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California’s end-of-life law

A patient must be at least 18 years old and terminally ill with no more than six months to live.

Two separate requests must be made to a doctor, at least 15 days apart, with one request in writing.

The doctor must determine the patient has the mental capacity to make the request and discuss alternatives such as pain control.

The physician must refer the patient to a second doctor to confirm the diagnosis and determine mental competence.

Two witnesses must attest to the voluntary request for life-ending drugs. Patients with dementia or severe Alzheimer’s disease likely would be precluded.

If both physicians sign off, the original doctor writes a prescription, likely for Seconal.

Patients must be able to drink the lethal cocktail on their own.

Death certificates will list the cause as the underlying illness, not suicide.

Gail Etzler can’t shake the image of her mother’s last tortured moments when she died in fits of agonizing pain from breast cancer.

Now, the Santa Rosa woman is facing her own potentially terminal diagnosis and is determined not to go out the same brutal way.

If it comes down to it, the retired notary public will take advantage of a new state law that begins Thursday allowing doctors to prescribe lethal doses of drugs to hasten death. She’ll grab control of her fate and spare her adult son and other loved ones the anguish of witnessing what threatens to be an unpleasant end.

“My mother died a horrible death,” said Etzler, 67, who was diagnosed with Stage 4 breast cancer in January and, without the treatment she receives, was given six months to a year to live. “I remember her pain. I don’t want my son and friends to see me suffer. If there’s an option to help you end your life with dignity, that’s what I’ll do.”

Etzler and others will now have that choice under the state’s End of Life Option Act, which allows physicians to prescribe life-ending medication to mentally competent adults with six months or less to live.

The controversial legislation is modeled on Oregon’s 1997 Death with Dignity law, which resulted in more than 130 doctor-assisted suicides in that state last year. After much debate in Sacramento, it gained political traction last fall after Brittany Maynard, a 29-year-old brain cancer victim from California, traveled to Portland in 2014 so she could receive lethal drugs prescribed by a doctor.

Maynard’s family pleaded with Gov. Jerry Brown and lawmakers to pass right-to-die legislation so terminally ill Golden State residents would not have to leave home to get help ending their lives.

Brown, a former Jesuit seminary student who struggled with the decision, signed Assembly Bill 15 after a period of reflection.

“I do not know what I would do if I were dying in prolonged and excruciating pain,” he said. “I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

California becomes the fifth state to allow doctor-assisted death behind Oregon, Washington, Vermont and Montana.

Divisive idea

The idea, which is opposed by the Catholic Church, has divided physicians, ethicists and elected officials.

Some fear it will cause the early death of vulnerable people while diminishing the use of palliative services. Others oppose it on moral or religious grounds, saying it undermines the sanctity of life. In addition, some doctors maintain it’s a violation of their professional duties.

St. Joseph Health, a Catholic health care system that operates Santa Rosa Memorial and Petaluma Valley hospitals, will not allow its physicians to issue death-hastening drugs. The focus instead will be on pain management, hospice care and spiritual support.

“It fills me with great sadness that people feel this is somehow their best option,” said Bishop Robert Vasa, who heads the Catholic Diocese of Santa Rosa. “In a society as great as ours … we can do better.”

But advocates say the law will provide much-needed relief for people suffering incurable diseases that have sapped enjoyment from their lives.

“These people are terminally ill,” said Maynard’s widower, Dan Diaz, who has become a spokesman for Compassion & Choices, a Denver nonprofit group that has led aid-in-dying campaigns in nine states. “They are fighting for their lives just like Brittany, and they want to know they don’t have to suffer in their final days on this green Earth.”

Statistics from Oregon and Washington, which enacted its law in 2008, dispel some concerns about doctor assisted-death legislation. Although the number of people taking advantage of end-of-life services in each state has risen steadily, fears that the law would somehow target the poor, uninsured or less educated have not materialized. According to a recent UCLA study, more than 97 percent of those who hastened their own deaths in Oregon between 1998 and 2013 were white and about 46 percent had a bachelor’s degree or higher education. About 60 percent had private insurance, and 38 percent were on Medicare or Medicaid.

Based on participation rates in Oregon, an estimated 945 people will take their own lives in California during the first year of the law, said Cindy Cain, a UCLA professor of policy and health management who co-authored the study.

The number could be lower because California is more racially diverse, she said.

“It’s a little bit tricky,” Cain said. “What has been true in Oregon and Washington, and is probably true in Vermont, is in the first year participation is low and in subsequent years it goes up slightly.”

Local family members said the case of Jan Zlotnick, a Sebastopol registered nurse and nursing instructor, presents a strong argument for aid-in-dying.

Zlotnick, who died in 2014 at age 63, developed such a tolerance for pain medication that doctors had to continually increase his dosage of morphine and other drugs as he battled metastatic prostate cancer. The lifelong athlete considered moving to Oregon to end his life but decided against it because he wanted to see his teenage son, Quincy, graduate from Analy High School.

Despite his struggle, Zlotnick didn’t make it. Sometime after Thanksgiving he realized he couldn’t hold on until June. His suffering was too awful. He died that New Year’s Eve.

“He felt so bad,” said his wife, Jeanette Lebell. “But they couldn’t control his pain. And the more they tried, the more the side effects limited and excluded anything positive from his life.”

After her husband’s death, Lebell and her son, now a college freshman, went to Sacramento to urge aid-in-dying legislation, joining forces with Maynard’s husband and Compassion & Choices.

A version of the original bill passed during a special session of the Assembly and was signed by the governor in October. By law, it couldn’t take effect until 90 days after the end of the session on March 9.

“There are those who say every family is one bad death away from needing this bill,” Lebell said. “I believe it to be true.”

The process

To qualify under the law, a patient must be at least 18 years old and terminally ill with no more than six months to live. Two separate requests must be made to a doctor, at least 15 days apart, with a third request in writing.

The doctor must determine the patient has the mental capacity to ask for the drugs and discuss alternatives such as pain control. That physician must refer the patient to a second doctor to confirm the diagnosis and determine mental competence.

Two witnesses, including one non-family member, must attest to the voluntary request for life-ending drugs. Patients with dementia or severe Alzheimer’s disease likely would be precluded.

If both physicians sign off, the original doctor writes a prescription, likely for secobarbital, sold under the brand name Seconal, which the patient may fill at a pharmacy. A fatal dosage is around 90 capsules. Patients can get help emptying capsules into a liquid such as juice but must be able to drink the lethal cocktail on their own.

Within minutes, they will fall asleep and die soon after. Death certificates will list the cause as the underlying illness, not suicide. Most are expected to end their lives at home. A doctor need not be present.

The deaths will be recorded and tracked by the state Department of Health.

It’s unclear if insurance companies will pay for Seconal, which skyrocketed to about $4,000 for a fatal dose with the pharmaceutical company’s recent acquisition by a Canadian investor, but it will be covered by Medicare. Health care providers, including Kaiser Permanente and Sutter Health, are expected to participate.

Dr. Dennis Pocekay of Petaluma, a retired Kaiser occupational medicine specialist who volunteers with a local chapter of Compassion & Choices, said many patients who get the drugs may never take them. Just knowing they have them provides peace of mind and a sense of control, he said.

In Oregon, for example, only about 65 percent of patients actually follow through, he said. Of the 1,545 people to receive a prescription under the state’s right-to-die law, 991 died from ingesting medications.

“A lot of people just like having it available,” said Pocekay. “They like that they are not totally at the mercy of their disease.”

He speaks from experience. Pocekay was prescribed morphine years ago while battling non-Hodgkin's lymphoma and estimated at one point he had enough to kill himself if symptoms worsened. Knowing he could do it “lifted the load” off dying, he said.

“It was just the idea,” Pocekay said. “Feeling like I had control over the last few days if it got bad.”

Doctors’ choice

The UCLA study said health care providers still are seeking guidance from the state about how to implement the law, asking questions about such things as how to ensure a six-month prognosis and what to do about complications after the prescribed drugs are ingested.

Although a number of health care providers back the new law, doctors are not required to prescribe life-ending drugs and pharmacies are not required to sell them. Identifying beforehand who will support the option will help avoid a scramble at the end, Pocekay said. He vowed to come out of retirement if there’s a shortage of willing doctors.

“I have always been supportive of this idea,” Pocekay said. “To me, it seems natural to interpret the Hippocratic oath as not just to prevent death at all costs but to prevent suffering at all costs.”

To that end, Dr. Gary Johanson, hospice and palliative care director at Santa Rosa Memorial Hospital, said the faith-based institution will offer “robust” end-of-life services from counseling to a no-dose limit on pain relief that can essentially keep someone asleep until they die.

“Our goal is to minimize the need for doctor-assisted suicide,” Johanson said. “We seek pain management so patients can pass naturally.”

However, Memorial doctors will be barred from helping patients trigger their own deaths, referring them instead to someone outside the St. Joseph system, Johanson said.

Meanwhile, Etzler said she’ll turn to her oncologist for a prescription if the cancer that has metastasized into her bones gets worse.

She doesn’t want to die. Etzler works out at a gym, and between chemotherapy treatments hikes the scenic Sonoma County countryside with her boyfriend, who also has cancer.

But she doesn’t see the point of living in extreme pain and is grateful for a dignified way to die.

“It’s a big commitment to play God with yourself,” said Etzler. “I might find it a blessing just to check out.”

You can reach Staff Writer Paul Payne at 568-5312 or paul.payne@pressdemocrat.com. On Twitter @ppayne.



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