If you’re a Colorado voter, you have probably received your 2016 Blue Book Voter Guide in the mail at this point. We encourage all Colorado voters to get informed about Proposition 106, and then vote YES on this vital measure. Coloradans deserve the facts about Prop 106, not misinformation. While we agree with the arguments in favor of the measure, there is so much more for you to learn about Proposition 106 by visiting our Frequently Asked Questions page. Unfortunately, the arguments opposed to the measure fall quite a bit short of telling the real story and go so far as to repeat some of the misinformation our opponents are spreading. To help, we fact checked the arguments featured in this year’s Blue Book below. Thank you for your support of Proposition 106, and for helping inform your community.

 

1) The opponents of Prop 106 write that, “Encouraging the use of lethal medication by terminally ill people may send the message that some lives are not worth living to their natural conclusion. People who are in the final stages of life are often in fear of the dying process. The availability of medical aid-in-dying may encourage people to make drastic decisions based on concerns about the potential loss of autonomy and dignity, not realizing that modern palliative and hospice care may effectively address these concerns. Services such as pain and symptom management, in-home services, and counseling can help individuals navigate the end of their lives while minimizing suffering. Promoting medical aid-in-dying may lead to a reduced emphasis on treatment and development of new options for end-of-life care.”

The reality: Proposition 106 explicitly states that in order to qualify for medical aid in dying the dying person must be making an “Informed Decision.” Under the measure, the definition of “Informed Decision,” mandates that the prescribing physician tell the person requesting the aid-in-dying medication about “all feasible alternatives or additional treatment opportunities, including comfort care, palliative care, hospice care, and pain control.”[1]

Independent reports, polls and studies have concluded that medical aid in dying promotes appropriate and increased hospice use, and results in greater knowledge about palliative, end-of-life and hospice care, and better physician palliative care training. The Journal of Palliative Medicine suggests that medical aid in dying in Oregon has resulted in “more appropriate palliative care training of physicians,”[2] and a New England Journal of Medicine article likewise noted that 88 percent of responding Oregon doctors who had cared for terminally ill patients reported actively improving their knowledge of pain management for those patients.[3]

Not only are health professionals more knowledgeable about palliative care, but adults in Oregon and Washington, where medical aid in dying is authorized, are also more knowledgeable about palliative, end-of-life and hospice care. A poll conducted by National Journal and Regence Foundation found that both Oregonians and Washingtonians were more familiar with the terminology “end-of-life care” than the rest of the country and residents of both states are slightly more aware of the terms palliative and hospice care.[4]

About 90% of people who use medical aid in dying in Oregon are enrolled in hospice, the gold standard of palliative care.[5] Unfortunately, traditional palliative care does not always relieve extreme pain and suffering for everyone, which can substantially impact the quality of life during a person’s last days. Palliative sedation, which is sometimes called terminal or comfort sedation, involves being sedated to unconsciousness. Typically the person remains unconscious until death. Whether or not it is a better option depends on the unique situation of the person and the person’s wishes. A healthcare provider must manage medication administration carefully, and often this means hospitalization, which some people would not choose.

2) Opponents of 106 also argue, “Proposition 106 creates opportunities for abuse and fraud. The protections in the measure do not go far enough to shield vulnerable people from family members and others who may benefit from their premature death.”

The reality: In the more than 30 combined years of medical aid in dying in the authorized states, there has not been a single substantiated accusation of abuse or coercion. Medical aid-in-dying laws are safe and work as intended. Terminally ill people choosing medical aid in dying are almost always under hospice care, where an interdisciplinary team that includes social workers, nurses and clergy screen them regularly for such concerns.[6] In Oregon, almost two decades of experience and medical investigation shows us the law has worked as intended, with none of the problems opponents had predicted.

The opponents of 106 go on to say, “Proposition 106 allows a family member or heir to be one of the witnesses to a request for the medication, potentially subjecting the individual to coercion. The measure does not require that a physician have any specific training in order to make an assessment of the individual or require independent verification that the medication was taken voluntarily or under medical supervision. Proposition 106 fails to ensure that the lethal medication will be stored in a safe location, potentially placing others at risk or leading to its misuse.”

The reality: Proposition 106 is explicit that the “Consulting Physician” must be “qualified by specialty or experience to make a professional diagnosis and prognosis regarding a terminally ill individual’s illness.”[8]

The measure requires two witnesses who personally know the dying person to attest that the person is making a voluntary, informed decision and without undue influence or coercion.[9] It is clear that it is a felony to coerce someone to request the medication or to forge a request.  Proposition 106 does not require any particular person to be present when the medication is taken because it is meant to ensure that the dying person, and not the government, decides who they want present for the profoundly personal experience. In the vast majority of cases, the person choosing to use medical aid in dying wants and has loved ones present when they take the medication.

Finally, in a combined 30 years of experience across four states, there has never been an accidental overdose of aid-in-dying medication. Because the medication requires a high dosage to work, it is not easily used accidently. Furthermore, the medication is bitter, and a person is likely to regurgitate it if they don’t take something to suppress vomiting prior to taking the aid-in-dying medication. One is far more likely to overdose on common over-the-counter medications like cough syrup or the many potentially lethal medications one is often prescribed at the end of life, such as morphine. But, to be on the safe side, the measure calls for physicians to teach patients about proper storage of the medication[10] and mandates that any unused medication be disposed of properly.[11]

3) Opponents of 106 also argue, “Proposition 106 may force physicians to choose between medical ethics and a request to die from a person for whom they feel compassion.”

The reality: The measure is explicit that no one is obligated to prescribe or dispense aid-in-dying medication. It specifically says “No duty to prescribe or dispense. A health care provider may choose whether to participate in providing medical aid-in-dying medication to an individual in accordance with this article.”[12]

Managing the death of a dying patient in accordance with that patient’s desires is compatible with the fundamental purpose and goal of medicine as well as consistent with the physician’s role in delivering patient-centered care and as a healer. On September 16, 2016, the Colorado Medical Society (CMS) adopted a position of studied neutrality in regard to medical aid in dying acting on a recommendation from its Council on Ethical and Judicial Affairs, which undertook a year-long study, and in response to a survey of the membership conducted in February 2016.[13] CMS is neither for nor against medical aid in dying because they feel “Proposition 106 represents the most personal of decisions that must be left to our patients.”[14]

Opponents of 106 go on to say, “The measure compromises a physician’s judgment by asking him or her to verify that an individual has a prognosis of six months or less to live, yet fails to recognize that diagnoses can be wrong and prognoses are estimates, not guarantees.”

The reality: Six months is the terminal prognosis a person must have to be referred to hospice under federal legislation, so it is a useful benchmark legally and medically, and doctors often use it as a guide to treatment decisions.[15] Studies show that, in general, physicians tend to overestimate their patient’s life expectancy in the face of a terminal disease. A medical team wrote in the Mayo Clinic Proceedings in November 2005, “…physicians are typically optimistic in their estimates of patient survival.”[16]

It is imperative that the dying person and only the dying person decides whether and when to voluntarily self-administer aid-in-dying medication. Because timing and control remain with the individual patients, outliving an expected prognosis has no impact on the appropriateness of medical aid in dying.

Finally, opponents of 106 say that “The measure also requires that the physician or hospice director list the terminal illness or condition on the death certificate, which requires these professionals to misrepresent the cause of death.”

The reality: Proposition 106, like the Washington measure and Oregon best practice, states that the underlying disease – not medical aid in dying – be noted as the cause of death on the death certificate. This practice is consistent with how the cause of death is reported for all other forms of palliative care and is important for epidemiological records and for loved ones. As an example, with terminal sedation, the underlying disease – not terminal sedation – is noted as the cause of death on the death certificate. The same is true with withdrawal of a feeding tube in that the underlying disease – not starvation – is listed as the cause of death.

 

[1] Colorado End of Life Options Act 25-48-102 (5) (V) http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[2] Wang, S, Aldridge, MD, Gross, CP, Canavan, M, Cherlin, E, Johnson-Hurzeler, R., et al. (2015) Geographic Variation of Hospice Use Patterns at the End of Life. Journal of Palliative Medicine. 18(9), 775.
[3] Ganzini, L, Nelson, HD, Schmidt, TA, Kraemer, DF, Delorit, MA, Lee, MA. (2000) Physicians’ experiences with the Oregon death with dignity act. New England Journal of Medicine. 342: 558.
[4]National Journal/Regence Foundation Poll, “Living Well at the End of Life,” 2010-2011. Available from http://syndication.nationaljournal.com/communications/NationalJournalRegenceToplines.pdf
[5] Oregon Public Health Division, Oregon’s Death With Dignity Act-2014, page 2, ninth bullet. Available from https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf
[6] Lee, M,A, & Tolle, S.W. (1996) Oregon’s assisted suicide vote: The silver lining. Annals of Internal Medicine. 124(2), 268.
[7] Colorado End of Life Options Act 25-48-119 http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[8] Colorado End of Life Options Act 25-48-102 (3) http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[9]  Colorado End of Life Options Act 25-48-104 (III)(c) http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[10] Colorado End of Life Options Act 25-48-106 (h) (III)  http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[11] Colorado End of Life Options Act 25-48-120 http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[12] Colorado End of Life Options Act 25-48-117 http://coendoflifeoptions.org./wp-content/uploads/2016/06/Full-Text-of-Measure.pdf
[13] Colorado Medical Society Member Survey, Physician Assisted Death, February 2016. Available from: http://www.cms.org/communications/physician-assisted-death-polling-shows-a-divided-membership
[14] Statement by CMS President-elect Katie Lozano, MD, FACR, regarding Ballot Proposition 106 http://www.cms.org/articles/statement-by-cms-president-elect-katie-lozano-md-facr-regarding-ballot-prop
[15] 42 CFR Part 418, Certification of terminal illness, Available from: http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_13
[16] Tough Question to Answer, Tough Answer to Heat, Brody, J. March, 6, 2007, New York Times, available via: http://www.nytimes.com/2007/03/06/health/06mbrody.html?_r=0