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End-of-Life Issues…A Public Health Challenge

posted on Mon, Nov 7 2016 10:08 am by Barak Wolff

With the large cohort of baby boomers (those born between 1946-64) reaching old age in coming years, there has been a renewed focus on end-of-life issues in general, with specific legislative and judicial attention to legalizing a new choice—aid in dying (AID). 

It’s no surprise that senior citizens (or “elders”, which sounds so much more interesting and sophisticated) use our health care system with more frequency and intensity than younger segments of the population.  As the end of life is approached, some will choose to have all possible treatments, regardless of risk, chance of success and expense.  Others will opt for comfort care and more control over their last months of life, perhaps preferring to be home with family and loved ones.  There is no “right” answer!  It’s a matter of personal choice as supported by both state and federal patient self-determination laws, and there is a full continuum of options to choose from.

Ideally each of us (and our loved ones) should engage in advanced care planning throughout our life span, including when we leave home, marry, have children, become ill or injured and so on. Such planning is critical if we are to have the kind of death we seek, which seems like an appropriate aspiration, at least to this leading-edge baby boomer.  And, of course, our choices will change over time as our lives evolve.  We can (and probably should) reconsider our choices as circumstances change.  These advance care planning decisions should be discussed with loved ones, health care providers, and designated health care decision-makers, and then written down as advance directives, values inventory, and other medical and physician orders such as POLST (physician orders for life sustaining treatment) and MOST (medical orders for scope of treatment).

From there, it is up to the health care system to respond accordingly, and to respect and honor these choices as the highest priority of care.  Levels of treatment should be fully explained to patients, families and designated decision-makers so that informed choices can be made.  When indicated and informed consent is given, advanced treatments should be accompanied by early palliative care to reduce and mitigate any negative side effects and to ensure frank discussions about priorities and choices that may lie ahead.

At any point that a patient (or surrogate) changes from seeking a cure to focusing on end-of-life care, early referral to hospice should be initiated as quickly as possible.  Hospice provides a full range of supportive care and services to patients and families at the end of life, consistent with their advance directives, and is fully covered by Medicare.

In a related development, AID refers to the practice of allowing a competent, terminally ill person (diagnosed with less than six months to live) to request and obtain a prescription for a lethal dose of medication from a willing physician in order to control the time and manner of their death.  It has been legal in Oregon since 1997, Washington State since 2009, and more recently Montana (via a Supreme Court decision), Vermont and California.  Data shows that AID is used infrequently (less than a quarter of 1 percent of all deaths in Oregon) and that those who choose AID tend to be white, insured, well-educated and enrolled in hospice.

Due to growing public awareness, in 2015 about 25 states initiated legislative campaigns to legalize AID.  Only California succeeded, but because of its size, an additional 44 million people now have access to AID, bringing the national total to 52 million.  It’s anticipated that there will be 20 to 25 legislative efforts again in 2017.  In most states the health department is tasked with developing forms, maintaining records, and providing an annual report regarding AID.

AID clearly represents a significant societal shift and there is strong opposition from some religious groups, right-to-life advocates, some members of the disability community, and others.  Strong concerns about devaluing life, irreversible diagnostic mistakes, the potential for abuse, and a “slippery slope” are all aspects for discussion and debate.  AID is an emotional and compelling issue that will be with us for years to come.

From a public health perspective what seems to be most important is that AID appears to enhance the overall system of end-of-life choices and care.  Once AID is implemented more people accomplish advance care planning, palliative care is utilized more fully, and hospice is accessed earlier in the process.   And, because these challenging issues have been publicly debated and discussed, it seems that the various involved sectors of the healthcare and social service systems collaborate more fully to meet the wishes of patients at the end of life, and that's a win-win and a public health success!

General End of Life Links/References:

Compassion & Choices

Death with Dignity

The Conversation Project

National Hospice and Palliative Care Organization

Get Palliative Care

Guest post by Barak Wolff, M.P.H., a Former Director of the Public Health Division, New Mexico Department of Health and current Policy Analyst for the Senate Public Affairs Committee of the New Mexico Legislature.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.

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