Key Information About the End of Life Option Act for Healthcare Professionals

Message to Providers:
The Coalition for Compassionate Care of California (CCCC) has prepared responses to the most commonly asked questions concerning provider participation in the California End of Life Option Act. These responses highlight important actions required of participating providers. This information is offered strictly as guidance on provisions in the legislation and is not specific methodology for provider participation.

Forms available from the California Department of Public Health (CDPH) are required under the law, and familiarity with these forms may assist both healthcare providers and patients to comply with the process. CCCC recommends healthcare professionals review all forms, especially the “Attending Physician Follow-up Form,” to ensure all required information is collected and documented.

Nothing on this web page is intended to be, and should not be interpreted as, specific medical or legal advice regarding this complex piece of legislation and related medical issues. This information may serve as a guideline for providers who are seeking general information about participation in the End of Life Option Act.

Note: Key terms defined in the legislation are listed in bold.

What are the obligations of an Attending Physician?

Before prescribing an aid-in-dying drug, an attending physician must make an initial determination of whether a patient is a qualified individual and so can receive aid-in-dying drug.

An individual patient is qualified if he or she :

  • Is an adult (18 years of age or older)
  • Is a California Resident
  • Has an incurable and irreversible terminal disease (6 month prognosis)
  • Has the capacity to make medical decisions
  • Is making an informed decision
  • Is making a fully voluntary request for aid-in-dying medication and the request does not arise from coercion or undue influence
  • Is physically and mentally able to self administer aid-in-dying drug, meaning a conscious and physical act of administering and ingesting an aid-in-dying drug to bring about death
  • Has submitted the signed, dated witnessed request form

The attending physician must receive, from the patient directly and not through a designee, two oral requests a minimum of 15 days apart, and a written request. The law does not specify when the written request should be submitted.

All written and oral requests must be recorded in the medical record. (There is no specific language required in the documentation.)

The attending physician must refer the patient to a consulting physician.

The attending physician must refer the patient to a mental health specialist if indicated.

A mental health special assessment is indicated for the purpose of determining that the patient has the capacity to make medical decisions and is not suffering from impaired judgement due to a mental disorder.

The attending physician must counsel the patient about the importance of:

  • Having another person present when aid-in-dying drug is ingested
  • Not ingesting aid-in-dying drug in a public place or place open to public view or access
  • Notifying next of kin of request for aid-in-dying drug (failure to do so is not reason to deny the patient the aid-in-dying drug)
  • Participating in a hospice program
  • Maintaining aid-in-dying drug in safe and secure location until self administered

At the time of counseling, the attending must remind the patient that he or she may rescind their request for aid-in-dying medication at any time in any manner.

To confirm that the patient is making an informed decision, the attending physician must discuss the following with the patient:

  • The patient’s diagnosis and prognosis
  • The risks associated with taking the aid-in-dying drug
  • Probable result of taking the aid-in-dying drug
  • The possibility that the patient may at any time choose not to obtain the aid-in-dying drug or may obtain the drug and choose not to take it
  • Feasible alternatives or additional treatment options, e.g., comfort care, hospice care, palliative care, pain control

The attending physician must comply with all documentation requirements and submit all necessary forms.

In addition, the attending physician must:

  • Offer the patient an opportunity to withdraw/rescind the request before prescribing the drug
  • Verify the patient is making an informed decision immediately before prescribing the aid-in-dying drug
  • Confirm all requirements are met and that appropriate steps are carried out before prescribing the aid-in-dying drug
  • Fulfill all documentation requirements
  • Complete the Consulting Physician Compliance Form and the Attending Physician Checklist & Compliance Form, place the forms in the patient’s medical record, and submit copies of both the Attending and Consulting Compliance forms and the patient’s written request to the California Department of Public Health (CDPH) within 30 days of writing the prescription
  • Give the requesting patient the Final Attestation Form and instruct the patient about completing it

The Attending Physician Follow-Up Form must be completed within 30 calendar days of the patient’s death. A copy of the form must also be submitted to CDPH. This form must be completed and signed by the attending physician.

What are the responsibilities of the consulting physician?

The consulting physician must:

  • Confirm in writing the diagnosis and prognosis of the patient and determine that the individual has capacity to make medical decisions and is making an informed decision
  • Refer for mental health evaluation if indicated
  • Determine that the individual has complied with requirements of the End of Life Option Act
  • Fulfill the documentation requirements for consulting physicians
  • Complete the Consulting Physician Compliance Form and submit it to the attending physician
Who can serve as a consulting physician?

A consulting physician must be independent from the attending physician. (Note: The law does not define “independent.”)

A consulting physician must:

  • Be qualified by speciality or experience to make a diagnosis and prognosis regarding the patient’s terminal disease
  • Not be a witness to a patient’s written request
  • Not be related to a patient by blood, marriage, registered domestic partnership, or adoption, or be entitled to a portion of the patient’s estate upon death
What is involved in the mental health assessment?

If the attending or consulting physician determines the patient may have a mental disorder, the physician must refer the patient for an assessment by a mental health specialist for the purpose of determining if the patient has capacity to make medical decisions and is not suffering from impaired judgement due to a mental disorder.

The Mental Health Assessment is required only if the attending or consulting physician determines the patient has indication of a mental disorder which may impact capacity to make medical decisions.

A prescription for an aid-in-dying drug cannot be given unless and until a mental health specialist determines the patient:

  • Has capacity to make medical decisions, and
  • Is not suffering from impaired judgment due to a mental disorder
Who is considered a mental health specialist?

A mental health specialist is a psychiatrist or licensed psychologist.

Who can serve as a mental health specialist?

A mental health specialist must be independent from the attending physician. (Note: The law does not define “independent.”)

The mental health specialist must:

  • Not be a witness to a patient’s written request
  • Not be related to a patient by blood, marriage, registered domestic partnership, or adoption, or be entitled to a portion of the patient’s estate upon death
Which physicians can prescribe an aid-in-dying drug?

Only a physician who meets the statutory definition of attending physician may prescribe an aid-in-dying drug.

Under the law, an attending physician is the physician who has primary responsibility for:

  • The health care of the requesting patient AND
  • Treatment of the requesting patient’s terminal disease
Do Medicare’s CPT codes for advance care planning cover discussions related to aid-in-dying?

For billing purposes, check with the related payer for the patients. California’s Medi-Cal program has agreed to provide coverage and reimbursement for physicians providing End-of-Life Option Act services (see APL 16-006). The Medi-Cal advance care planning codes may be appropriate–check with your billing services.

Because federal law does not support aid-in-dying, it is possible End of Life Option Act services are not reimbursable under the Medicare CPT codes for advance care planning. For Medicare Advantage enrollees it is advised to check with the patient’s health plan.

What forms are used and where do I get the forms?

Forms and instructions on submitting the forms are available through the California Department of Public Health (CDPH). All forms except the Patient’s Final Attestation must be submitted to CDPH. (The Patient’s Final Attestation should be returned to the attending physician to be included in the patient’s medical record.)

The End of Life Option Act requires various forms.

Provider Forms:

  1. Attending Physician’s Checklist & Compliance Form
  2. Consulting Physician’s Compliance Form
  3. Attending Physician’s Follow-up Form

Patient Forms:

  1. Patient’s Request for Aid-in-Dying Drug
  2. Final Attestation for Aid-in-Dying Drug
  3. Interpreter’s Declaration

Visit the CDPH website to download the provider forms.

How do I submit the forms?

Within 30 calendar days of writing a prescription for an aid-in-dying drug, the attending physician must submit the following completed, signed, and dated forms to the California Department of Public Health (CDPH):

  • A copy of the qualifying individual’s written request
  • Attending Physician’s Checklist and Compliance form
  • Consulting Physician’s Compliance form.

Within 30 calendar days of a qualified individuals’ ingestion of the aid-in-dying drug obtained under the terms of the Act, or death from any other cause, whichever comes first, the attending physician shall submit the Attending Physician Follow-Up Form.

The forms can be sent to the California Department of Public Health.

How Will Cause Of Death Be Reported?

This “All County Letter” from the California Department of Public Health provides information regarding accurate reporting on the cause of death on the California Certificate of Death when a person uses an aid-in-dying drug to end his or her life, as authorized by the End of Life Option Act.

Download the letter as a PDF

What are the best practices regarding POLST forms for patients who choose to participate in the End of Life Option Act?

All patients approaching the end of life should discuss their preferences for end-of-life care, complete an advance directive, select a surrogate, and be offered a POLST form to protect those wishes.

For patients choosing  the End of Life Option Act—to request, receive and ingest an aid-in-dying drug—a POLST form should be completed to reflect choices consistent with their wish to actively end their life. For those patients we recommend selecting:

A: Do Not Attempt Resuscitation

B: Comfort-Focused Treatment

C: No Artificial Nutrition

Where can I find education and training on The End Of Life Option Act?

The Coalition for Compassionate Care of California does not take a position on the End of Life Option Act, but we are experts in helping healthcare professionals learn how to have quality conversations with patients about serious illness, choices in end-of-life care, life-sustaining treatments, advance directives and POLST.

For healthcare professionals:

California End of Life Option Act (Coalition for Compassionate Care of California) $49
This webinar provides an insightful overview of the End of Life Option Act, patient eligibility requirements, ethical considerations, and a look at the demographics on how this option is used in areas of the country where similar legislation is in place.

The webinar also covers approaches to communicating with patients about treatment choices in the setting of life-limiting illness.

The California End of Life Option Act: An Overview (California Medical Association)
A free web account must be created with the California Medical Association to download this webinar.

For health systems, medical practices and others:

The CCCC Consulting Service can bring a customized training to your organization. Learn more here.

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