Death with Dignity is
- an end-of-life option that allows certain qualified individuals to legally request and obtain medications from their physician to end their life in a peaceful, humane, and dignified manner;
- state legislation, such as the California End of Life Option Act, codifying such an end-of-life option
- a family of organizations promoting the end-of-life option around the United States.
Learn more about
- Death with Dignity as an end-of-life option
- California End of Life Option Act, a Death with Dignity law
- Impact of Death with Dignity legislation
- Death with Dignity organizations and supporting Death with Dignity in California
What is the California End of Life Option Act?
The California End of Life Option Act is a statute that allows certain terminally ill adults to request and obtain a prescription for medication to end their lives in a peaceful manner. The Act outlines the process of obtaining such medication, including safeguards to protect both patients and physicians. The Act was enacted in 2015 with Governor Brown’s signature on October 5 and took effect on June 9, 2016.
There is no state program for participation in the California End of Life Option Act, and people do not apply to state health departments. It is up to eligible patients and licensed physicians to implement the Act on an individual, case-by-case basis.
Three other states currently have physician-assisted dying statutes in effect: Oregon since 1997, Washington since 2009 (the law was passed in 2008), and Vermont since 2013. In Montana, physician-assisted death is legal (since 2009) by the state Supreme Court ruling.
Who can participate in the California End of Life Option Act ?
Anyone who meets the eligibility criteria can use their state’s physician aid in dying law. Participation in the law is strictly voluntary.
To qualify for a prescription of medication under existing physician-assisted dying laws, you must be
- an adult resident of California;
- mentally competent, i.e. capable of making and communicating your healthcare decisions;
- diagnosed with a terminal illness that will lead to death within six months.
You must also must be able to self-administer and ingest the prescribed medication. Two physicians must determine whether all these criteria have been met. The process entails two oral requests, one written request, waiting periods, and other requirements.
There are no exceptions to these requirements.
Can my family member or a proxy request participation in medical aid in dying on my behalf (for example, if I am in a coma or suffer from Alzheimer’s disease or dementia)?
No. The law requires that you ask to participate voluntarily on your own behalf and meet all the eligibility criteria at the time of your request and the time of taking the medications.
Can the California End of Life Option Act be used with an advance directive/living will?
An advance directive, also known as a living will, is a legal document that describes what you as a dying person want done (or not done) medically if you can no longer communicate. The California End of Life Option Act cannot be used under advance directives because you would no longer be of sound mind when the advance directives kick in.
What are the residency requirements under the California End of Life Option Act?
You must provide adequate documentation to the attending physician to verify that you are a current resident of California. It is up to the attending physician to determine you have adequately established residency. Factors demonstrating residency include, but are not limited to any of the following:
- a state-issued ID or driver license;
- a lease agreement or property ownership document showing that you rent or own property in the state;
- a state voter registration; or
- a recent state tax return.
There is no length-of-residency requirement. You must simply be able to establish that you are currently a state resident.
Can I move to California in order to use the California End of Life Option Act?
There is nothing in the law that prevents you from doing this. You must simply must be able to prove to the attending physician that you are currently a resident. However, relocating in and of itself, not to mention across state lines, is a challenge, particularly if you are terminally ill and if you are elderly (the median age of aid-in-dying participants in Oregon is 72).
Can I just fly to California and then back home with the medication?
No. You must be a resident of California and be planning to die in California. Taking the medication prescribed under the California End of Life Option Act out of the state may result in your and your physician’s losing the legal protections afforded by the law in question.
The California End of Life Option Act contains a number of safeguards, protecting patients from abuse and coercion:
- Patients must meet stringent eligibility requirements, including being an adult, state resident, mentally competent, and having a terminal diagnosis with a 6-month prognosis as confirmed by two licensed physicians.
- Only the patient him or herself can make the oral requests for medication, in person. It is impossible to stipulate the request in an advance directive, living will, or any other end-of-life care document.
- The patient must make two oral requests, at least 15 days apart.
- The written request must be witnessed by at least two people, who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request. One of the witnesses cannot be a relative of the patient by blood, marriage or adoption; anyone who would be entitled to any portion of the patient’s estate; an owner, operator or employee of a health care facility where the eligible patient is receiving medical treatment or is a resident or the patient’s attending physician.
- The patient must be deemed capable to take (self-administer and ingest) the medication themselves, without assistance.
- The patient may rescind the request at any time.
- Two physicians, one of whom is the patient’s attending physician, familiar with the patient’s case, must confirm the diagnosis. Each physician must be licensed to practice medicine and certified to prescribe medications in the state of California.
- If either physician determines the patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, they must refer the patient for evaluation by a state licensed psychiatrist or psychologist to determine their mental competency. Medication cannot be prescribed until such evaluation determines the patient is mentally competent.
- The attending physician must mail or hand-deliver the prescription to the pharmacy.
- The request process must be stopped stop immediately if there is any suspicion or evidence of coercion.
- The physicians must meet strict reporting requirements for each request.
- Anyone who falsifies a request, destroys a rescission of a request or who coerces or exerts undue influence on a patient to request medication under the law or to destroy a rescission of such a request commits a Class A felony. The law also does not limit liability for negligence or intentional misconduct, and criminal penalties also apply for conduct that is inconsistent with it.
Data and studies show these safeguards work as intended, protecting patients and preventing misuse. No evidence of coercion or abuse has been documented in the Oregon since 1998 and Washington since 2009, when these states’ respective laws were first used.
How does the California End of Life Option Act safeguard confidentiality?
Federal statutes, such as HIPAA, protect confidentiality of all patient records.
While the state of California may collect the names of patients in order to cross-check death certificates, the law guarantees the confidentiality of all participating patients as well as physicians. Patients’ or doctors’ identifying information is never released to the public or media. The identity of participating physicians is coded, but the identity of individual patients is not recorded in any manner.
If your death results from taking medications legally prescribed and obtained under a physician aid-in-dying statute, your death certificate will list your underlying illness as the cause of death.
How does using the California End of Life Option Act impact my insurance?
The California End of Life Option Act does not specify who must pay for the services. Individual insurers determine whether the procedure is covered under their policies, just as they do with any other medical procedure. Federal funding, including Medicaid and Medicare, cannot be used for services or medications received under these laws. In California, a portion of the cost will likely be covered by Medi-Cal.
The California End of Life Option Act specifies that participation under it is not suicide. Therefore, your decision to end your life under an aid-in-dying statute has no effect on your life, health, or accident insurance or annuity policy.
How many people use the California End of Life Option Act?
Because implementation of the California End of Life Option Act only began on June 9, 2016, the California Department of Public Health has not yet issued a report on the use of the law.
In 2014, a total of 155 terminally-ill adult Oregonians received a prescription for medications under the provisions of the Oregon Death with Dignity Act, while 105 of them (67.7%) ingested the medications to die peacefully. This corresponds to 31 Death with Dignity Act deaths per 10,000 total deaths, or 0.31%. Since 1998, when the first person in Oregon took medication prescribed under the Death with Dignity Act, a total of 1,327 patients have received the prescription, of whom 859 (65%) ingested it and died.
In Washington, 176 individuals received medications in 2014, of whom 126 died after ingesting the medication, 17 died without having ingested the medication, and for the remaining 27 people who died ingestion status is unknown. Since Washington’s law was passed in 2008, a total of 725 people have had prescriptions written under the Act, and 712 patients have died from ingesting the medications.
These figures highlight that
- only a small number of people use the law to die; and
- more than one third of those who do obtain the medication prescribed under the law never take it.
The existing Death with Dignity Acts continue to work flawlessly and to provide ease of mind and relief to people facing the end of life.
Who uses the California End of Life Option Act? What are their demographics?
From the Oregon and Washington experience we know that people who access physician-assisted dying laws tend to be well educated and have excellent health care, good insurance, access to hospice, and financial, emotional, and physical support. Two out of three are aged 65 years or older; the median age at death is 72 years. Most patients have cancer (69 percent in Oregon according to the latest report) or ALS (16 percent). Most people die at home and are enrolled in hospice care. The three most frequently mentioned end-of-life concerns are loss of autonomy decreasing ability to participate in activities that made life enjoyable, and loss of dignity.
The California experience will likely mirror that of Oregon and Washington.
Does the California End of Life Option Act obligate or encourage anyone to use it?
Participation in the California End of Life Option Act is strictly voluntary, for both patients and physicians. No one is encouraged obligated to use the law, which merely provides an option to those who wish to use it.
No one qualifies under the California End of Life Option Act solely on the basis of age or disability. Many seniors and people with disabilities support physician-assisted dying legislation, not because they are disabled but because they are people.
Opponents of the California End of Life Option Act like to allege that the mere existence of physician-assisted death laws encourages the elderly, people with disabilities, minorities, or poor, undereducated, uninsured and other marginalized persons to prematurely end their lives. These laws, including California’s, however, provide a voluntary option to anyone who qualifies and wishes to voluntarily use it. No one is forced, obligated, or encouraged to use the California End of Life Option Act; access to the California End of Life Option Act by any one person does not preclude others from opting out.
Do people move to California in order to use the California End of Life Option Act?
Only current residency matters for the purposes of the California End of Life Option Act, the annual reports issued by the California Department of Public Health will not contain information about the patients’ prior domicile.
Similarly, there are no statistics about people moving to Oregon, Washington, or Vermont in order to use those states’ physician aid-in-dying laws. Because only current residency matters under aid-in-dying laws, annual reports released by the Oregon Department of Human Services and Washington State Department of Health do not contain information about how many individuals moved to theses states in order to avail themselves of their respective Death with Dignity Acts (Vermont’s Patient Choice and Control at End of Life Act does not have a reporting requirement).
Can the federal government overturn the California End of Life Option Act?
No. The George W. Bush administration in the early 2000s attempted to use the federal Controlled Substances Act (CSA) to overturn the Oregon Death with Dignity Act, both through Congress and the courts. However, since the CSA bans the use and trafficking of illegal drugs and regulates the use of legal narcotics for approved medical purposes, and the Oregon Death with Dignity Act specifies only the use of legal narcotics for physician-assisted dying, their efforts failed.
In the U.S., it is the states, not the federal government, that licenses physicians and determines what is and is not legitimate medical practice. In 2006, the US Supreme Court affirmed this by ruling, in the case Gonzales v. Oregon, that the federal government overstepped his authority in seeking to punish doctors who prescribed drugs to help terminally ill patients end their lives.
What is Death with Dignity as an end-of-life option?
Death with Dignity is an end-of-life option that allows certain terminally ill people to voluntarily and legally request and receive a prescription medication from their physician to hasten their death in a peaceful, humane, and dignified manner.
Death with Dignity is governed by state legislation.
What are some other terms used to refer to Death with Dignity?
Death with Dignity is a term originating in the title of the Oregon statute governing the prescribing of life-ending medications to eligible terminally ill people; because our founders authored the Oregon law, our family of organizations bears its name and it’s our preferred term for the practice.
Other terms include
- physician-assisted death
- physician-assisted dying
- aid in dying
- physician aid in dying
- medical aid in dying
Incorrect and inaccurate terms that opponents of physician-assisted dying use in order to mislead the public include: “assisted suicide,” “doctor-assisted suicide,” “physician-assisted suicide” (“PAS”), and (active) “euthanasia.”
How can I use a Death with Dignity law such as the California End of Life Option Act?
To qualify for a legal prescription for life-ending medications under the California End of Life Option Act, you must be
- an adult resident of California;
- mentally competent, i.e. capable of making and communicating your healthcare decisions; and
- diagnosed with a terminal illness that will lead to death within six months, as confirmed by two physicians.
The process entails two oral requests, one written request, waiting periods, and other requirements.
Should I tell my family I want to use the California End of Life Option Act ?
Every family is different, and many families have had strained relations. However, even if there has been little communication for years, the months or weeks before death is a time when many people attempt to open up to each other. It is amazing how many families reestablish communication and offer support.
It is truly in the best interest of those who will be left behind that you tell your family what you are planning, and give them the option to accept or reject it, or to work out personal past differences. This helps those family members cope better after you die, as they have some good, positive memories.
Even if your family cannot support you in what you are choosing to do, by starting the dialogue you have at least given them the chance to understand and grow. And most families rise to the occasion by providing help, support, and understanding.
However, if after thought and consideration, you still feel strongly that telling your family would not be helpful, we encourage you to discuss this a neutral third party like a friend, a religious counselor, or a social worker.
How can I find a doctor in California who will prescribe life-ending medications?
There is no lists of physicians who participate in the California End of Life Option Act, for both confidentiality and safety reasons. Doctor participation in the law is strictly voluntary.
You are more likely to find a participating physician in a non-faith-based hospital and in larger cities.
To find out if your doctor is willing to participate in the law, make an appointment with him or her to discuss your end-of-life goals and concerns, including the option available under the California End of Life Option Act. Ask any kind of doctor: your hospice doctor, or your oncologist, or pulmonologist, or neurologist, or even your dermatologist or psychiatrist. Any physician licensed to practice in California is allowed to participate if s/he agrees; the law also says every physician has the choice not to participate.
If the first physician says yes, ask them for a referral to another doctor who will participate or ask another of your (probably many) doctors if they will participate. Both physicians need to certify that you meet the criteria under the law. The first physician will be your attending physician for the law. He or she will guide you through all the requirements of the law and, if you qualify, will write the life-ending medication prescription for you. The second certifying doctor will be the consulting physician under the law who has to certify all the criteria under the law have been met.
Nurse practitioners and physician’s assistants, while they can treat your basic disease, are not allowed to act as licensed physicians for the California End of Life Option Act.
Where can I take the medication?
You can take (self-administer and ingest) the medications at a place of your choosing, though the law advises your physician to ask you not to do so in a public place. Most people, about 90%, choose to take the medications at home; those who reside in assisted-living or nursing home facilities tend to take them there.
If you take a dose prescribed under the California End of Life Option Act outside the state, you may lose the legal protections afforded by the law. For example, your death may be ruled a suicide under another state’s law, which may affect your insurance coverage.
What kind of prescription will I receive?
Any and all medications under the California End of Life Option Act require the attending physician’s prescription. The Act does not tell your physician exactly what prescription to give you. It is up to the physician to determine the prescription. To date, most patients in Oregon and Washington, where death with dignity laws have been in effect since 1997 and 2009, respectively, have received a prescription for an oral dosage of a barbiturate (pentobarbital/Nembutal or secobarbital/Seconal); beginning in 2015, a phenobarbital/chloral hydrate/morphine sulfate/ethanol mix has also been used.
How much does the medication cost?
Cost varies based on medication type and availability as well as the protocol used (additional medications must be consumed prior to the lethal medications at an extra cost), ranging from approx. $500 for the new compound described above to $5,000 for Seconal, the most frequently used drug.
When will I know it is the time to take the medication?
No one can answer this question for you.
Some people know when it’s time, when they’ve reached a point where their disease or the pain and suffering it causes has robbed them of the quality of life they find essential.
If you decide the time is not right, that’s fine; it only means the California End of Life Option Act is working as intended because it has given you the freedom and empowerment to set your own timeframe. Some people (about 1 in 3 in Oregon and Washington) never take the medication. Simply knowing they have this option, if they need it, gives them comfort.
What happens with unused medications?
One in three people who obtain medications under existing aid-in-dying laws choose not to take them. Anyone who chooses not to ingest a prescribed dose or anyone in possession of any portion of the unused dose must dispose of the dose in a legal manner as determined by the federal Drug Enforcement Agency or their state laws, if any. Physicians must report all prescriptions for lethal medications to the California Department of Public Health.
What other options do I have for hastening my death if I don’t qualify for the California End of Life Option Act?
- voluntarily stop eating and drinking.
- stop treatment or not start treatment at all. Every competent individual has a right to refuse medical therapies.
- use palliative sedation.
Such measures can take anywhere from several days to several weeks to result in death. Stopping treatment or medication may lead to unanticipated effects or pain.
Discuss your options with your physician.
Death with Dignity legislation has yielded numerous direct and indirect benefits, which can also be expected to emerge in California.
For the terminally ill, the greatest comfort these laws provide is having the freedom to control their own ending. Most people who obtain medications under these laws value being able to make their own decisions, including the where and when of their death. We know this because people using the law cite loss of autonomy as their chief end-of-life concern.
In addition, if you are terminally ill the option to die a peaceful death at a time and place of your choosing provides you with invaluable peace of mind, which is especially important at the end of life. In fact, so many people get reassurance from simply filling the prescription that one in three choose not to use it.
Most people who are dying wish to die at home. While on the national level only about 20% of people die at home, 90% or more of people accessing the Oregon Death with Dignity Act do. The stringent safeguards in these laws also protect patients from possible abuse, coercion, and wrongful medical practice.
The relief from my terminally-ill patients and their families is palpable. I’ve helped families accept their family members’ final wishes in the face of terrible illness. Aid in dying for terminal patients is an essential part of good, compassionate end of life care.
Family members, too, derive peace of mind from knowing they will not have to helplessly endure watching a loved one die a horrible death.
What are the benefits of the California End of Life Option Act for physicians?
For physicians, the California End of Life Option Act codifies and brings to light the common practice of giving life-ending medications to their patients. The California End of Life Option Act protects physicians by stipulating the steps they must follow and, provided they follow the law, providing them with immunity from civil and criminal liability as well as professional disciplinary action.
Where do physicians stand on physician-assisted dying?
A 2014 Medscape survey found that 54% of medical doctors favor physician-assisted dying, up from 46% in 2010. We also know that many physicians who support the end-of-life option are reluctant to declare so publicly for fear of repercussions in their workplace or medical community.
The American Medical Association opposes aid-in-dying laws. However, not only does the AMA represents a declining number of physicians (only about 1 in 3 doctors are AMA members), a 2011 survey of physicians conducted by Jackson & Coker found that 77% of physicians believe the AMA no longer reflects their views. In 2015, the California chapter of the AMA changed its position on physician-assisted dying from opposed to neutral, stating that they “believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage.”
A number of medical associations have endorsed physician-assisted dying, including the American Public Health Association, the American College of Legal Medicine, the American Medical Women’s Association, the American Medical Student Association, and the Denver Medical Society.
For my patients who have used this law, I was honored that I could be with them every step of the way, ensuring that they were cared for, and that they had control of the final days of their lives. That’s what death with dignity really means.
Does the California End of Life Option Act have any broader, societal effects?
Death with Dignity legislation leads to improvements in end-of-life care, which we reasonably expect to happen in California as well. The experience in California after the End of Life Option Act passed in 2015 has shown that the passage of a physician-assisted dying law, even before it takes effect, heightens the urgency of improving end-of-life care. Whereas conversations in the Golden State are only beginning, we are confident that the End of Life Option Act will ultimately lead to improvements in end-of-life care there.
Oregon consistently ranks as a top state in end-of-life care. The Oregon Death with Dignity Act has dramatically improved end-of-life care, particularly in pain management, hospice care, and support services for family members. Reports show that up to 97% of people using Oregon’s Death with Dignity Act are on hospice at the time of death, as compared to 45% in the US overall, according to the National Hospice and Palliative Care Organization. Oregon has the best pain, palliative and hospice care in the nation because the law made physicians get better at diagnosing depression, pain management, and hospice referrals.
Residents of states with aid-in-dying laws are better-versed in end-of-life care issues than of those with no such statutes. A poll by National Journal and The Regence Foundation has found residents in Oregon and Washington to be more knowledgeable and supportive of a variety of end-of-life options, including hospice and palliative care, than most Americans. According to the same poll, support for Death with Dignity legislation has grown in both Oregon and Washington, and a 2012 poll found 80% of Oregonians support the Act.
Many healthy Oregonians and Washingtonians today discuss end-of-life issues with their doctors and increasingly demand active participation and decision making in their own end-of-life care. Oregon and Washington doctors, as a result, today work harder to prolong patients’ lives and enhance quality of life, while respecting patients’ final wishes when their suffering becomes intolerable. Because of the law’s protections, most Oregonians know their doctors won’t abandon them when the suffering becomes unbearable and use of the law is requested.
Oregon’s medical aid in dying law has also helped foster an open and honest conversation between doctors and patients about end of life.
What is the Death with Dignity family of organizations?
What is the Death with Dignity National Center and what does it do?
The National Center expands the freedom of all eligible terminally ill Americans to make their own end-of-life decisions, including how they die. We achieve this by promoting Death with Dignity laws around the United States based on the groundbreaking Oregon model and by providing information, education, and support about Death with Dignity as an end-of-life option to patients, family members, legislators, advocates, healthcare and end-of-life care professionals, media, and the interested public.
What is the Death with Dignity Political Fund and what does it do?
The Political Fund is a 501(c)4 nonprofit organization that acts as the political arm of the National Center. The Fund drafts Death with Dignity laws based on the groundbreaking Oregon model; campaigns, lobbies, and advocates for Death with Dignity legislation in the states that lack them; and defends Death with Dignity statutes against legal and legislative challenges. The Political Fund staff and volunteers authored, passed, and defended the Oregon law (1994/1997/2006); spearheaded the successful efforts to pass Death with Dignity statutes in Washington (2008), Vermont (2013), and California (2015); and led the Maine (2000), Hawaii (2002), and Massachusetts (2012) campaigns, which were all defeated by narrow margins.
How long have Death with Dignity organizations been in existence?
The Death with Dignity family of organizations have been advancing physician-assisted dying policy reform for more than 20 years. The earliest predecessor organization, Oregon Right to Die, was established in 1993. In the current form, the Death with Dignity family of organization has been in existence since 2003.
What is your charity evaluation ranking?
Charity Navigator only rates 501(c)(3) organizations with budgets over $1 million. The combined budget of our 501(c)(3) and 501(c)(4) organizations, the Death with Dignity National Center and Death with Dignity Political Fund, respectively, this year is $600,000. We are not rated by Charity Navigator because we do not meet their budget criterion for evaluation.
How can I promote Death with Dignity in my community?
How can I financially support Death with Dignity?
There are many ways you can contribute funds to promoting and passing Death with Dignity laws:
This page includes information adapted from FAQs by Oregon Department of Human Services, Washington State Department of Health, and Vermont Department of Health as well as from a guest article by Dr. Carol Parrot, MD.