Policy

Envision Hospice (“Envision”) reaffirms a basic element of the hospice philosophy that states that because dying is a natural process, hospice neither seeks to hasten nor postpone death. Envision acknowledges that there may be hospice patients who will wish to avail themselves of their legal right to pursue medical aid-in-dying as their end-of-life option and Envision will not abandon these patients or their families.

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Purpose

The Washington Death with Dignity Act (the “Act”) allows terminally ill, mentally capable Washington residents that are adults (18 years or older) with a prognosis of six months or less the option to request medication from a medical or osteopathic physician that they can choose to self-administer to shorten their dying process and bring about a peaceful death. 

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Procedure

General Description:

1. It is the mission of Envision to meet the needs of patients and families in a way that honors how people want to live their final months or days. Envision is ready to discuss and support end-of-life decisions with our patients while being sensitive to individual values and/or belief systems.

2. Patients requesting medication for medical aid in dying must satisfy all of the requirements of the Act in order to obtain a prescription for the medication. Envision, acknowledging the legal right of qualified patients to exercise this choice, supports patients in completing the requirements of the Act so that the patient may self-administer the medication and end his or her life as the law intends, “in a humane and dignified manner.”

3. Patients who inquire about the option of securing the medical aid-in-dying drug will be asked to contact their attending physician.  Envision will continue to provide standard hospice services to patients, regardless of their stated interest or intent in pursuing their legal right. 

4. Envision permits hospice physicians and pharmacists (and other staff and volunteers) to participate in the Act if they so choose and permits other Envision staff and volunteers to treat patients in the same manner as all other patients.

5. Staff and volunteers who are morally or ethically opposed to medical aid-in-dying will have the option of transferring care responsibilities to other staff if their patient states an intent to pursue medical aid in dying.

6. If applicable, Envision permits the self-administration and ingestion of medication for medical aid in dying, under the Act, in its facilities. Under the Act, the patient must self-administer the medication.

7. Envision shall honor Washington state law and shall honor our hospice patients’ wishes regarding end of life. No patient will be denied medical care or treatment because of the patient’s participation under the Act. We will continue to provide quality end-of-life care, symptom management and services to patients and families with the goal of providing excellent patient care, safe and comfortable dying and positive life closure.

8. Envision provides procedures for staff involvement in discussions around requesting medical aid-in-dying medication under the Act;

1. • hospice support for patients who choose to pursue the Act;
   • staff presence when patients ingest medication; 
   • hospice responsibilities following death;
   • documentation standards around discussions and patient requests for medical aid-in-dying medication; 
   • staff conscientious objections.

9. While recognizing that the request for medical aid-in-dying medication is a discussion between a patient and their attending physician, hospice staff will provide information, resources and support to patients who are exploring this option. 

Process:

1. As is customary, Envision will explore and evaluate patients’ statements related to all end-of-life options, including medical aid in dying if they arise during intake and/or routine visits.
2. If patient or family members make an inquiry about seeking medication for medical aid-in-dying, Envision will respond to inquiries or requests for information and refer them to their attending physician or the medical director, who may act as an Attending or Consulting Physician.
3. Staff or volunteers who are aware that a patient is considering procuring medication for medical aid in dying will notify the appropriate designated staff (e.g. Registered Nurse Case Manager and the Director of Hospice Care Services).
4. Patients who verbalize this intent will be informed that this information will be shared with the hospice team for appropriate support
5. Staff and volunteers working with a patient/family who has verbalized an interest in this end-of-life option will document all discussions with patient, family, other team members, and any other person who may be involved with the patient. This documentation will become part of the patient’s permanent medical record.
6. During Case Conference, or as needed, the interdisciplinary group will examine the patient’s reasons for considering medical aid in dying and discuss how to address these issues with the patient without attempting to interfere with the patient’s decisions.
7. Staff having contact with such patients will consult with and be supported on an ongoing basis.
8. If the patient chooses to pursue medical aid-in-dying as an option, the patient/family will be informed of the role of Envision regarding participation in the law, that is, Envision will continue to serve the patient and family; will offer customary hospice services, and seek to meet not only the physical needs of the patient/family, but the emotional, social, and spiritual needs as well.
9. The Medical Director may serve, if he or she chooses, as the attending or consulting physician as defined in the Act to determine patient’s eligibility.
10. If a patient asks his/her physician for a prescription for medication for medical aid in dying, the patient and family will receive ongoing support.
11. As is customary, bereavement support will be available to all families.
12. Envision Ethics Committee will meet, as needed, to review cases involving medical aid in dying and to review our Washington Death with Dignity Act policies and procedures. The Committee will also meet at the request of staff to discuss any concerns, to review an individual case, or to review any and/or all of our Washington Death with Dignity Act policies.
13. Envision will not administer the medication for medical aid-in-dying.

Staff Roles in the Washington Death with Dignity Act 

1. It is the responsibility of Envision staff to educate and inform patients and families regarding end-of-life options and care when patients ask.
2. At time of admission or anytime the patient is under the care of Envision, if asked by a patient or family, staff will inform patients about their rights under the Act, as well as our policy to continue to provide standard hospice services to patients regardless of their stated interest or intent in pursuing this legal right.

3. This information will be contained in a Patient Information sheet regarding the Act which will be given to the patient/family upon request.
4. If a patient indicates their wishes to participate in the Act, the interdisciplinary team, including the person’s physician and/or Medical Director, should work to identify the factors contributing to the person’s desire for medical aid in dying and to try to address them as part of the Care Plan.
5. If a patient obtains a medical aid-in-dying prescription, staff will continue to provide standard hospice services.
6. Envision staff can respectfully ask their supervisor to transfer patients who are considering or have obtained medical aid-in-dying medication to another staff person without any fear of discipline or retaliation.
7. If upon arriving at a patient’s home, a staff member discovers that a patient who had not divulged their intention to utilize the Act is in the process of or has taken the medical aid-in-dying prescription, you may leave the premises but must notify your supervisor immediately. If you arrive at a patient’s home and find that the person has taken the medication and has died, you are to provide your professional services as in any other case and initiate the usual bereavement follow-up with the family/significant other(s).

Patient Discussions Related to the Washington Death with Dignity Act 

1. Patients may want to discuss the option of the Act with staff. Envision staff will respond to patient questions or statements regarding the end-of-life option with respect and compassion. Staff should inquire about the patient’s concerns, fears, symptoms, etc. to encourage deeper exploration, to identify the patient’s experience and priorities, with the goal to improve patient care.
2. Patients who are requesting further information or who are seriously considering making a request for medical aid-in-dying medications should be advised of the need to begin the process by speaking to their physician [or the Medical Director] and start reviewing the Act forms with the patient.
3. Envision staff will: 

• Notify the appropriate staff (Registered Nurse Case Manager and Director of Hospice Care Services) of the patient’s inquiry, along with patient name, medical ID, and a brief summary of the contact.
• Notify other involved members of the interdisciplinary team on a need-to-know basis; all staff will be respectful of patient’s privacy.
• Obtain patient permission prior to any communication with a patient’s family members or others. While it is recommended that patients inform their families of their wishes around obtaining medical aid-in-dying medication, patients are not legally required to inform their families or caregivers of their wishes.

Care of Patients Who Pursue Obtaining Medical Aid-in-Dying Medications 

1. Envision staff will respect the patient’s decision; continue to provide care as indicated by the patient’s physical, emotional, and spiritual needs; communicate and coordinate, as needed, with the designated staff (Registered Nurse Case Manager and Director of Hospice Care Services).
2. Prior to the patient ingesting the medical aid-in-dying medication and while continuing to provide any usual hospice care, staff will assist with the following routine hospice care standards:

• Ensuring the patient’s POLST form is complete and in the home.
• Making funeral arrangements, including discussion of disposition of remains, if needed.
• Encouraging the patient to complete any other end-of-life arrangements.
• Instructing caregivers around time of death and contacting hospice at time of death.
• Identifying next of kin who are to be notified of death if they will not be in attendance.
• Providing patient and family members or other caregivers with information around safe disposal of medications.
• Complete any additional documentation needed in patient’s chart, i.e. non-clinical notes, end-of-life notes, etc.
• If patient dies without self-administering the medical aid-in-dying medication and these medications are in the home, staff will assess for safety and provide information around safe disposal of medications.

Staff Presence at Time of Patient Deaths 

1. Envision staff may be present at the time of death to provide emotional support for the patient, family, and others in attendance, only under the following circumstances: 

• the patient specifically requests staff presence. No staff member shall assist the patient in the administration of medical aid-in-dying medications. This is not intended to prohibit the provision of appropriate comfort measures, even if such measures, such as symptom management for pain or nausea, have the consequence of hastening death;
• staff member can be present in the home or with patient while medication is taken;
• staff member discusses patient request for presence at time of death with the appropriate or designated staff (Administrator and Director of Hospice Care Services) in a timely fashion and receives approval prior to agreeing to attend patient’s death. This discussion should include planning for staff to inform the family that they may not remain in the home until patient dies if the dying process is prolonged;
• staff member will not assist with the preparation of medication;
• staff presence is to meet the needs of the patient and family; Registered Nurse Case Manager and Director of Hospice Care will consult with the Administrator prior to approving staff presence (staff may be required to have another clinician accompany them);
• the patient will be self-administering the medication in a private home, property, or residence, i.e. not a public place;
• patient is planning to self-administer medication during the staff member’s normal work time; the patient will also have another adult present in addition to staff; the visit is treated like any other end-of-life visit in which symptom management and comfort are the focus. Staff member is not expected to remain in the home until the patient’s death, as there will be considerable time variations between the time that a patient ingests medication until the time of death.

On-call and time of death instructions visit standards 

1. Time of death visits will be handled according to normal procedures with on-call staff making a determination according to the individual family needs and specific circumstances.
2. Hospice staff will inform on-call if they are aware that the patient is planning to ingest medical aid-in-dying medication during on-call hours.
3. Time of death announcements to staff will not list information related to the Act.
4. Time of death calls to coroners, which are rarely required, will list patient’s underlying illness as cause of death. 

Specific medical record issues related to patients making requests for end-of-life medications 

1. Staff will document discussions with patients requesting information about the Act or who are pursuing medical aid-in-dying medications including:

• Case communication note indicating notification to designated/appropriate staff. (Director of Hospice Care Services and Administrator)
• Medications dispensed under the Act.
• Documentation in notes that medical aid-in-dying medications have been dispensed and are in the patient’s home.

2. Staff presence at time of death will be documented in routine visit and/or death notes as with any hospice death.
3. Documentation at time of death visit should include:

1. • healthcare professional/staff presence
   • time of death
   • bereavement concerns

4. If Attending Physician or another licensed healthcare provider is present at death, there is an additional form to fill out and should go in medical records.

Reporting a Washington Death with Dignity Act Death 

1. Envision will report a patient’s cause of death after ingesting medical aid-in-dying medications as the patient’s underlying hospice diagnosis. We do not report medical aid in dying or the Act as cause of death.
2. The underlying terminal disease must be listed as the cause of death.
3. The manner of death must be marked as “Natural.”
4. The cause of death section may not contain any language that indicates that the Washington Death with Dignity Act was used, such as:
   • Suicide
   • Assisted suicide
   • Physician-assisted suicide
   • Death with Dignity
   • Mercy killing
   • Euthanasia
   • Medication 

Conscientious Objections and Personal Responsibility Related to Patients Requesting Medical Aid-in-Dying Medications

1. The Envision management team and staff recognize that each staff member will need to thoughtfully consider whether it is within their own ability, values, and beliefs to provide care for patients who are requesting medical aid-in-dying medications.
2. It is not the intent of the management team to assume staff involvement. It is the staff member’s responsibility to inform appropriate staff (their Administrator or Director of Hospice Care Services) of concerns or reluctance around caring for patients who are requesting medical aid-in-dying prescriptions, including discussions and requests for information.
3. The Director of Hospice Care Services and Registered Nurse Case Managers will be responsible for assessing and, if needed, re-assigning staff to ensure excellent patient care.
4. Staff should think about and discuss this issue in order to clarify their personal and professional understanding of the ramifications of the Act. Education and training on the Act will be available on an as-needed basis.
5. Envision staff may never coerce or exert undue influence on a patient with respect to these issues.
6. If at any time staff do not desire to continue to provide care to a person because their decision to participate in the Act conflicts with your personal values, please inform the patient’s designated staff (Registered Nurse Case Manager and Director of Hospice Services) and they will identify another staff member who can provide the necessary care.

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References

Washington Death with Dignity Act, Initiative 1000, codified as RCW 70.245

Washington State Medical Association website https://wsma.org/

Washington State Hospital Association website https://www.wsha.org/for-patients/end-of-life/