COMPASSION & CHOICES of OREGON
ORAL PRESENTATIONS by TOM LEACH
1. Hospice background
2. Personal experience with DwD
B. Introductory remarks
1. Going to give some info and data about DwD; Physician Aid-in-Dying
2. Question time at end but interrupt anytime
3. Have handouts and evaluation provided at end of presentation
II. OREGON DEATH WITH DIGNITY ACT (ORS 127.800-127.897 10/97)
A. History of the Law
1. First introduced to OR legislature by Sen. Frank Roberts in late 80’s
2. Statewide voter initiative passed 1994 by slim 51/49% margin
3. Attempts to repeal brought to public vote again in 1997; passed 60/40
4. First used in 1998 by 16 persons
5. Challenged inU.S. Congress in 1998, 1999, and 2000; not voted on
6. 2001 Atty General John Ashcroft tries to authorize federal drug agents to
prosecute physicians who write these prescriptions
7. Lower courts intervened; On appeal U.S. Supreme Court in January 2006
affirmed 6-3 that the Atty General did not have the authority to prosecute
physicians in Oregon.
B. What it says
1. General: If certain specific conditions are met, the law allows licensed
Oregon physicians (M.D. and D.O.) to write a prescription that a terminally-
ill, mentally-competent patient can self-administer to bring about their own
death. The law protects physicians and pharmacies; it states that the cause of
death on the Death Certificate will be from the underlying illness, i.e. natural
causes; death benefits cannot be withheld by insurance companies because, by
law, the physician assisted death is not a “suicide.” The Act does not change
or delete the existing laws making it a felony to assist a person in a suicide.
C. The Conditions and Safeguards of the law (All must be met to be in compliance)
1. The patient must initiate the request him- or herself, not an agent. Altogether
the patient will have to make 3 separate requests: two oral and one written.
2. The patient must be at least 18 years old and a legal resident of Oregon
3. The patient’s attending (prescribing) physician and a 2nd consulting physician
must be licensed to practice in Oregon and both must confirm that the patient
has a terminal diagnosis with a prognosis of death expected within the next 6
4. The attending and consulting physicians must confirm that the patient has
mental capacity to understand the dx, px, and that the rx being requested will
end his or her life, and that the patient is not suffering from mental illness
such as depression, other impaired judgment, nor is being coerced into making
5. If either physician questions the patient’s mental capacity to make this
decision, the patient must be referred for a psychological evaluation to
determine if the process can continue.
6. The prescribing physician is required to recommend that the next of kin be
notified of the patient’s request.
7. The second oral request can be made only after 15 days have passed since the
8. The patient must fill out and deliver to the prescribing physician a written
request form required by Oregon Department of Health Services which form
has to be witnessed by two adults, only one of which can be a family member.
9. The prescribing physician can write the rx only after 48 hours have elapsed
from receiving the State-form written request (and when the 15-day waiting
period has elapsed).
10. The physician must deliver the rx to a pharmacy. No specific medicine is
specified by the Act. The patient cannot take the script to the pharmacy.
11. The patient must be able to self-administer the medication. It cannot be
injected or otherwise introduced solely by another person.
12. The patient can rescind the request at anytime and the patient does not have to
take the medication.
13. Physicians and pharmacists are not required to write or fill the prescription if
they are opposed to doing so.
D. Timeline and Procedure
1. Attending physician notifies “qualified” patient of terminal dx with px of
expected death within 6 months.
a. Physician offers to make referral to hospice
2. Patient makes oral request of physician to prescribe a lethal medication to
allow patient to hasten death as allowed under Oregon DwD Act.
3. If physician agrees to be the prescribing physician, physician is required to
discuss with patient and chart the following:
a. Diagnosis and prognosis
b. Potential risks of taking the medication
c. Probable result (death) of taking the medication
d. Feasible alternatives for symptom and comfort care including hospice
e. Recommends patient discuss intentions with close relatives
f. Verify mental competency of patient to make informed choice not
i. If physician has concerns about patient capacity or mental
health a referral for psychological evaluation must be
completed before process can continue.
4. A referral is made to a consulting physician who must confirm the dx, px, and
capacity of patient
a. Consulting physician documents consult on OHD Consulting
Physician Compliance Form; informs attending of results
b. If consulting physician has concerns about capacity he or she must
make referral for psychological evaluation
5. Once consulting physician has completed the compliance form patient can
then execute the written request form required by OHD. The form must be
witnessed by two persons, only one can be a relative or medical caregiver.
6. Anytime after 15 days have passed since the first oral request, the patient can
make the second oral request.
7. Once the prescribing physician has received both oral requests and the written
request; and 48 hours have elapsed since execution of the written request; and
physician still believes that patient has capacity for informed choice; the
physician may write the rx for the lethal dose of medication.
8. The physician delivers the rx to the pharmacy—not to the patient.
9. Patient or agent can purchase the rx at the pharmacy and take it home.
10. Patient may self-administer the medication at anytime and anyplace he or she
chooses, but the prescribing physician must recommend that it not be taken in
a public place.
11. Patient retains the right to rescind and may elect to not consume the
12. Patient is asked to destroy the medication if not used by blending it with kitty
litter or coffee grounds, but not flushing into the sewer system or disposing
unaltered in the trash.
E. Acquiring and Taking the Medication
1. The law does not state what medications to use but leaves it to the discretion
of the prescribing physician.
2. The panel of physicians consulted by Compassion & Choices of Oregon
recommends the following medications which have been used successfully by
over 99% of the patients.
a. 10 grams of secobarbital (Seconal) available as 100-1mg capsules
which must be opened and the powder dissolved in 5 oz of liquid for
the patient to drink. Current retail cost $400-$700
b. Or 10 grams of liquid pentobarbital (Nembutal) that can be consumed
by drinking. Current retail cost $2500-$3000.
c. Regardless of the choice of barbiturate, the patient should ingest an
anti-emetic 45 to 60 minutes prior to drinking the barbiturate to
prevent vomiting the bitter liquids. Recommended anti-emetics are
metoclopramide (Reglan) 20mg and ondansetron (Zofran) 8mg.
Another anti-emetic available is brand-name Kytril.
3. Some insurance companies will cover part of the cost if the rx is written
properly. Federally funded insurance will not cover any of the cost.
4. To enhance absorption of the medication the patient should not consume
anything but clear, non-fatty liquids for 4-6 hours prior to ingesting the
5. The entire 5oz of liquefied Seconal or 10 grams of Nembutal must be
consumed within 2 minutes of starting because the barbiturate induced coma
can begin as early as 2 minutes.
6. Cessation of respirations and heartbeat can occur as soon as 5 minutes or take
several hours. Average is 3-4 hours. There is one case of the patient remaining
in a coma for 108 hours before death. 2 patients who vomited a substantial
part of the medication have awakened from coma with no negative side
F. Who has used the DwD
1. 1998 through 2009
a. 460 Oregonians ingested the rx
b. 715 rx have been written
2. 2009 Statistics from Oregon Department of Human Services
a. 95 rx written by 55 physicians
b. Number of mental health consults= 0
c. Total deaths from the medication= 59
d. Of the 95:
i. 53 took the medication (56% of total written rx)
ii. 30 died of their underlying disease w/o taking the med
iii. 12 patients still alive at end of year
iv. 6 patients who rec’d rx in 2008 took it in 2009 to make 59
e. In 2009, 28,507 persons died in Oregon of natural causes
f. The DwD option exercised by 59 people = 2/10 of 1% of total deaths
g. Year 2008 saw 60 deaths by rx and 2010 appears on track for same.
3. Demographics of patients electing DwD in 2009 (Source: ODHS)
a. 91.5% in hospice care
b. 80% cancer; 7.5% ALS; 12.5% all other
c. 98.3% died at home
d. 78% between 55 and 84; median 76; youngest, 20; oldest, 109
e. 31 men; 28 women
f. 98.3% white
g. 48.3% had bachelor degree or above; % had high school or above
h. 98.7% had some form of health insurance.
i. Reasons cited: Loss of autonomy (96.6%); Loss of dignity (91.5%); <
ability to participate in activities that made life enjoyable (86.4%);
Inadequate pain control (10%)
4. Additional Demographics collected from clients of C&C
a. 39% Republican; 44% Democrat; 17% other
b. 86% expressed belief in higher power
c. 14% attended a Protestant church; 6% Catholic, 2.3% Jewish
synagogue, 2.4% Unitarian; and 1% Buddhist temple
III. COMPASSION AND CHOICES
A. National organization
1. Formed in 2004 by merger of End of Life Choices (formerly Hemlock
Society) and Compassion in Dying
2. Headquarters in Portland and Denver
3. Advocates on national level for death with dignity laws
C. Compassion and Choices of Oregon
1. Started in 1998; 501(c)3
2. 1575 client contacts in 12 years; 1530 died;
3. 78% of all Oregonians using DwD since 1998 have been clients
4. Mission Statement:
5. Services Offered:
6. 2009 Data
a. 240 clients served
i. 190 died; 121 naturally; 57 DwD; 12 vsed or sedation
ii. 50 new referrals to hospice
iii. 17 violent suicides prevented among of 190 who died
iv. 12 pain management consults with improved outcomes
b. 57 of the 59 state DwD deaths were C&C clients
i. 31 men, 26 women; ages 34 to 93; median 74
ii. 46 cancer; 5 ALS; 3 COPD; 3 other
iii. 55 had family members present; 23 had friends
iv. 43 had C&C client support volunteer present; 7 a physician
v. 54 were in hospice care
vi. 56 Caucasian; one African American
vii. 44 education >high school; 28 college and post grad
viii. 41 self-identified as religious or spiritual
ix. 22 self-identified as Republican; 28 Democrat; 7 other
a. Talk with patient and family members about Aid-in-Dying process
b. Make referrals to hospices
c. Advocate for clients in obtaining palliative medications
d. Assist clients in finding physicians and pharmacists for DwD
e. Emotional support for patients and families
f. Attend hastenings to assist in process
IV. GANZINI REPORTS
A. Experiences of Oregon Nurses and Social Workers with Hospice Patients Who
Requested Assistance with Suicide, Linda. Ganzini, MD, etal., N Engl J Med 2002;
Vol. 347, No. 8, 359-365, August 22, 2002.
“In summary, hospice nurses and social workers in Oregon corroborated the views of
physicians that patients request assistance with suicide because they want to control
the circumstances of death and maintain their independence and because they view
their quality of life as poor and are ready to die. Even though not all hospice nurses
and social workers support the Death with Dignity Act, they are all willing to care for
patients who make this choice. The high quality of care at the end of life provided by
hospice programs may explain, in part, the very low rate of assisted suicide among
patients in Oregon who are enrolled in such programs.”
“Eighty-four percent of the nurses rated the caregivers of patients who received
prescriptions as finding at least as much meaning in caring for the patient as the
caregivers of other hospice patients. Overall, families of patients who received
prescriptions for lethal medications were more accepting of and prepared for the
patient’s death, although they were somewhat more likely to be distressed than were
the family members of other hospice patients.”