5.1.2015 – Patient Choices at the End of Life and Health Care
Well, it has finally happened! Spring has come to Montpelier! The weather warmed slightly, the State House lawn greened up almost overnight, and the Frisbee players immediately appeared. I wonder if there are other State Houses in the country where citizens are welcome to play sports, recreate, and picnic on the front lawn. The accessibility to the State House and the people who work here is one of the benefits of living in Vermont.
One of the issues that garnered a lot of attention and debate was the “Patient Choices at the End of Life” or Death with Dignity law, which we passed in 2013. To understand the situation better, it might be helpful to review some of the provisions of the law. To be able to request and receive a prescription for medication that will hasten death one must be 18 years of age or older, a resident of Vermont, capable of making and communicating health care decisions for him/herself, and diagnosed with a terminal illness with a life-expectancy of no more than six months. The patient must have the terminal illness and life-expectancy diagnosis verified by two different doctors.
There are also specific requirements regarding a timeline for an applicant to follow. The initial request is made verbally to a doctor by the patient. There is then a 15-day waiting period after which a second verbal request is made to the same doctor. This is followed with a written request to the doctor at which time the doctor may write the prescription for the medication that will hasten death. Finally, there is a 48-hour waiting period before the patient may pick up the prescription.
It was extremely important to us that this law not be abused so we included many additional safeguards for the patient, as well as the doctor. When the patient submits their written request, it must be witnessed by two people who are not family members or primary care givers. They can rescind both the verbal and written requests at any time. When the doctor makes the diagnosis, they must also certify that the patient is mentally competent to make and communicate health care decisions. If, for some reason, the doctor finds that the judgment of the patient is impaired, a psychological examination is required. The doctor must let the patient know about other options including pain management, palliative care, and hospice. The doctor must also request that the patient let their next-of kin know about the decision to obtain this medication. The patient must be able to take the medication themselves, they may not be helped. The law also stipulates that if a patient uses this option, their health or life insurance policies can’t be affected.
The patient is in full control of the process – we wanted to make sure that the process was done on the patient’s terms and of their own free will. Our goal was that no coercion would be possible as a result of the process and all of the safeguards that were put in place.
So why were we dealing with this bill again? When the Senate reviewed the legislation in 2013, they added a provision that would sunset many of these safeguards. For instance, the requirement to have a psychiatric evaluation if there was a question about impaired judgment, the 15-day waiting period between the oral requests, the 48-hour waiting period after the last request prior to writing the prescription, the written request signed by the patient in the presence of two witnesses who are not-interested parties, and the second opinion from another doctor would all disappear if the sunset took effect. This was very concerning to many of us who had supported the bill in 2013 – the sunset needed to be repealed in order for the safeguards to continue. Some of the provisions also protect doctors from liability, which we felt was important to maintain. Doctors and patients who follow the law are protected from criminal prosecution.
It should be stressed that participation in this process is completely voluntary on the part of patients, doctors, and the pharmacists who fill the prescriptions. The Vermont Department of Health oversees compliance with the law, which requires doctors to report all prescriptions to the state.
Now that Act 39 has been in place for a couple of years we have some experience with how it is working. A small number of people have gone through the process and had the prescription filled. To our knowledge only two have taken the medication hastening their deaths. One patient filled the prescription and died of their illness a few days later without having taken the medication. What is reported is that having the medication gives people comfort knowing that if things get bad they have a dignified way of ending the pain. House members voted to repeal the sunset so the safeguards will continue.
This week the House also passed a health care bill that will continue on the path to increased coverage for all Vermonters. We recognize that the Vermont Health Connect has been very problematic but do not want to lose our momentum as we move toward universal coverage. We have seen successes as a result of what we have done: Vermont has the second lowest uninsured rate in the country, we have begun to bend the skyrocketing spending curve, and we have improved patient outcomes with our managed-care program, the Blueprint for Health.
The bill passed this week would increase Medicaid payments to primary care providers, which makes it easier for underinsured Vermonters to access medical services. Low- and middle-income citizens who get exchange coverage would realize a reduction in out-of-pocket costs through increased subsidies. The $12 million cost is paid for by expanding the Meals Tax on vending machine food and drink sales, an increased tax on cigarettes and other tobacco products, and a sales tax on soda and candy.