronically.

The pharmacist may dispense the drug to the patient, attending physician, or another person designated by the individual, according to the bill.

The request for an “aid-in-dying drug” would include the following statement in the required form:

“I request that my attending physician prescribe an aid-in-dying drug that will end my life in a humane and dignified manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.”

California Pharmacists Association (CPhA) CEO Jon R. Roth, CAE, told Pharmacy Times that the pharmacy association opposed laws or regulations that mandate or prohibit the participation of pharmacists in end-of-life options for mentally competent, terminally ill patients.

CPhA also supports laws or regulations that give immunity from liability for pharmacists who participate in lawful end-of-life activities, Roth said.

“It will be critical for pharmacists to be highly engaged with patients, their physicians, and caregivers in discussions about end-of-life considerations,” he said. “As a member of the health care team and expert in medication use, pharmacists may be placed in situations that require their expertise and should be conversant in the medication-related aspects of these choices, regardless of whether they choose to actively participate in end-of-life actions or not.”

Because California pharmacists are already required to counsel a patient receiving a new medication, the End of Life Option Act would also apply to patients receiving the 2 most commonly prescribed medications used in these situations: secobarbital or pentobarbital.

Roth outlined 3 key questions that pharmacists should ask patients who wish to receive an aid-in-dying drug:

· What did the prescriber tell you the medication was for?

· How were you told to take the medication?

· What were you told to expect from the medication?

“The patient’s answers to these questions would allow the pharmacist to reinforce instructions already provided and ensure the patient understood the consequences of the lethal medication,” Roth told Pharmacy Times.

Pharmacists should also reinforce the importance of complying with the directions for use of secobarbital or pentobarbital, he added. Other information that pharmacists should review include what patients should do if they experience unusual circumstances such as vomiting or decide not to end their life after taking the drugs.

“The pharmacist may also wish to discuss preparation, administration, and techniques for self‐monitoring or monitoring by a caregiver,” Roth said.

Taking an aid-in-dying drug does not constitute suicide, so health and insurance coverage will not be exempted on that basis, according to the California bill.

The bill is modeled after the Oregon Death with Dignity Act, according to NPR. If Gov. Brown signs the bill, California will join 4 other states with right-to-death laws: Oregon, Washington, Vermont, and Montana.

Oregon Board of Pharmacy president Roberto Linares, RPh, told Pharmacy Times that the Oregon bill was well written and has worked in the state.

In practice, pharmacists will have to check on the availability of secobarbital or pentobarbital, and then ensure that the patient has received and understood the instructions for the medications, Linares said.

Other pharmacist counseling points include informing the patient about the importance of keeping the medication secure and out of reach of children, and also giving instructions to the patient and/or caregiver on how to properly dispose of unused medications.

In general, these medications should be taken on an empty stomach to improve speed of absorption, though patients can take juice with pentobarbital or secobarbital to mask the bitter taste of the medications, Linares said.

“Physicians may prescribe an antiemetic to take prior to taking the secobarbital or pentobarbital, so the pharmacist should ensure the patient understands when to take the antiemetic,” he added.

In providing advice to California pharmacists, Linares suggested that they read and make sure they understand the bill and board of pharmacy communications.

“Ensure your pharmacy has clear policies and procedures, so all pharmacy employees know what to do in the event they are asked to provide this service to a patient,” Linares advised.

Linares said the Oregon Board of Pharmacy does not know where most pharmacists in the state stand on this issue, but there have not been any pharmacy complaints related to Oregon’s Death with Dignity Act since he has been on the board.

“Physicians typically identify a pharmacy or pharmacist that is willing to participate when they give the patient a prescription, so the patient usually knows ahead of time that the pharmacy they use will provide the medication for them,” Linares said.

Gov. Brown has not shared his stance on the bill yet, according to NPR. He has until October 11, 2015, to sign or veto the bill.

A group called Californians Against Assisted Suicide was planning a vigil and “speak-out” on September 24, 2015, at the state capitol to express their opposition to the bill.