Flowchart of California hospitals excluded and included in study.
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Cain CL, Koenig BA, Starks H, et al. Hospital Responses to the End of Life Option Act: Implementation of Aid in Dying in California. JAMA Intern Med. 2019;179(7):985–987. doi:10.1001/jamainternmed.2018.8690
The End of Life Option Act (EOLOA) allows terminally ill adult Californians to request a prescription for medication to hasten death under some conditions.1,2 No clinician or health system is required to participate in the EOLOA. While patient access to aid in dying is influenced by how health care organizations implement the law,3 the prevalence of hospitals and health systems opting out is unknown.
We surveyed California hospitals from September 2017 to March 2018. Although the EOLOA is not designed to be implemented in hospitals, hospitals often are central to health care networks, and health system policies may cover physicians in affiliated settings. We constructed the universe of California hospitals using the Office of Statewide Health Planning and Development data4 and excluded children’s, rehabilitation, long-term acute care, and psychiatric hospitals (Figure). All aspects of this study were considered and approved by the IRB, which determined that this study was not human-participant research, and thus consent was waived. Data analysis was conducted from April to August 2018.
Our survey asked whether a hospital had an EOLOA policy and to whom it applied: “Has your organization created any policies about the End of Life Option Act? [yes, no, unsure],” and “Do the policies apply to just your hospital or all of [health system name]? [single hospital, all of health system, unsure].” The interviewer then clarified whether responses included outpatient clinics. Survey responses were collected anonymously by telephone from the hospital representative most knowledgeable about the institution’s implementation of EOLOA. The survey and Office of Statewide Health Planning and Development data were merged to compute bivariate associations between EOLOA policy, hospital characteristics, and number of discharges in 2016.
Of 315 California hospitals, we obtained survey responses for 270 (86%). Nonresponding hospitals were more likely to be rural and for-profit, and less likely to be part of a hospital system. The responding 270 hospitals were covered by 89 unique policies. Fifty-three EOLOA policies (among 229 hospitals) applied to all health system inpatient and outpatient facilities. In contrast, 36 policies applied to 41 hospitals, but offered no guidance for outpatient locations (Figure).
Of the 270 hospitals, 235 (87%) had a formal policy for the EOLOA. Overall, 106 (39%) hospitals permitted physicians to write EOLOA prescriptions: 97 had a formal EOLOA policy and 9 did not. These hospitals accounted for 42% (1 289 236) of hospital discharges in 2016. Of the 164 (61%) hospitals forbidding physicians to write prescriptions under the EOLOA, 138 hospitals had formal policies explicitly prohibiting EOLOA prescribing, and an additional 26 hospitals had no written policy. Hospitals opting out of the EOLOA accounted for 48% (1 501 452) of hospital discharges.
Association of hospital characteristics with stance on the EOLOA is detailed in the Table. Because some hospitals shared policies, we also analyzed these factors at the level of the policy (35 policies permitting vs 54 policies prohibiting the EOLOA). Hospital policies permitting the EOLOA were less likely to be religiously affiliated (3% [n = 1] vs 20% [n = 11]; P = .02), more likely to be nonprofit (71% [n = 25] vs 44% [n = 24]; P = .01), and more likely to offer palliative care (86% [n = 30] vs 67% [n = 36]; P = .05), EOLOA training to physicians (83% [n = 29] vs 41% [n = 22]; P < .001), and information for patients (57% [n = 20] vs 30% [n = 16]; P = .01).
About 18 months after implementation of the EOLOA, most hospitals in California had an EOLOA policy, and the majority prohibited physicians from participating while under the organization’s purview. The preponderance of restrictive policies likely affects the availability of the EOLOA for a substantial number of Californians. Of the 164 hospitals that prohibit prescriptions under the EOLOA, 134 (82%) also prohibit prescriptions in affiliated outpatient settings. More research is needed on these settings and physicians’ practices.
This study has limitations, including its focus on hospitals and not physicians, lower response rates in rural areas, and imprecision concerning the policies of nonhospital clinics. However, this survey shows that hospitals and health systems that allowed the EOLOA were more likely to offer palliative and bereavement services than those hospitals prohibiting aid in dying. This suggests that where the EOLOA is permitted, it is not as a replacement for, but a complement to, existing end-of-life services.
Accepted for Publication: December 16, 2018.
Corresponding Author: Cindy L. Cain, PhD, University of Alabama at Birmingham, 1401 University Blvd, Birmingham, AL 35294 (firstname.lastname@example.org).
Published Online: April 8, 2019. doi:10.1001/jamainternmed.2018.8690
Author Contributions: Dr Cain had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Cain, Koenig, Forbes, Wenger.
Acquisition, analysis, or interpretation of data: Cain, Starks, Thomas, McCleskey, Wenger.
Drafting of the manuscript: Cain, Koenig, Wenger.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cain.
Obtained funding: Cain, Koenig.
Administrative, technical, or material support: Thomas, Forbes, McCleskey.
Conflict of Interest Disclosures: None reported.
Funding/Support: Drs Cain, Koenig, Forbes, and Wenger reported grants from the California Health Care Foundation and grants from the Stupski Foundation during the conduct of the study.
Role of the Funder/Sponsor: Neither the California Health Care Foundation nor the Stupski Foundation had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We would like to acknowledge the California Health Care Foundation and the Stupski Foundation for supporting this work, as well as Thomas R Weinberger, MA, MBA, for supporting efforts that led to this project. We would also like to thank members of steering committee, who offered valuable feedback at various stages. They received no compensation for their assistance.
Additional Information: For more information regarding the steering committee meetings, please visit http://www.eoloptionacttaskforce.org/
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