Death with Dignity is an end-of-life option that allows certain terminally ill eligible individuals to legally request and obtain a prescription from their physician to end their life in a peaceful, humane, and dignified manner.1
As of October 2016, legal prescriptions for life-ending medications are only available in states with dignity laws: Oregon since 1997, Washington since 2009, Vermont since 2013, and California since 2016. Physician-assisted dying is also legal in Montana by way of 2009 State Supreme Court ruling. To qualify under the Death with Dignity, the following criterion must be met:
- Adult resident where Death with Dignity law is in effect. (Oregon, Washington, Vermont, California).
- Mentally competent (i.e., capable of making and communicating of his/her healthcare decisions).
- Diagnosed with a terminal illness that will lead to death within 6 months as confirmed by two physicians.
- The process entails oral and written requests and waiting periods.
A recent study published in JAMA Oncology reviewed data from Washington State Death with Dignity prescriptions and medications dispensed at Seattle Cancer Care Alliance at an outpatient clinic for the Fred Hutchinson Research Center and University of Washington. Since 2010, 73 scripts were dispensed to terminally ill patients. Secobarbital ( Seconal) , an oral barbiturate, was the most commonly prescribed. Oral pentobarbital (Nembutal) was the next most common, although prescriptions dropped sharply in 2014 after the manufacturer halted sales in response to its increased use in state executions.2
The mean out-of-pocket cost of secobarbital has steadily increased from 2010 at $387 to $2878 in 2016. Since Death with Dignity drugs are not considered therapeutic, they are rarely covered by public or private health insurance plans. The patient must bear the cost of the prescription.
Considering secobarbital has been used since 1929, the sudden profiteering from such an old drug raises concerns. Outside of aid-in-dying, this drug has few clinical uses which includes sedation before surgery or for insomnia.
Raising the price of this medication seems objectionable when one considers that the outlay for research and development occurred long ago and has certainly been recouped. New drug pricing seems to bear no relationship to its novelty or efficacy. Fortunately, creative pharmacists in the study started to refer patients to an outside compounding pharmacy to receive a cocktail of phenobarbital, choral hydrate, and morphine sulfate costing $500. It may be an alternative strategy for those patients who cannot afford secobarbital; however, it is not without side effects.
The Death with Dignity statute intends to give the patient the freedom and empowerment to set their own time frame. One-third of patients never take the Death with Dignity medication. Simply knowing they have this option--if they need it--gives them comfort. Ninety percent of patients who use the Death with Dignity are enrolled in hospice.
How can this financial blow to terminally ill patients be addressed? Can organizations lobby to promote legislation to prevent this situation? Can we explore effective cocktails at a reasonable cost to ensure death with dignity? Can our oncologists and healthcare professionals work with hospice and pharmaceutical representatives to ensure that these terminally ill patients are provided with safe, effective, and affordable drugs?
We must respect the need for autonomy and dignity of these terminally ill patients. Itís enough that many have had to deal with financial toxicity during the cancer treatment phase itself.
- Death with Dignity National Center. FAQs.
- Shankaran V, LaFrance RJ, Ramsey SD. Drug Price Inflation and the Cost of Assisted Death for Terminally Ill Patients-Death With Indignity. JAMA Oncol. 2016 Oct 6.