End of Life Option Act (EOLOA) Frequently Asked Questions

Our team has compiled frequently asked questions about the End of Life Option Act (EOLOA), as well as details about the process. Please reach out to your care team if you have additional questions.

The California End of Life Option Act allows physicians to prescribe an aid-in-dying drug for individuals who qualify under the Act. This act allows terminally ill patients with a life expectancy of six months or less to end their lives peacefully at a time of their choosing.

California’s EOLOA has specific criteria that define which patients can access the aid-in-dying medication. You can qualify if you are:

• An adult (18 years of age or older)
• Terminally ill with a life expectancy of six months or less as determined by two physicians (your attending physician and a consulting physician)
• Capable of making your own health care decisions, and you don’t have a mental disorder that might interfere with this capacity
• Able to prove that you are a California resident
• Acting voluntarily
• Making an informed decision that includes having information about other end-of-life options that may be helpful to you
• Aware that you may choose to obtain the aid-in-dying drug but not take it
• Capable of self-administering and ingesting the aid-in-dying drug without assistance from another person
• Willing and able to comply with all procedures as required by the law

In brief, the steps that the patient and physician must complete are as follows:

• Patient must make three requests for the aid-in-dying drug to their attending physician. Two requests must be made orally (at least 48 hours apart) and one must be in writing on a special form that is witnessed.
• Attending physician must be willing to prescribe an aid-in-dying drug and must make sure the patient legally qualifies.
• Attending physician must explain all end-of-life options to patient, encourage patient-family discussion and review what it means to ingest an aid-in-dying drug.
• Patient must discuss the decision with their physician without anyone else present (except an interpreter, if needed) to make sure the decision is voluntary.
• The patient must see a consulting physician who confirms the terminal diagnosis and that the patient is qualified to receive an aid-in-dying drug according to the law.
• If the patient has a mental disorder, they must be evaluated by a mental health specialist to make sure their judgment is not impaired.
• Before writing the aid-in-dying drug prescription, the physician must discuss with the patient how to administer the drug, give the patient a chance to withdraw their request and encourage the patient to enroll in hospice. The patient then signs a consent form for the prescription to be sent to the pharmacy.
• When ready to use the aid-in-dying drug, the patient or a designated person retrieves the drug from the pharmacy, receives additional education on drug usage and stores it appropriately until used.
• The patient ingests the drug according to the instructions. The drug must be ingested while in a private place with another person present.
• Any unused drug is disposed of appropriately.

The process begins when you express a request for the aid-in-dying drug to your physician. By making the request, you are not committing to using the drug. Your request starts a process through which you can obtain more information and determine your eligibility. You decide if you want to take the next steps.

• If you think you might want an aid-in-dying drug or would like more information, you should tell your physician.
• If your physician participates in providing aid-in-dying drugs as permitted by the Act, they will refer you to a clinical consultant who will help you and your physician comply with the law. The clinical consultant will also allow you to explore your thoughts and needs.
• If your physician does not participate, they are not legally obligated to act upon your request. You may choose to go to a different physician who is voluntarily willing to prescribe an aid-in-dying drug.
• If your physician does not prescribe the aid-in-dying drug, you can ask members of your medical team to connect you with a clinical consultant who will provide you with more information. No UCLA Health medical team member is legally obligated to participate. Only medical professionals and staff who voluntarily participate will assist you.

Requests
You must make a total of three requests:

• Make two oral requests, at least 48 hours apart, directly to your doctor. Neither of these requests can come from anyone else; you must initiate them and make them voluntarily.
• These requests can only be made to your doctor and cannot be relayed to your doctor by a resident, fellow, nurse, nurse practitioner, or any other medical employee.
• Make a third written request, which you can make on the same day as the second oral request or at a later time. You must make the written request on the Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner form. You can also ask your UCLA Health clinical consultant for a copy of the form.

Witnesses
You and two adult witnesses must sign your written request. The two witnesses attest that to the best of their knowledge and belief, you are:

• The person requesting the drug
• Known to them or have provided proof of identity
• Voluntarily signing the request in their presence
• Appearing to be of sound mind and not under duress, fraud, or undue influence

There are also specific rules about who can be a witness, including the following:

• Only one of the two witnesses to the written request may be related to you by blood, marriage, registered domestic partnership, adoption, or be entitled to a portion of your estate upon your death.
• Only one of the two witnesses may own, operate or be employed at a health care facility where you are receiving medical treatment, including a health facility where you reside.
• A witness may NOT be your attending physician, a consulting physician, a mental health specialist or your clinical consultant.

Proof of residency
You must provide proof of residency in the state of California with one of the following:

• A driver’s license or other identification issued by the state of California
• Registration to vote in California
• Evidence that you own or lease property in California
• Filing of a California tax return for the most recent tax year

Informed decision
You must make an informed decision based on an understanding and acknowledgment of relevant facts. These relevant facts must come from your physician and include:

• Your medical diagnosis and prognosis
• Potential risks associated with taking the aid-in-dying drug
• The understanding that taking the prescribed drug will likely aid your dying
• The possibility that you may choose not to obtain the drug
• The possibility that you may change your mind and decide not to take it
• The availability of other feasible alternatives or additional treatment opportunities including, but not limited to, comfort care, hospice care, palliative care (symptom management) and pain control

You may withdraw the request for an aid-in-dying drug at any time. You can decide that you do not want to ingest the drug at any time.

Family members, caregivers and loved ones can play important roles in the EOLOA process. They can help you explore your options and support you as you near the end of life.

• Your physician and the clinical consultant will counsel you about notifying a family member, if you have one, regarding your request for an aid-in-dying drug.
• You will not be denied access to the drug if you do not notify your next of kin or family member. However, we strongly encourage patients to discuss this important action with family members or those you identify as closest to you.
• Your physician and clinical consultant will also provide counseling on the importance of having another person present when you take the drug, although this does not have to be a family member. One important reason for this is that the drug must be ingested within two minutes so that you do not fall asleep before taking the full dose.
• Your clinical consultant may help you identify how and what to tell your family members. This person can also help you decide if family members should participate in counseling sessions to discuss why you have chosen to take an aid-in-dying drug.
• We recommend you consider the impact this action may have on your family members. The end of life can be a particularly meaningful time for you and those who love and care about you. By shortening this phase, you and your family might miss out on specific, meaningful events and healing. Shortening the end-of-life phase may have some benefits, too. If you choose to proceed with the aid-in-dying drug, you might want to prepare those closest to you for your imminent death. We encourage this for all our patients as they face serious illness, but these communications are even more important as the disease progresses.
• The people who love and care for you will miss you and grieve your absence, whether you die from your illness or from taking an aid-in-dying drug. Sometimes, loved ones need time to talk about the loss and think about what it will mean to live without you. Families that approach the end of life with open lines of communication are often more prepared, and the survivors typically manage the grief process better than families that do not discuss the inevitable loss.
• The end of life also provides an opportunity to express one’s wishes and feelings, such as sadness and grief. We encourage patients and families to take some time to think about the ways they may want to express themselves to each other. It can be a time to heal relationships, express and feel love, recount accomplishments and share life histories. We encourage individuals to take this time to be thoughtful about their current situation and to make self-directed choices.
• Your clinical consultant will talk to you about whether there are any letters, videos or notes you may wish to leave to specific people as legacies. Legacies can be lasting gifts of your words and feelings expressed to your loved ones. These can help facilitate healing through the grief process.

Your attending physician is one of the doctors primarily responsible for your health care. The attending physician will most likely be the one caring for your disease (e.g., your oncologist, neurologist or cardiologist), but it could also be your primary care physician or a palliative care physician.

If your attending physician participates in the EOLOA, they will be responsible for prescribing the aid-in-dying drug. If your attending physician does not participate in the Act, you may need to be referred to an additional attending physician who participates and can write the prescription. It is common for patients with complex medical conditions to have multiple attending physicians who care for them.

Examination
A physical examination is an essential part of the EOLOA process. The physician must:

• Examine you and determine if they believe you have a terminal diagnosis with a life expectancy of six months or less. They must document these findings in your chart.
• Document both of your required oral requests for an aid-in-dying drug in your medical chart and ensure that the requests are at least 48 hours apart.
• Put the completed Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner form into your medical record. This form, which is your only required written request, should be your third request.

Referral to a clinical consultant
UCLA Health policy requires that your physician refer you to a clinical consultant. This advocate will:

• Familiarize you with the law and what is required of you and your physicians
• Discuss your understanding of your current medical condition and what an aid-in-dying drug means to you
• Provide you with appropriate referrals to additional resources that might be helpful to you
• Facilitate a referral to an independent consulting physician, which is required by the law
• Answer questions and help you, and potentially your loved ones, think through your thoughts, concerns and feelings as you go through this process
• Advocate for you when appropriate, develop a plan to ensure that your needs have been met and confirm that you have made this decision on your own, without being pressured by others
• Ensure that a uniform practice is used here at UCLA Health, taking into consideration each patient’s needs

Counseling by your physician
Your physician is obligated to discuss the following with you before writing a prescription for an aid-in-dying drug:

• Explain and ensure you understand your medical diagnosis and prognosis and clarify any misunderstandings
• Tell you about the potential risks associated with taking the aid-in-dying drug
• Inform you of the likely result of taking the prescribed aid-in-dying drug (the hastening of the dying process)
• Inform you that you may choose not to obtain the drug
• Inform you that you may change your mind at any time and decide not to take it
• Offer you other feasible alternatives or additional treatment opportunities, including, but not limited to, comfort care, hospice care, palliative care (symptom management) and pain control
• Suggest to you the importance of telling your family or next of kin
• Inform you that by law, you must take the aid-in-dying drug in a private place and that it may never be consumed in a public place (beach, park, etc.)
• Inform you to store the drug in a safe location where other people, such as children or vulnerable individuals, cannot access it
• Inform you and your loved ones where to return this drug if there is any remaining or if you choose not to use it

Other physician obligations
Your attending physician must also:

• Determine that you have the capacity to make this complex health care decision
• Refer you to a mental health specialist (psychologist or psychiatrist) if they are uncertain of your capacity to make health care decisions or if a mental health condition is impacting your decision
• Ensure that you have seen a consulting physician to confirm that you have a terminal diagnosis with a life expectancy of six months or less
• Ask you if you have changed your mind before writing the aid-in-dying drug prescription
• Mail or hand deliver the prescription to the UCLA Health designated pharmacy (the physician cannot give you the prescription)
• Make sure that you are a California resident, as defined above
• Complete a checklist to ensure that all steps are followed
• At UCLA Health, your physician must complete a Physician Orders for Life-Sustaining Treatment (POLST) with you; this form reviews important issues such as Do Not Attempt Resuscitation (DNAR) requests. The POLST is described in more detail below.
• If at any point you are determined ineligible for this act, your physician who accepted the request and referred you to the clinical consultant must inform you of disqualifying reasons
• Your physician cannot prescribe this drug solely based on your age or a disability
• Within 30 calendar days of writing a prescription for an aid-in-dying drug, the attending physician must submit a copy of your written request (the Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner form) to the California Department of Public Health (CDPH) through the Office of Regulatory Affairs at UCLA Health.
• Your physician will also submit additional mandatory forms to the CDPH, as required by the End of Life Option Act.

The consulting physician must:

• Examine you and determine if you have a terminal diagnosis with six or fewer months to live. They must document these findings in your medical chart.
• Determine that you have the mental capacity to make health care decisions
• Refer you to a mental health specialist (psychologist or psychiatrist) if there are indications that you have a mental disorder

What are the responsibilities of the mental health specialist (if you are referred to one) under the End of Life Option Act?

The mental health specialist can be a psychologist or psychiatrist. Through one or more appointments with you, they will determine, in their best professional judgment, whether you:

• Have the mental capacity (as defined by the Act) to make this decision
• Are not suffering from impaired judgment due to a mental disorder

The pharmacist will:

• Fill the prescription and provide it to you or an individual you have designated to pick up the drug
• Educate you and provide information about the best way to ingest this drug
• Educate you about an antiemetic (anti-nausea) medication and how to take it
• Educate you about a timeline of eating, drinking and how to achieve the desired outcome of the drug while reducing the chance of other effects

Psychological support
Having a serious illness can cause feelings of sadness, depression, anxiety, loss, and fear. These feelings are normal under the circumstances. Many patients who experience these feelings benefit from someone they can talk to about their worries and concerns. One role of the clinical consultant is to help address these issues and provide you with recommendations that may be helpful.

Many times, patients benefit from both psychological counseling and appropriate anti-anxiety and antidepressant medications. Together, these interventions can help improve the quality of your life even though the disease may still be progressing. We want you to live as well as you can despite the limitations of the disease, even if you decide that using an aid-in-dying drug is the best option for you near the end of your life.

Receiving psychological support or taking anti-anxiety or antidepressant medications can be part of your end-of-life care. This is true regardless of whether you choose to have an aid-in-dying drug available to you.

Palliative care
Palliative Care is a medical specialty focused on optimizing quality of life for patients with serious illness. It is provided by an interdisciplinary team that works alongside your other treatment teams to prevent and treat symptoms and psychosocial distress.

Palliative care can and should occur throughout the entire continuum of cancer care and is an essential component of high-quality advanced cancer care.

Hospice care
Hospice care is end-of-life care that prioritizes alleviating symptoms and reducing suffering over prolonging life. This kind of care:

• Emphasizes the treatment or alleviation of physical discomforts, as well as psychological and spiritual discomforts, during a time when life nears its end – although the timeframe may be somewhat uncertain
• Is an option for humane and compassionate care when a disease cannot be stopped, and comfort is the highest priority
• Can be done in the home or in a skilled nursing facility (a few hospice programs are actual freestanding facilities)
• Focuses on the patient and the family as a unit

Patients are usually more comfortable in hospice care when they have had some time to stop invasive medical treatments, which can cause additional discomfort. Too often, referrals to hospice care occur just days before a death, and this is often traumatic for everyone involved.

Sometimes, families or physicians do not consider hospice, or there is a concern that entering hospice care means you are “giving up.” Another way to frame this is that hospice care is the best care available for the phase of the disease you are dealing with.

Hospice does not provide all the caregiving that a patient needs. But it does assist the family in making good decisions around pain medications and reducing symptoms, such as nausea or constipation. Hospice companies always have a 24-hour on-call nurse and a telephone number for assistance. Hospice care allows patients to stay in their own environment rather than be rushed to a hospital to address symptoms.

It is a reasonable choice to have hospice care, whether you ultimately decide to use the aid-in-dying drug or you choose not to take it. One option does not exclude the other.

Physician Orders for Life-Sustaining Treatment (POLST)
The POLST form states what kind of medical treatment patients want toward the end of their lives. The POLST gives seriously ill patients more control over their end-of-life care. If you are seeking an aid-in-dying drug, you should complete a POLST to prevent unwanted treatments at the end of life.

You will keep the bright pink POLST form with you (it is often placed on the back of a door or at the foot of your bed in case the paramedics are called). A copy of the form is also placed in your medical record. The POLST:

• Is completed and signed by both the patient (or legally recognized surrogate) and a physician (or nurse practitioner or physician assistant)
• Communicates information about your preferences with respect to attempted resuscitation in the setting of cardiopulmonary arrest, medical interventions, and artificial nutrition.

For patients who want to die naturally or by taking an aid-in-dying drug, it is important to have a completed POLST indicating “Do Not Attempt Resuscitation” (DNAR).
If you previously completed a POLST but did not indicate DNAR, you should complete a new one before ingesting the aid-in-dying drug. Your clinical consultant can help you prepare a POLST that you can take to your physician to discuss further and finalize.

If you are not an English speaker, you may still request the aid-in-dying drug. But you must use a trained interpreter when your health care provider does not speak the same language as you do. You will need an interpreter to engage in all formal counseling and attestations. Your clinical consultant can arrange this for you. The UCLA Health Interpreter/Translation and Deaf Services Program is available to our patients and families. You can reach them at 310-267-8001.

The interpreter may not be related to you by blood, marriage, registered domestic partnership or adoption. Also, the interpreter cannot be entitled to a portion of your estate upon your death. An interpreter must meet the standard put forth by the California Healthcare Interpreting Association, the National Council on Interpreting in Health Care or another standard accepted by the CDPH. The interpreter may read the Request for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner form to you and verify your agreement with this document by making an additional declaration about their fluency.

Your physician cannot administer a medication through injection or IV that is intended to end your life. The EOLOA only allows the physician to prescribe a life-ending medication that you ingest yourself if you have a terminal illness and are expected to live fewer than six months.

No, you cannot take the aid-in-dying drug in a UCLA Health hospital. At UCLA Health, you may make a request for the aid-in-dying drug while an inpatient, but you cannot bring the drug to the hospital and take it as an inpatient.

The physician will comply with the law, which states that the cause of death on the death certificate will not be listed as suicide. No actions taken per the End of Life Option Act constitute suicide, assisted suicide, homicide or elder abuse. The physician will list the underlying disease as the cause of death, as recommended by the CDPH.

The End of Life Option Act specifically mandates that you should not be negatively affected by making this choice. The law states that wills, insurance, contracts and annuities are not affected if a qualified individual shortens their time before dying by taking an aid-in-dying drug that their physician prescribed.

There is more than one drug or combination of drugs that may be used as an aid-in-dying medication. Discuss this with your physician and pharmacist. Your doctor should prescribe an antiemetic medication to reduce the likelihood of you becoming nauseated or vomiting the drug.

Yes. Oregon, Vermont, Washington and other states have similar laws that allow for patients to ingest a prescribed drug when they have a terminal illness. These states have a documented history of using this process. Oregon and Washington have published their data and outcomes, which we reviewed here at UCLA Health prior to implementing the EOLOA.

While only a small number of qualified individuals have utilized these acts, there have been positive effects on end of life. These acts have sparked dialogue among patients, physicians and loved ones about death and health care. In Oregon, hospice care has increased in recent years, and the number of hospital deaths has decreased

Be sure to follow these important steps immediately before you take the aid-in-dying drug:

• Review the step-by-step instructions for taking the drug given to you by your pharmacist and follow them precisely
• Have someone with you when you take the drug
• Make sure whoever is with you understands that you DO NOT WANT ANYONE TO ATTEMPT RESUSCITATION

For additional resources, visit the UCLA Health End of Life Option Act Resources & Materials page. You can also read the entire law by visiting California End of Life Option Act (SB-380). Compassion & Choices, an organization that has supported the passage of the EOLOA, has a wide range of educational materials on its website.

If you are a UCLA Health patient and have further questions, please contact your doctor or another member of your care team. We can help you understand and explore your options.