Act 39

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Act 39 of 2013 established the U.S. state of Vermont's Patient Choice and Control at End of Life Act (Vermont Statutes Annotated Sec. 1. 18 V.S.A. chapter 113), [1] which legalizes medical aid in dying (commonly referred to as physician-assisted suicide) with certain restrictions. Vermont was the first state to enact this Law through legislative action; it permits some terminally ill patients to determine the time of their own death.

Contents

The measure was passed by both House and Senate and signed into law by Vermont Governor Peter Shumlin on May 8, 2013.

The law

Under the law, a competent adult Vermont resident who has been diagnosed, by a physician, with a terminal illness that will kill the patient within six months, may request in writing, from his or her physician, a prescription for a lethal dose of medication for the purpose of ending the patient's life. Exercise of the option under this law is voluntary and the patient must initiate the request. A patient who obtains a prescription for the intended purpose of hastening death may change his or her mind at any time. Any physician, pharmacist or healthcare provider who has moral objections may refuse to participate.

The request must be confirmed by two witnesses, at least one of whom is not related to the patient, is not entitled to any portion of the patient's estate, is not the patient's physician, and is not employed by a healthcare facility caring for the patient. The prescribing physician must refer the patient to a second physician for medical confirmation of the diagnosis, prognosis, and a determination that the patient is capable, is acting voluntarily, and is making an informed decision. After the request is made, another physician must examine the patient's medical records and confirm the diagnosis. The patient must be determined to be free of a mental condition impairing judgment. If the request is authorized, the patient must wait at least fifteen days and make a second oral request before the prescription may be written. The patient has a right to rescind the request at any time. Should either physician have concerns about the patient's ability to make an informed decision, or feel the patient's request may be motivated by depression or coercion, the patient must be referred for a psychological evaluation.

The law protects doctors from liability for providing a lethal prescription for a terminally ill, competent adult in compliance with the statute's restrictions. Participation by physicians, pharmacists and health care providers is voluntary.

The process

A physician may prescribe medication to a terminally ill adult patient that will be self-administered for the purpose of hastening the patient's death. In order to comply with Vermont law, the physician must: [2]

  1. the medical diagnosis consisting of the prognosis, including an acknowledgment that this is a prediction of life expectancy and an estimate based on the physician's best medical judgment; that this is not a guarantee of the actual time remaining in the patient's life and that the patient could live longer than the time predicted;
  2. provide the range of treatment options appropriate for the patient's diagnosis;
  3. if the patient is not enrolled in hospice care, all feasible end-of-life services, including palliative care, comfort care, hospice care and pain control;
  4. the range of possible results, including potential risks associated with taking the prescribed medication;
  5. The probable result of taking the prescribed medication.

History

Dick and Ginny Walters, founders of Patient Choices Vermont (PCV) began working to pass Vermont's Act 39 in 2002, based on the Oregon Death with Dignity Act. They were both 77 years old and had no idea that it would take eleven years to pass the bill and another two years to solidify it. They began by studying the Vermont legislative process, and based on numerous meetings in their living room a small group formed a 501(c)(4) corporation. Their daughter, Betsy Walkerman, an attorney who is now President of PCV, drafted the first Vermont bill following the pattern of the Oregon Death with Dignity Act. Their daughter Nancy Hawley set up PCV's first website.

As the issue moved forward in the legislature, opponents stated that Vermont was targeted by a national organization to pass this law. This was far from the truth. Vermont's death with dignity movement was Vermont-based from the start. Dick and Ginny, knowing that Vermonters, who see themselves as independent thinkers, would not want to be directed by outsiders, they made sure that the organization maintained and displayed its clear Vermont roots.

To find sponsors in the legislature, Dick contacted representatives and senators who were likely to be in favor of right-to-die legislation. Early on, thirty-nine representatives and a number of senators agreed to co-sponsor the proposed DWD bill.

PCV enlisted the assistance of national organizations to make use of their experience. Both Death with Dignity National Center and Compassion and Choices helped with advice, telephoning, funding, and connections to Oregon people who flew in to testify in legislative committee hearings. Among them were a rabbi, the head of the state hospice organization, and a researcher from Oregon Health & Science University who worked extensively on the statistics in Oregon.

From the beginning, PCV's Board of Directors included professors and medical doctors. All were committed to the mission and worked persistently through many years, enabling the group to become close-knit. Early in the process, Dick and Ginny were introduced to the lobbying firm of Sirotkin and Necrason (now the Necrason Group), with whom PCV developed a close and lasting relationship. Their steadfast dedication, invaluable expertise and guidance in strategic planning was critical to the organization's success.

In 2004, at the request of the legislature, the Vermont Legislative Counsel studied Oregon's Death with Dignity law and published a report detailing its efficacy and positive outcomes. Through 2009, legislation was proposed in the Vermont House and Senate, and committees in both chambers conducted extensive hearings. PCV organized written and verbal testimony by a wide range of people, including people experienced with the adoption and implementation of the law in Oregon, and numerous individuals with deeply personal and family stories. The underlying theme was freedom to choose. Repeatedly, independent polls showed Vermonters favored the bill by two to one, across political parties and religions. Many individuals with disabilities testified in favor of the legislation because people with disabilities, like everyone else, want to control their own medical decisions when diagnosed with a terminal illness. Opposition was strong and vocal, raising a number of concerns. PCV persistently presented the facts from Oregon.

PCV worked strategically through the years to build knowledge and support among legislators and legislative leadership. It took time and citizen action to educate representatives about freedom of choice at the end of life. Throughout Vermont, the proposed legislation gained attention and supporters because of letters to the editor and media accounts.

Some PCV Board members spoke at Rotary Clubs, at gatherings at the homes of supporters and at professional meetings of healthcare providers. PCV expanded its database of supporters by setting up DWD displays and collecting signatures at Town Meetings, which take place every year throughout Vermont in the month of March. Among PCV's thousands of supporters were activists who contacted legislators, wrote letters to the editor, and contributed to the campaign. During the most active part of the campaign, PCV engaged a grassroots organizing firm to activate a database by organizing telephone trees, continually updating the website, posting on social media, using email and snail mail and setting up TV ads.

Although the Vermont Medical Association testified that Act 39 was not needed, PCV developed a list of 200 supporting physicians. They understood that for the terminally ill patient, just knowing that it's legal to avoid a protracted painful dying process brings peace of mind.

By 2013, Vermont had a Governor who was a committed advocate for DWD. The Speaker of the House, a strong and determined leader, also was eager to see the legislation passed. To achieve a majority vote in the Senate, a compromise consisting of a “sunset” provision that would have allowed most of the safeguards to disappear in 2016 was necessary. PCV celebrated passage but was concerned that weakening the required safeguards would make the law vulnerable to repeal. [3]

In 2015, Act 39 was revised to remove the sunset provision, and the final bill was signed on May 20, 2015, thereby solidifying Vermont's Act 39. The Governor, the House Speaker, legislators and thousands of ordinary Vermonters came together to establish the Patient Choice at End of Life Act. [4]

Impact

Twenty-four prescriptions have been written within the first three years after inception of Vermont's Act 39. Sixteen of them were written in 2016, showing a careful, steady utilization increase. [5]

Opposition

In July, 2016 the Vermont Alliance for Ethical Healthcare and Tennessee-based Christian Medical and Dental Association filed a lawsuit against the State of Vermont. The groups claim both Act 39 and Vermont's Patient Rights law violate the plaintiffs’ religious rights by requiring doctors to discuss all end-of-life care options with their patients. [6]

During the first hearing in the case on Nov. 8, the plaintiffs’ attorneys suggested his physician clients would be willing to “…tell a patient that they can Google assisted suicide on their cell phone and that's a reasonably available source of information…” [7]

“The notion that doctors could fulfill their professional duty to ensure patients can make fully-informed decisions by Googling to learn about their end-of-life care options is the height of irresponsibility,” said Linda Waite-Simpson, Vermont state director for Compassion & Choices. “It would be tantamount to doctors abandoning their patients at the most vulnerable time of their lives, especially given the danger of them Googling -- and relying upon -- fake news posted online.” [8]

U.S. District Court Judge Geoffrey W. Crawford has granted a motion by Compassion & Choices, Patient Choices Vermont and two terminally ill Vermonters that allows them to argue in court against a lawsuit brought by religious groups to undermine Vermont's End-of-Life Choice Act (Act 39). In granting the motion to allow Compassion & Choices and Patient Choices Vermont to intervene in the case, Judge Crawford wrote: “As people potentially eligible for consideration under Act 39, both individual (patient) intervenors have strong personal reasons for resisting the type of silence or boycott which Plaintiffs seek to preserve for themselves on an issue of patient choice … the intervenor organizations (Compassion & Choices and Patient Choices Vermont) appear to have considerable experience in the field. The court welcomes their advice and expertise…” [9]

“The Vermont law respects everyone’s personal beliefs because it allows any person or healthcare professional to refuse to directly participate in medical aid in dying,” said Kevin Díaz, national director of legal advocacy for Compassion & Choices. “But these doctors contend their personal beliefs should trump their patients’ rights when it comes to simply referring them to a healthcare professional to advise them about all their end-of-life care options. It should send shivers down the spine of every patient.”

“This case is about a patient’s right to know what their options are at the end of life,” said Betsy Walkerman, President of Patient Choices Vermont. “Physicians should not impose their personal religious values on their patients by preventing them from receiving information about all of their end-of-life care options.” [10]

On April 5, 2017, U.S. District Court Judge Geoffrey Crawford ruled that two medical organizations failed to show that their members — two doctors, a nurse and a pharmacist who oppose the law for religious and ethical reasons — faced any harm and dismissed their legal challenge of Vermont's 2013 end-of-life law. [11]

See also

Related Research Articles

Assisted suicide, also known as assisted dying, is suicide undertaken with the aid of another person. The term usually refers to physician-assisted suicide (PAS), which is suicide that is assisted by a physician or other healthcare provider. Once it is determined that the person's situation qualifies under the physician-assisted suicide laws for that place, the physician's assistance is usually limited to writing a prescription for a lethal dose of drugs.

Right to die freedom to end ones life

The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, or without the will to continue living, should be allowed to end their own life, use assisted suicide, or to decline life-prolonging treatment. The question of whom, if anyone, should be empowered to make this decision is often central to the debate.

Measure 16 of 1994 established the U.S. state of Oregon's Death with Dignity Act, which legalizes medical aid in dying with certain restrictions. Passage of this initiative made Oregon the first U.S. state and one of the first jurisdictions in the world to permit some terminally ill patients to determine the time of their own death.

In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying patient's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

Terminal illness or end-stage disease is a disease that cannot be cured or adequately treated and is reasonably expected to result in death of the patient. This term is more commonly used for progressive diseases such as cancer or advanced heart disease than for trauma. In popular use, it indicates a disease that will progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply terminal. There is no standardized life expectancy for a patient to be considered terminal, although it is generally months or less. Life expectancy for terminal patients is a rough estimate given by the physician based on previous data and does not always reflect true longevity. An illness which is lifelong but not fatal is a chronic condition.

Compassion & Choices is a nonprofit organization in the United States working to improve patient rights and individual choice at the end of life, including access to medical aid in dying. Its primary function is advocating for and ensuring access to end-of-life options.

Gonzales v. Oregon, 546 U.S. 243 (2006), was a U.S. Supreme Court case which ruled that the United States Attorney General cannot enforce the federal Controlled Substances Act against physicians who prescribed drugs, in compliance with Oregon state law, to terminally ill patients seeking to end their lives, often referred to as medical aid in dying. It was the first major case heard by the Roberts Court under the new Chief Justice of the United States.

The Hemlock Society was an American right-to-die and assisted suicide advocacy organization which existed from 1980 to 2003. It was co-founded in Santa Monica, California by British author and activist Derek Humphry, his wife Ann Wickett Humphry (1942-1991), and Gerald A. Larue. It relocated to Oregon in 1988 and, according to Humphry, had several homes over the course of its life. The group took its name from Conium maculatum, a highly poisonous biennial herbaceous flowering plant in the carrot family. The name was a direct reference to the method by which the Athenian philosopher Socrates took his life in 399 B.C., as described in Plato's Phaedo.

Dignity in Dying organization

Dignity in Dying is a United Kingdom nationwide campaigning organisation. It is funded by voluntary contributions from members of the public, and as of December 2010, it claimed to have 25,000 actively subscribing supporters. The organisation declares it is independent of any political, religious or other affiliations, and has the stated primary aim of campaigning for individuals to have greater choice and more control over end-of-life decisions, so as to alleviate any suffering they may be undergoing as they near the end of their life.

Kathryn Tucker American lawyer

Kathryn Tucker is the executive director of the End of Life Liberty Project, which she founded during her tenure as executive director of the Disability Rights Legal Center. She graduated from Georgetown University Law Center in 1985 and Hampshire College in 1981. Tucker has been an adjunct law professor at Lewis and Clark School of Law, Seattle University the University of Washington, Loyola/LA and Hastings. Beginning in 1990, while an attorney at the Seattle firm of Perkins Coie, she did pro bono work for Washington Citizens for Death with Dignity, which led her into the movement to expand end of life liberty.

Barbara Coombs Lee is an American activist, author, former family nurse practitioner and physician assistant, and president of Compassion & Choices, a national non-profit organization dedicated to expanding and protecting the rights of the terminally ill.

Washington Death with Dignity Act

Initiative 1000 (I-1000) of 2008 established the U.S. state of Washington's Death with Dignity Act, which legalizes medical aid in dying with certain restrictions. Passage of this initiative made Washington the second U.S. state to permit some terminally ill patients to determine the time of their own death. The effort was headed by former Governor Booth Gardner.

Electronic prescribing is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, pharmacist, nurse practitioner, or physician assistant to use digital prescription software to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy. It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of the major reasons for the push for electronic medical records. By sharing medical prescription information, e-prescribing seeks to connect the patient's team of healthcare providers to facilitate knowledgeable decision making.

Assisted suicide in the United States

Assisted suicide is defined as suicide committed with the aid of another person, sometimes a doctor. “Assisted suicide" has been used to describe what proponents refer to as medical aid in dying in the United States for terminally ill adults who self-administer barbiturates if they feel that they are suffering significantly. The term is often used interchangeably with physician-assisted suicide (PAS), "physician-assisted dying", "physician-assisted death", "assisted death" and "aid in dying".

Baxter v. Montana, is a Montana Supreme Court case, argued on September 2, 2009, and decided on December 31, 2009, that addressed the question of whether the state's constitution guaranteed terminally ill patients a right to lethal prescription medication from their physicians. The Montana Supreme Court sidestepped the question of if medical aid in dying is guaranteed under Montana State Constitution, but it instead ruled, on narrower grounds, that neither legal precedent nor the state's statute deem such assistance to be against public policy or illegal. Montana is one of nine states in which aid in dying is authorized. The others are California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, and Washington: it is authorized in the District of Columbia as well.

Death with Dignity National Center

Death with Dignity National Center is a 501(c)(3) nonpartisan nonprofit organization, headquartered in Portland, Oregon, that has led the legal defense of and education about Death with Dignity laws throughout the United States for 20 years. The Death with Dignity National Center helped write and defend in courts the nation's first successful assisted dying law, the Oregon Death with Dignity Act, protecting the right of persons with terminal illness to control their own death. The Death with Dignity National Center is affiliated with the Death with Dignity Political Fund, a distinct and separately incorporated 501(c)(4) organization responsible for the promotion of death with dignity legislation in other states around the U.S.

Compassion & Choices of Oregon was a US nonprofit organization launched in 1998 as a provider of services for persons eligible for the Oregon Death with Dignity Act, and their physicians and pharmacists. The organization recruited and trained volunteers to provide legal and medical consultation and direct service at no cost. It was a state affiliate of Compassion & Choices, and provides education, information and support to approximately 1000 Oregonians each year.

Massachusetts Death with Dignity Initiative

The Massachusetts "Death with Dignity" Initiative, also known as Question 2, appeared on the November 6, 2012 general election ballot in the state of Massachusetts as an indirect initiated state statute to allow physician-assisted suicide. The measure was filed with the Massachusetts Attorney General and would establish, according to those who filed the measure, an "Act Relative to Death with Dignity". The petition number for the initiative was 11-12, and was filed by Michael Clarke as "An Initiative Petition for an Act Relative to Death with Dignity".

Collaborative practice agreement

A collaborative practice agreement (CPA) is a legal document in the United States that establishes a legal relationship between clinical pharmacists and collaborating physicians that allows for pharmacists to participate in collaborative drug therapy management (CDTM).

California End of Life Option Act is a law enacted in June 2016 which allows terminally ill adults resident in the state of California to access medical aid in dying by self-administering lethal drugs, provided specific circumstances are met. The law was signed in by California governor Jerry Brown in October 2015, making California the fifth state to allow physicians to prescribe drugs to end the life of a terminally ill patient, often referred to as physician-assisted suicide.

References

  1. ↑ "Vermont Act 39 Patient Choice and Control at End of Life" (PDF). Vermont General Assembly.
  2. ↑ "Title 18: Health, Chapter 113: Patient Choice At End Of Life". Vermont General Assembly.
  3. ↑ "'DEATH WITH DIGNITY' SIGNED INTO LAW IN VERMONT". VT Digger. May 20, 2013. Retrieved 10 April 2017.
  4. ↑ "Permanent version of Vt. assisted suicide bill signed". USA Today. May 20, 2015. Retrieved 10 April 2017.
  5. ↑ "VERMONT END-OF-LIFE CHOICE LAW WORKING WELL AT THE THREE-YEAR MARK". VT Digger. May 20, 2016. Retrieved 10 April 2017.
  6. ↑ "Case 5:16-cv-00205-gwc Document 1 Filed 07/19/16" (PDF). Compassion & Choices. Archived from the original (PDF) on 2017-04-10. Retrieved 2017-04-10.
  7. ↑ "See page 40 of hearing transcript" (PDF). Compassion & Choices. Archived from the original (PDF) on 2017-04-10. Retrieved 2017-04-10.
  8. ↑ "COMPASSION & CHOICES AND PATIENT CHOICES VERMONT INTERVENE TO PROTECT VT AID-IN-DYING LAW". Compassion & Choices. Archived from the original on 2017-04-10. Retrieved 2017-04-10.
  9. ↑ "See pages 4-5 of intervenor order" (PDF). Compassion & Choices. Archived from the original (PDF) on 2017-04-10. Retrieved 2017-04-10.
  10. ↑ "COMPASSION & CHOICES AND PATIENT CHOICES VERMONT INTERVENE TO PROTECT VT AID-IN-DYING LAW". Compassion & Choices. Archived from the original on 2017-04-10. Retrieved 2017-04-10.
  11. ↑ "Federal Judge Upholds Vermont's End-of-Life Law". Seven Days. April 7, 2016. Retrieved 10 April 2017.
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